*Reprint requ

New Haven, CT

E-mail addre

J Shoulder Elbow Surg (2009) 18, e1-e4

1058-2746/2009

doi:10.1016/j.jse

www.elsevier.com/locate/ymse

Midshaft clavicle fracture and acromioclaviculardislocation: A case report of a rare injury

Peter C. Yeh, MDa,*, Seth R. Miller, MDb, James G. Cunningham, MDb,Paul M. Sethi, MDb

aDepartment of Orthopaedics and Rehabilitation, Yale University, New Haven, CTbOrthopaedic & Neurosurgery Specialists, Greenwich, CT

Combined injury involving a distal clavicle fracture andacromioclavicular (AC) separation is not uncommon;however, fractures of the midshaft clavicle with an ipsi-lateral AC dislocation are rare. There have only been3 reports in the American literature on this type ofcombination injury.1,2,7 We report a case of a horsebackrider who fell on the affected shoulder and presented withthis injury. She was treated surgically and has an excellentclinical result at 1 year postoperatively. This case illustratesthe challenges of treating a displaced clavicle fracture andconcurrent AC separation. It also shows that surgicalintervention for this rare combination injury yields anexcellent functional outcome. The patient consented topublication of this report.

Case report

A 46-year-old, right-handedominant woman fell off a horse andlanded on her right shoulder. Examination of the shoulder shortlyafter the accident showed ecchymosis and swelling in the regionof the posterior aspect of the mid trapezius. She had markedtenderness at the mid clavicle, as well as posteriorly in thetrapezius, and a nonpalpable clavicle at the level of the acromion.The neurologic and vascular status of the right upper extremitywas normal. Her medical history was significant for a previous falloff a horse 3 years earlier when she sustained a grade I ACseparation that resolved without sequelae.

ests: Peter C. Yeh, MD, 800 Howard Avenue, 133 YPB,

06519.

ss: pda@aya.yale.edu (P.C. Yeh).

/$36.00 - see front matter � 2009 Journal of Shoulder and Elbo

.2008.09.011

Radiographic examination of the right clavicle and AC jointshowed a displaced midshaft fracture of the clavicle and wideningof the AC joint with posterior displacement of the distal clavicularfragment (Figures 1 and 2). A computed tomography scanconfirmed the posterior displacement of the distal clavicle and ACjoint widening and also showed degenerative changes at the ACjoint (Figure 3). The operative and nonoperative options werecarefully reviewed, and surgery was elected.

The patient was placed in the semiebeach chair position.Closed reduction of the AC joint was unsatisfactory; the joint wasirreducible, and the manipulation increased the deformity at thefracture. At this point, isolated or percutaneous treatment, by useof a screw into the coracoid, was eliminated as a possible option.A transverse incision was then made across the clavicle toward theAC joint. The distal clavicle was clearly posteriorly displacedthrough a buttonhole defect in the trapezius muscle, the likelyreason for the failed closed reduction (Figure 4). An attempt toreduce the AC joint was made, once the clavicle was extricatedfrom the buttonhole, but this maneuver forced the fracture apexmore superiorly. The AC and coracoclavicular (CC) ligamentswere also found to be ruptured completely (Figure 5).

The 2 fracture fragments were identified. The lateral claviclewas completely denuded of all soft-tissue attachments, suggestiveof a degloving injury. After reduction of the fracture, fixation ofthe clavicle was performed with a precontoured plate. We alteredthe placement of the screws in order to reconstruct the CC liga-ments anatomically. Despite open reductioneinternal fixation(ORIF) of the clavicle, the AC joint was still unstable, withsuperior and posterior displacement evident under stress. Giventhis finding, the AC and CC ligaments were reconstructed witha semitendinosus allograft placed through a single drill hole in theclavicle, looped around the coracoid, and sewn to itself (Figure 6).The patient’s extremity remained in a sling for 4 weeks, and sheattended physical therapy sessions.

w Surgery Board of Trustees.

Figure 1 AP radiograph showing midshaft clavicle fracturewith widening of the AC joint.

Figure 2 Axillary radiograph showing a reduced shoulder withposterior displacement of the distal clavicular fracture.

Figure 3 CT scan showing widened and posteriorly displacedAC joint, with degenerative changes at the joint.

e2 P.C. Yeh et al.

The 1-year follow-up showed painless full active and passiverange of motion with good strength of the right shoulder. Thepatient has no pain on axial loading of the AC joint and hasresumed her normal preinjury activities, including riding horses(Figure 7).

Figure 4 Intraoperative photograph showing buttonhole defectwhere the clavicle was embedded.

Discussion

Midshaft fractures of the clavicle or AC joint separations asisolated injuries are quite common. However, the combinedinjury to the ipsilateral shoulder is quite rare. Fractures ofthe distal end of the clavicle with involvement of the ACjoint are well recognized and were classified by Neer5 toinclude nondisplaced fractures (type I), displaced fractureswith tearing of the CC ligaments (type II), and fracturesinvolving the articular surface (type III). Reviewing theAmerican literature, we found only 3 reports that included

fractures at the midshaft clavicle. In 1990, Lancourt et al2

reported the case of a 19-year-old horseback rider who wasthrown from the animal and landed on her shoulder,sustaining the combination injury to her midshaft clavicleand AC joint. Closed reduction was unsuccessful, andsurgical exploration, reduction, and fixation of the AC jointwere performed with 2 crossed Steinmann pins. Theclavicle fracture was not opened, and the CC ligaments

Figure 6 Intraoperative photograph showing plate fixation ofclavicle as well as reconstructed AC and CC ligaments withallograft.

