CLAVICLE FRACTURECLAVICLE FRACTUREPRESENTATOR:DR MOHD HAIDI SYUHAIRI BIN PRESENTATOR:DR MOHD HAIDI SYUHAIRI BIN

HANAFIHANAFI

SUPERVISOR:MISS (DR) ISNONI ISMAILSUPERVISOR:MISS (DR) ISNONI ISMAIL

Department of Orthopaedic Surgeryand Rehabilitation

OVERVIEWOVERVIEW

AnatomyAnatomy OssificationOssification FunctionsFunctions ClassificationClassification Signs and SymptomsSigns and Symptoms Physical ExaminationPhysical Examination TreatmentTreatment RehabilitationRehabilitation

ANATOMYANATOMY

OSSIFICATIONOSSIFICATION

11stst bone to ossify and last bone to finish bone to ossify and last bone to finish ossification.ossification.

from 3 centers :from 3 centers : - 2 primary centers, medial and lateral- 2 primary centers, medial and lateral5th or 5th or

6th week intrauterine life6th week intrauterine life - secondary center(sternal end)- secondary center(sternal end)18th or 20th 18th or 20th

year, unitesyear, unites25th year25th year

VARIATIONSVARIATIONS

- thicker and more curved in manual workers, - thicker and more curved in manual workers, sites of muscular attachments more marked.sites of muscular attachments more marked.

- right clavicle stronger and shorter.- right clavicle stronger and shorter. - In females- In femalesshorter, lighter, thinner, smoother shorter, lighter, thinner, smoother

and less curved.and less curved. -females-femaleslateral end little below medial end; lateral end little below medial end; -males-malessame level or slightly higher than the same level or slightly higher than the

medial endmedial end

FUNCTIONSFUNCTIONS

  Acts as a strut to keep the scapula Acts as a strut to keep the scapula in positionin positionarm can hang freelyarm can hang freely

Cover cervicoaxillary canalCover cervicoaxillary canalprotects protects neurovascular bundleneurovascular bundle

Transmits physical impacts from Transmits physical impacts from upper limb to axial skeleton.upper limb to axial skeleton.

may be congenitally absent or may be congenitally absent or imperfectly imperfectly developeddevelopedcleidocranial dysostosis cleidocranial dysostosis +shoulders droop+shoulders droop

+can be approximated anteriorly in +can be approximated anteriorly in front chest.front chest.

Clavicle FracturesClavicle Fractures

MechanismMechanism– Fall onto shoulder Fall onto shoulder

(87%)(87%)– Direct blow (7%)Direct blow (7%)– Fall onto outstretched Fall onto outstretched

hand (6%)hand (6%) Trimodal distributionTrimodal distribution

0

10

20

30

40

50

60

70

80

Group I(13yrs)

Group 2(47yrs)

Group 3(59yrs)

Percent

The clavicle is the last ossification

center to complete (sternal end) at about 22-25yo.

ClassificationClassification

A.Group 1A.Group 1 Middle Third (80%)Middle Third (80%)

B.Group 2 B.Group 2 Distal Third (15%)Distal Third (15%) Type 1:lateral to cc ligamentType 1:lateral to cc ligament Type 2a:medial to cc ligamentType 2a:medial to cc ligament Type 2b:between cc ligament(conoid Type 2b:between cc ligament(conoid

torn,trapezoid intact)torn,trapezoid intact) Type 3:# into ACJType 3:# into ACJ

C.Group 3 C.Group 3 ProximalThird (5%)ProximalThird (5%)

ComplaintsComplaints

PainPain SwellingSwelling Possible nausea, dizziness, spotty Possible nausea, dizziness, spotty

visionvisiondue to extreme paindue to extreme pain

Physical examinationPhysical examination

Attitude-arm held close to body,supported Attitude-arm held close to body,supported by handby hand

TendernessTenderness DeformityDeformity SwellingSwelling CrepitusCrepitus

EcchymosisEcchymosis BleedingBleedingopen fracture (rare)open fracture (rare) Decreased breath soundsDecreased breath soundsindicating indicating

possible pneumothoraxpossible pneumothorax Decreased pulsesDecreased pulsessuggesting vascular suggesting vascular

compromisecompromise Diminished sensation or Diminished sensation or

weaknessweaknesssuggesting neurologic suggesting neurologic compromisecompromise

Nonuse of the arm on the affected sideNonuse of the arm on the affected side

DiagnosticDiagnostic

XrayXrayAP viewAP view CT scan CT scan maybe requiredmaybe required

Middle 3Middle 3rdrd # #

Distal 3Distal 3rdrd # #

Proximal 3Proximal 3rdrd # #

Other testOther test

Chest radiographyChest radiographyif pneumothorax if pneumothorax suspectedsuspected

AngiographyAngiographyif vascular injury if vascular injury suspectedsuspected

TreatmentTreatment

Medial and Middle fractureMedial and Middle fractureusually usually nonoperativenonoperative

1.Ice1.Ice

2.Analgesic2.Analgesic

3.Sling immobilization3.Sling immobilizationfor3-4 weeks with early for3-4 weeks with early ROM ROM

Distal fractureDistal fracture1.1. Much controversy exists regarding the Much controversy exists regarding the

appropriate management. appropriate management.

