The treatment of lateral clavicle fractures

Mark C.B. Webber*, John F. Haines

Department of Orthopaedics, Tra�ord General Hospital, Moorside Road, Davyhulme, Manchester M41 5SL, UK

Accepted 18 October 1999

Abstract

This study assesses the results of surgical treatment of 15 displaced Neer type II fractures of the lateral clavicle in 15 patients,which occurred between November 1988 and March 1995 and which were followed up for a mean period of 4.6 years (range 2±9 years). The patients fell into two groups, one `acute group' and one `non-union' group.

Patients treated initially by a non-operative approach had su�ered prolonged morbidity and time o� work prior to and aftersurgery. The ultimate result was good. The ®xation used was a Dacron arterial graft as a sling around the clavicle and coracoidprocess. Delayed (non-union) cases were augmented with bone graft and inter-fragmentary screw ®xation. All fractures

eventually united.We question the place of prolonged non-operative management in the treatment of displaced Neer type II fractures of the

lateral clavicle. # 2000 Elsevier Science Ltd. All rights reserved.

1. Introduction

Fractures of the lateral end of the clavicle werecharacterised by Neer into three types [1]. Type I frac-tures are undisplaced fractures without disruption ofthe coraco-clavicular (conoid and trapezoid) ligaments.Type II fractures occur at the level of the coraco-clavi-cular ligaments, which are detached from the medialfragment. Type III fractures occur distal to the liga-ments and enter the acromio-clavicular joint. Type IIfractures represent a potential problem with respect tobony union, and are the subject of this study.

Although, these fractures account for 3% of frac-tures of the clavicle, they can cause considerable mor-bidity. There is a high (22±31%) rate of non-union,and these fractures account for half of all clavicularnon-unions when treated non-operatively [6,8]. Jupiter,in 1987, indicated that non-union could cause painand loss of function [7]. Nevertheless, it is still com-mon practice to treat these fractures non-operatively.

Several methods of surgical treatment of these frac-

tures have been described, such as K-wire stabilisation

[2,3], excision of the lateral end of the clavicle and

screw stabilisation from the clavicle to the coracoid

process, as described for stabilisation of the acromio-

clavicular joint [9]. These methods have complications

of migration [4], and breakage or infection of the K-

wires, as well as loosening or breakage of the screw.

Prevention of such complications can only be achieved

by prolonged immobilisation of the a�ected shoulder.

Plating of such fractures may not be possible because

the distal fragment is small and often comminuted.

From November 1988 all new displaced Neer type

II fractures of the lateral end of the clavicle were trea-

ted operatively using a Dacron arterial graft as a sling.

Some patients treated at other hospitals by non-oper-

ative management were later referred for operative

treatment and were treated in a similar manner but

with the addition of an inter-fragmentary lag screw

and iliac crest bone graft.

Fifteen fractures were treated in 15 patients and fol-

lowed up for a mean period of 4.6 years (range 2±9

years), between November 1988 and March 1995. This

Injury, Int. J. Care Injured 31 (2000) 175±179

0020-1383/00/$ - see front matter # 2000 Elsevier Science Ltd. All rights reserved.

PII: S0020-1383(99 )00276 -4

www.elsevier.com/locate/injury

* Corresponding author. 14 Beccles Road, Brooklands, Sale, Che-

shire M33 3RP, UK. Tel.: +44-161-282-2862; fax: +44-161-285-

8568.

Fig. 1. (a) X-ray showing displaced Neer type II fracture. (b) Same fracture, 6 weeks post-sling ®xation.

M.C.B. Webber, J.F. Haines / Injury, Int. J. Care Injured 31 (2000) 175±179176

paper reviews the results with particular attention tooutcome scores and radiographic appearance.

2. Method

Some lateral clavicle fractures may not appear dis-placed on the original X-ray. It is important to take astress X-ray with the patient standing and holding a10-lb (4.5-kg) weight in the a�ected hand. Such a ®lmwill demonstrate the loss of ligamentous attachment ofthe medial clavicular fragment.

2.1. Dacron graft sling ®xation (operative procedure foracute injuries)

A vertical skin incision is made commencing 1 cmmedial to the fracture, overlying the superior aspect ofthe clavicle and running 4 cm distally to end overlyingthe coracoid process.

The wound is deepened through the super®cial softtissue and the fracture ends exposed. Periosteum is el-evated from the fracture edges and reduction obtained.This is usually straightforward once the proximal frac-ture end is freed from the super®cial trapezius layerthrough which it sometimes button-holes.