Figure 7 One year follow-up radiograph of healed claviclefracture and reconstructed AC joint.

Figure 5 Intraoperative photograph showing reduced claviclefracture (note the denuded bone fragments) and disrupted AC andCC ligaments. Figure 8 Axillary radiograph with outline of clavicular frag-

ments and acromion clearly demonstrating posterior displacementof distal clavicle fragment.

Midshaft clavicle fracture e3

were not explored. The pins were removed in the office8 weeks later, and at 3-year follow-up, the authors reporteda healed clavicle fracture, as well as full, painless range ofshoulder motion with no AC separation on weight-bearingfilms.

In 1992, Wurtz et al7 reported this combination injury in4 patients. Two had fallen off a horse, one had fallen froma bicycle, and another was involved in a motor vehicleaccident. Three of the patients (all with grade IV ACseparation) underwent successful ORIF and went on tohave asymptomatic range of motion. Two of the three weretreated operatively by internal fixation with a CC cancel-lous bone screw. In the third, AC transfixation Steinmannpins were used. In each of these patients, the fixation devicewas removed approximately 6 to 8 weeks postoperatively.The fourth patient was diagnosed with a grade II injury andwas treated nonoperatively with early range-of-motionexercises, which resulted in a good outcome of painless,full range of motion.

In 1995, Heinz et al1 reported on the case of a competitivecyclist who sustained the injury during a race. This patientwas treated conservatively with a figure-of-8 clavicle bracefor 5 weeks. Although the authors report that the patientreturned to cycling without problems with equal strength andmotion compared with the unaffected side, follow-upradiographs showed a wide AC separation with superiordisplacement of the healed clavicle that was greater than thewidth of the clavicle. It is unclear what significance this will

e4 P.C. Yeh et al.

have on future function for the cyclist. It should bementioned, however, that there is increasing evidence thatsequelae from nonoperative treatment of clavicle fracturesare more common than once thought6 and that shorteningfrom a clavicle fracture yields decreased abduction endur-ance strength and overall patient satisfaction.4

It is important to complete a full clinical and radiologicworkup after an axial trauma to the shoulder. As shown inFigure 1, an anteroposterior radiograph, which is commonlyobtained in the emergency department, can underestimate thedisplacement of the distal clavicle. An axillary radiograph iscritical in determining the nature of the AC separation if onesees AC joint widening on the anteroposterior radiograph.The history of previous AC separation could erroneously leadthe surgeon to believe that the patient has osteolysis and toignore the posterior displacement. An axillary radiographwas important in our case because it showed the posteriordisplacement of the distal end of the clavicle (Figure 8).

It should be recognized that this injury is not only a bonyinjury but also a soft-tissue one. As such, examination of boththe AC and CC ligaments is important to the success of therepair. This is not only achieved with direct visualization ofthe ligaments; it is also important to stress the clavicle afterreduction and fixation of the fracture. In this case, whenstressed, the clavicle tended to subluxate posteriorly andsuperiorly at the AC joint. Therefore, to achieve stability of theclavicle to the acromion and coracoid, repair of the AC and CCligaments was undertaken with a semitendinosus allograft.

It was only after both bony and soft-tissue repair wasperformed that successful management of the fracture-dislocation was achieved. There are many techniques torepair these ligaments, not limited to the technique usedhere. Choosing the right technique for a specific patientpopulation is important to the successful management ofthe injury.3

To our knowledge, this is the only report that addressesORIF of a clavicle fracture with ipsilateral AC and CCligament reconstruction.

References

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III acromioclavicular separation. J Shoulder Elbow Surg 1995;4:141-2.

2. Lancourt JE. Acromioclavicular dislocation with adjacent clavicular

fracture in a horseback rider. Am J Sports Med 1990;3:321-2.

3. Mazzocca AD, Arciero RA, Bicos J. Evaluation and treatment of

acromioclavicular joint injuries. Am J Sports Med 2007;35:316-29.

4. McKee MD, Pedersen EM, Jones C, Stephen DJG, Kreder HJ,

Schemitsch EH, et al. Deficits following nonoperative treatment of dis-

placed midshaft clavicular fractures. J Bone Joint Surg Am 2006;88:35-40.

5. Neer CS II. Fractures of the distal third of the clavicle. Clin Orthop

Relat Res 1968;58:43-50.

6. Nowak J, Holgersson M, Larsson S. Sequelae from clavicular fractures

are common. Acta Orthop 2005;76:496-502.

7. Wurtz LD, Lyons FA, Rockwood CA. Fracture of the middle third of

the clavicle and dislocation of the acromioclavicular joint. A report of

four cases. J Bone Joint Surg Am 1992;74:133-7.