Injury Extra 44 (2013) 9–12

Case report

Surgical management of a midshaft clavicle fracture with ipsilateralacromioclavicular dislocation: A report on 2 cases and review of the literature

Coen A. Wijdicks a, Jack Anavian b, Thuan V. Ly c, Stanislav I. Spiridonov c, Matthew R. Craig d,Peter A. Cole c,*a Department of Biomechanical Engineering, Steadman Philippon Research Institute, Vail, CO, United Statesb Department of Orthopaedic Surgery, Brown University, Providence, RI, United Statesc Department of Orthopaedic Surgery, University of Minnesota, Regions Hospital, Saint Paul, MN, United Statesd Department of Orthopaedic Surgery; OrthopaediCare, Willow Grove, PA, United States

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Injury Extra

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A R T I C L E I N F O

Article history:

Accepted 4 September 2012

1. Introduction

The clavicle articulates with the acromion at the acromiocla-vicular (AC) joint and is tethered to the scapula’s coracoid processby the coracoclavicular ligaments. Injuries to the clavicle are verycommon as they constitute 4% of all fractures in adults andcomprise up to 44% of all shoulder girdle trauma [1–3]. Fractures ofthe clavicle have been reported to be 12 times more common thandislocations of the AC joint [4,5]. The location of the AC joint on thesuperolateral aspect of the shoulder and the bony anatomy of theshoulder girdle make it susceptible to dislocation injury. Nearlyone-fifth of shoulder girdle injuries involve the AC joint. Evenpartial disruption of the AC joint may lead to subluxation [6,7].While both clavicle and AC joint injuries are common, it is a rareevent for both to occur concomitantly in the same shoulder [2,5,8–10].

Review of the literature produced one case series whichdescribed four fractures to the middle third of the clavicle(classified as an Allman Group) [11] associated with threeRockwood Type IV and one Type II AC disruptions [8]. A separatecase report described a Group I clavicle fracture associated with aType VI AC joint separation in an ice hockey player [9]. Anothercase report described a midshaft clavicle fracture associated with aType III AC joint disruption in a cyclist [12]. In all cases, however,there was no report of operative technique since all patients weremanaged nonoperatively.

The purpose of this report is to describe two cases of this uniqueinjury and the operative strategy utilized by the surgeon. In both

* Corresponding author at: Division of Orthopaedic Trauma, Department of

Orthopaedic Surgery, University of Minnesota, Regions Hospital, 640 Jackson Street,

Saint Paul, MN 55101, United States. Tel.: +1 651 254 2815; fax: +1 651 254 1519.

E-mail address: peter.a.cole@healthpartners.com (P.A. Cole).

1572-3461 � 2012 Elsevier Ltd.

http://dx.doi.org/10.1016/j.injury.2012.09.007

Open access under the Elsevier OA license.

cases, a dual plating technique with independent fixation was usedto achieve fracture reduction and joint relocation.

1.1. Case 1

A 44-year-old right hand dominant male, who was involved in amotocross bike accident presented to a regional emergencydepartment after unsuccessfully landing a jump. Chest radiographswere obtained upon presentation and revealed a completelydisplaced right-sided midshaft clavicle fracture, AC joint disloca-tion, multiple rib fractures, and a pneumothorax. A chest tube wasplaced prior to arrival to our Level I trauma facility. The patient’sright upper extremity exam detailed a normal C5-T1 motor andsensory exam. Clavicle radiographs, including anteroposterior (AP)view centred on injured clavicle with 158 cephalad tilt, and a bi-lateral, panoramic view, centred on the manubrium with 158cephalad tilt (Panoramic), and a computed tomography (CT) scanrevealed a right displaced, mid diaphyseal, oblique (Allman, GroupI) clavicle fracture (OTA Type 15-B1.2) [13] with approximately 208of apex anterior angular deformity (Fig. 1). The AC joint wasdiagnosed as a Rockwood Grade III dislocation. The indication forsurgery included complete fracture displacement in the context ofa multiply fractured forequarter and ipsilateral, unstable AC joint,which was felt by the treating surgeon (initials blinded for review) toportend a poor prognosis if treated nonoperatively. On day 2 post-injury, the ipsilateral AC joint dislocation and clavicle fractureunderwent open reduction and internal fixation.

While in the beach chair position, a straight incision was madefrom the medial side of the clavicle extending laterally over the ACjoint. Two supraclavicular nerves were dissected and protected(Fig. 2A). The dissection was further taken through the platysmamuscle down onto the clavicle shaft, and the midshaft fracture wasreduced with reduction forceps. The dissection was taken laterallyand superiorly over the AC joint. Complete disruption of the jointcapsule and coracoclavicular ligaments was appreciated. The ACjoint was debrided of devitalized tissue. At this juncture, a 2.7 mmand a 2.0 mm lag screw were placed to achieve anatomic reductionof the clavicle diaphysis, leaving the AC joint fully dislocated. Next,a precontoured, titanium, 8-hole superior clavicle plate (AcumedLLC, Hillsboro, OR) was applied on the cephalad surface. This

Fig. 1. Preoperative anteroposterior view of bilateral clavicles. Note the fractured

clavicle and displaced acromioclavicular joint (Case 1).