2.2. Current recommendationsCurrent recommendationsfix surgicallyfix surgically

3.3. Neer found that although distal third clavicle Neer found that although distal third clavicle fractures are rare, they account for approximately fractures are rare, they account for approximately half of all clavicular nonunions.half of all clavicular nonunions.

Surgical indicationsSurgical indications

1.1. Fractures with neurovascular injuryFractures with neurovascular injury

2.2. Fractures with severe associated chest Fractures with severe associated chest injuriesinjuries

3.3. Open fracturesOpen fractures

4.4. Group II, type II fracturesGroup II, type II fractures

5.5. Cosmetic reasons, uncontrolled deformityCosmetic reasons, uncontrolled deformity

6.6. NonunionNonunion

Surgical choiceSurgical choice

OR+plate fixationOR+plate fixation OR+pin insertionOR+pin insertion

Advantages of plate fixationAdvantages of plate fixation

1.1. • • Easily availableEasily available

2.2. • • Commonly usedCommonly used

3.3. • • Standard techniqueStandard technique

4.4. • • Direct osteon healingDirect osteon healing

Complication of plate Complication of plate fixationfixation

Painful, prominent hardwarePainful, prominent hardware Soft tissue strippingSoft tissue stripping Non-cosmetic scarNon-cosmetic scar Multiple stress risersMultiple stress risers

Permanent if 33% of clavicle diameterPermanent if 33% of clavicle diameter Nerve damageNerve damage InfectionInfection

Infection after plate fixationInfection after plate fixation • • Reports range from 0.4% - 7.8%Reports range from 0.4% - 7.8% • • Bostman:Bostman:

– – 7.8%7.8% • • Liu, et al (2008):Liu, et al (2008):

– – Average time to presentation: 28 daysAverage time to presentation: 28 days

– – 4.9%4.9%• • Kaohsiung J Med Sci. 2008 Jan;24(1):45-9Lateralization of cantilever effKaohsiung J Med Sci. 2008 Jan;24(1):45-9Lateralization of cantilever eff

Post op carePost op care

• • No immobilization utilizedNo immobilization utilized • • Return to full ADL’s as soon as Return to full ADL’s as soon as

toleratedtolerated • • Limit forward flexion ~ 3-4 weeksLimit forward flexion ~ 3-4 weeks • • Pin removed under local anesthesia Pin removed under local anesthesia

8 -8 -

12 weeks post-op12 weeks post-op

Problems with pinProblems with pin

• • Limited sizesLimited sizes • • MigrationMigration • • Static distraction Static distraction

(fully treaded pins)(fully treaded pins) • • Pin irritationPin irritation

Plate vs Pin vs Non-opPlate vs Pin vs Non-op • • Pinning:Pinning:

– – 100% union within 2-4 months100% union within 2-4 months

– – Shorter hospital stayShorter hospital stay • • Plate:Plate:

– – 23.5% scar related pain23.5% scar related pain

– – 17.5% prominent hardware & discomfort17.5% prominent hardware & discomfort • • NonopNonop

– – 23.5% nonunion23.5% nonunion

– – 29.4% cosmetic complaints29.4% cosmetic complaints

– – 6% malunion6% malunionAAOS 2005AAOS 2005

Plate or Pin?Plate or Pin?

• • Plate or intramedullary fixation can be Plate or intramedullary fixation can be

considered for bothconsidered for both • • However, both have their limitationsHowever, both have their limitations • • Plate fixation is probably ideal with:Plate fixation is probably ideal with:

– –transverse, simple fracturestransverse, simple fractures

– –nonunions with bone lossnonunions with bone loss • • For all the rest, consider IM fixationFor all the rest, consider IM fixation Lee et al, Orthopedics. 2007, Nov;30(11):959-6Lee et al, Orthopedics. 2007, Nov;30(11):959-6

1.1. Brachial Plexus InjuriesBrachial Plexus Injuries

2.2. Vascular InjuryVascular Injury

3.3. Rib Fractures Rib Fractures

4.4. Scapula FracturesScapula Fractures

5.5. PneumothoraxPneumothorax

Associated injuryAssociated injury

RehabilitationRehabilitation

Most fracture heal in about 3 months. Most fracture heal in about 3 months. Rehabilitation exercises will begin as soon Rehabilitation exercises will begin as soon

as patient can tolerate motion with very as patient can tolerate motion with very gentle exercises (gentle exercises (pendulum exercisespendulum exercises) ) designed to regain motion. designed to regain motion. 

PrognosisPrognosis

Generally excellentGenerally excellentshoulder has shoulder has the largest range of motion of any the largest range of motion of any joint in the body.joint in the body.

Even if the fracture fragments do not Even if the fracture fragments do not heal exactly in their normal heal exactly in their normal position,the shoulder joint can easily position,the shoulder joint can easily compensate and provide with a well compensate and provide with a well functioning shoulder joint.functioning shoulder joint.

Thank you for your attentionThank you for your attention