Fig. 3. Postoperative anteroposterior view of the right clavicle (Case 1).

C.A. Wijdicks et al. / Injury Extra 44 (2013) 9–1210

titanium plate was applied and fixed with minimal contouringwhile leaving enough area for the anticipated placement of asecond plate distally (Fig. 2B). Next, a 3.5 mm clavicle hook plate(Synthes/AO, Paoli, PA) was placed so that its distal extension(hook) was placed underneath the acromion in order to lever downthe clavicle, effectively reducing the AC joint. The stem of the hookplate was then fixed to the shaft of the clavicle. Suture repair of theAC joint capsule and the coracoclavicular ligaments wasperformed. Due to the concern for the stress riser between theadjacent plates on the cephalad clavicular surface, a 10-hole,2.7 mm locking reconstruction plate (Synthes/AO, Paoli, PA) wasplaced with 4, 2.7 mm screws to span this zone (Fig. 2C).Postoperative AP radiographs were obtained to confirm adequatereduction and fixation (Fig. 3). Postoperatively, the patient wasmanaged in a sling and swath to support the weight of the upperextremity for two weeks; however, the patient was instructed onpassive range of motion exercises starting with Codman’sactivities.

At three months follow-up the patient was progressing well buthad limitation of motion with regard to forward flexion of hisshoulder. He had resumed normal daily and other physicalactivities, and was back to motocross, lifting heavy weights, and

Fig. 2. (A) Intraoperative view of the medial clavicular diaphyseal fracture. Note the

protected supraclavicular nerves, and the torn acromioclavicular joint and

coracoclavicular ligaments. The pointed bone reduction clamp is approximating

the displaced previously displaced clavicle shaft. (B) The clavicle is reduced. (C) This

is a view demonstrating the fixation montage (Case1).

using a chain saw. He denied pain. The hook plate was removed 4months postoperatively and the patient noted an improvement inmotion specifically in forward flexion. The hook plate removal wasperformed to prevent the well described entity of acromialosteolysis [14]. No other hardware was removed at that time.

At 13 months follow-up, the patient returned and was given anUpper Limb Disabilities of the Arm, Shoulder and Hand (DASH) [15]follow-up questionnaire, and AP clavicle radiographs were taken(Fig. 4). Radiographs revealed the reduction of the AC joint to besatisfactory though showing a mild degree of subluxation. Physicalexamination revealed a well healed scar, no tenderness, and noskin tenting. Range of motion demonstrated symmetry withrespect to the unaffected shoulder in regards to forward flexionand abduction and the patient had returned to work with nolimitation in function. His DASH score was 3.33 (on a one hundredpoint scale for which lower values are better), which was lowerthan the reported normative U.S. general population value of 10.10[16]. The work module demonstrated a score of 6.25, which wasalso below the U.S. normative value of 8.81 [16].

1.2. Case 2

A 36-year-old male who sustained a severe constellation ofinjuries from an ATV rollover, presented to our department. Thepatient had a right-sided acetabular fracture and scapulothoracicdissociation also on the right side which eventuated in a rightforequarter amputation. These operations had already taken placeprior to attention to his left shoulder injury. Shoulder and clavicleradiographs, including anteroposterior (AP) view centred oninjured clavicle with 158 cephalad tilt, and a bi-lateral, panoramicview, centred on the manubrium with 158 cephalad tilt (Panoram-ic), revealed a left displaced, mid diaphyseal, oblique (Allman,Group I) clavicle fracture (OTA Type 15-B1.2) [13]. The distalclavicle had been displaced through the trapezius posteriorly,representing a Rockwood Type IV dislocation. A 3D-computed

Fig. 4. Anteroposterior view of the right clavicle 13-months post-operative. The

acromioclavicular joint shows mild subluxation in the asymptomatic patient

(Case 1).

Fig. 5. Preoperative 3D-CT of shoulder (Case 2).

C.A. Wijdicks et al. / Injury Extra 44 (2013) 9–12 11

tomography (CT) scan from his initial spiral CT trauma scan wasreformatted to elucidate the injury further (Fig. 5). The indicationfor surgery included complete fracture displacement and ipsilat-eral, unstable AC joint. At one month post-injury, the ipsilateral ACjoint dislocation and clavicle fracture underwent open reductionand internal fixation. In the operating room, a straight incision wasmade extending from 2 cm lateral to the left side of midline of thesternum and extending anteriorly over the clavicle and thensuperiorly over the AC joint. After reduction, an anterior lateralplate (Synthes/AO, Paoli, PA) was applied for fixation. The hookplate (Synthes/AO, Paoli, PA) was placed as in Case 1. Postopera-tively the patient was placed in a sling for comfort and was allowedpassive range of motion of the entire left upper extremity for amonth, followed by active range of motion for the second month.

By three months follow-up the patient was progressing well(Fig. 6). He claimed to have a painless shoulder and on physicalexamination the patient demonstrated 908 of forward flexion, 808of abduction and was nontender over his incision. At six monthsfollow-up, after Hook Plate removal, the patient’s range of motionreturned to near normal. Radiographs revealed the reduction of theAC joint to be excellent (Fig. 7). His 30-item DASH outcomemeasure score was 30. This patient lived out of state and did notreturn for further follow up.

2. Discussion

There have been few published cases that report a concomitantclavicle with either AC or CC ligament disruption, and none

Fig. 6. Anteroposterior view of left clavicle 3-months post-operative (Case 2).

evaluated surgical results with fixation of both injuries[2,3,5,8,12,17]. Though a different scenario than what we werepresented, surgical treatment of a distal clavicle fracture withdisruption of the ipsilateral coracoclavicular ligament withconcomitant AC disruption has been described in various reports[2,3,17]. Surgical management of these injuries was performedwith different techniques, ranging from suture anchors, intrame-dullary Kirshner-wires, Mersilene tape, and cannulated screwfixation. With regard to midshaft clavicle fractures associated withcomplete AC disruptions, we were only able to identify threeprevious reports. Wurtz et al. reported four cases of combinedmiddle third clavicle fractures with dislocation of the AC joint [8].There were three Type IV and one Type II AC joint dislocations. TheAC joint injuries dictated the decision to operate, whereas theentire clavicle in this series was treated expectantly withoutinternal fixation. The three Type IV AC joint dislocations weretreated with AC transfixation pins (2) or with a coracoclavicularbone screw (1). The fourth case had a Type II AC joint injury andwas treated conservatively along with the clavicle fracture.Another report described a single case of a combined middlethird clavicle fracture with a Type VI AC joint separation in ahockey player [9]. Both of these injuries were treated nonopera-tively. Lastly, a case report described a conservatively managedmidshaft clavicle fracture with a Type III AC joint disruption in acyclist, which was the only report that we found with a similarclavicle and AC classification to our Case 1, but again, these authorsdid not report an open reduction and internal fixation [12]. Due tothe nonoperative care of this cyclist, the patient continued to have

Fig. 7. Anteroposterior view of left clavicle 6-months post-operative showing a well

reduced acromioclavicular joint (Case 2).

C.A. Wijdicks et al. / Injury Extra 44 (2013) 9–1212

deformity of the middle distal clavicle and continued AC separationafter 2-years, although reported no subjective problems orlimitations in his activity.

Historically, Type I, II, and III AC joint injuries have beensuccessfully treated conservatively [18–22]. Surgical managementfor the Type IV, V, and VI has been advocated [22–24]. Whiletreatment of AC joint injuries followed more of an algorithm, thetreatment options for displaced fractures of the clavicle includevarious methods of open reduction with internal fixation as well asnonoperative treatment and no definite agreement on the optimalmanagement strategy [25]. Conservative treatment of displacedclavicle fractures will necessarily eventuate in malunion, thoughthis outcome is generally well tolerated and associated withreasonably good function. However, there have been studies thatsuggest that there are subpopulations of patients with functionaldeficits following nonoperative treatment [26–30]. Moreover,there is evidence that suggests that there is an increased risk ofnonunion following displaced clavicle fractures with no contact ofthe bone ends, especially in distal fractures and those which occurin elderly patients [25,31]. Malunion and nonunion can impair thefunction of the clavicle, in terms of its linkage of the axial to theappendicular skeleton and the consequent affect on stability andmotion of the upper extremity, as well as possibly the protectiverole to the underlying subclavian vessels and brachial plexus [32].

3. Conclusion

A surgically managed diaphyseal fracture of the clavicle, inconjunction with an ipsilateral dislocated AC joint, has not beenpreviously reported. We provide an account of two such injuries,their respective treatment, and documented good clinical out-comes for the patient that had sufficient follow up.

Conflict of interest statement

P.A.C. has received honoraria from AOF, AONA. P.A.C. is aconsultant for Synthes, Inc. Authors and their immediate family,have no commercial associations (e.g. consultancies, stockownership, equity interest, patent/licensing arrangements, etc.)that might pose a conflict of interest in connection with thesubmitted article.

Role of the funding source

A research grant was received from Synthes, Inc. though thesponsors had no involvement in the study design; collection,analysis and interpretation of data; the writing of the manuscript;nor the decision to submit the manuscript for publication.

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