Deltoid is split to expose the coracoid process and apair of curved forceps is used to pass a suture aroundit, keeping close to the bone at all times. A path is cre-ated around the posterior aspect of the medial claviclefragment, with the same suture. A woven Dacron

aortic graft, split longitudinally in half, is thenattached to the suture at one end and pulled through.

The fracture is again reduced and the graft tiedantero-inferior to the clavicle whilst reduction is main-tained. Care is taken to ensure a close ®t of the slingto hold the medial fracture fragment. The knot can befurther secured with a suture through the Dacron ma-terial if desired. Post-operatively, the arm is supportedin a broad arm sling for 2 weeks, allowing pendulummovements, proceeding to mobilisation below the levelof the shoulder for a further 4 weeks (Fig 1(a) and(b)).

2.2. AO screw and bone graft ®xation (operativeprocedure for non-unions)

These fractures were all referred to as establishednon-unions. In these instances, the sling method alonewas considered to be of insu�cient rigidity to maintainthe fracture position whilst the bone graft was incor-porated. These fractures were therefore treated by AOsmall fragment inter-fragmentary lag screw ®xationacross the fracture site and iliac crest bone graft, aswell as a Dacron graft sling (Fig. 2). The post-operat-ive regime was the same as in group A.

Patients and notes were assessed at a series ofspecial outpatient clinics in May and June of 1997.The Constant score was calculated [11]. Evaluation of,bony union and evidence of clavicular erosion werealso undertaken using X-rays.

Fig. 2. Post-operative X-ray with bone graft, lag screw and sling ®xation of a non-union.

M.C.B. Webber, J.F. Haines / Injury, Int. J. Care Injured 31 (2000) 175±179 177

3. Results

There were 15 patients with a mean age of 29.8years (range 17±46 years) at injury and a sex distri-bution of 11 (73%) male and 4 (27%) female. Theacute group consisted of 11 patients (eight males andthree females), whereas the non-union group consistedof four patients (three males and one female). Thedominant limb was injured in six (40%) patients andnine (60%) injured the non-dominant side. There wereeight left and seven right shoulders involved. The frac-tures occurred as isolated injuries in 12 (80%) of thepatients, and three were associated with another singleinjury. Of the three, two were in the acute group; onehead injury and one fractured rib. The other, in thenon-union group, sustained a shoulder dislocation onthe ipsilateral side. In the acute group, the mean timeto surgery was 10 days (range 2±28 days), whereas inthe non-union group, the mean time to surgery was147 days (range 101±252 days). The most commoncause of injury was a fall onto the point of theshoulder �n � 11, 73%), mainly from sport or RTAs.

3.1. Time to union

All fractures eventually united. Diagnosis of fractureunion was made on clinical grounds, with the patientsbeing able to withstand fracture site compression com-fortably [5]. The mean time to union, post-operatively,in the acute group was 43.5 days (range 21±56 days)and that in the non-union group was 123.3 days(range 42±283 days).

One of the cases in the non-union group united atonly 42 days, having shown signs of good callus for-mation after bone graft incorporation and havingpassed all clinical parameters.

In each of the non-union cases, it was noted that thelateral fracture fragments had united into a single frag-ment, as opposed to the marked comminution presentin the acute presenters. This facilitated the use of theinter-fragmentary lag screw.

3.2. Mobility

All patients achieved a full range of movement ofthe a�ected shoulder. In the acute group, the meantime to full mobility from operation was 47.1 days(range 35±70 days), whereas in the non-union groupthe mean time to full mobility was 65 days (range 42±84 days).

3.3. X-rays

All fractures united radiologically. In the acutegroup of patients, with the Dacron sling ®xationalone, three out of the 11 patients showed slight but

visible bony erosion of the clavicle at the area of con-tact with the Dacron sling (Fig. 3). All three of thesepatients remained clinically asymptomatic and X-rayappearance remained unchanged 1 year after the ®rstappearance.

3.4. Constant score

Constant scoring was performed on all patients atthe most recent review. Out of a maximum of 100, themean score in the acute group was 98.9 (range 90±100)and in the non-union group it was 96 (range 88±100).Both groups were very similar after union was com-plete.

3.5. Return to work

The patients' occupations were broken down intosubclasses related to vigour and labelled as light ormoderate/heavy in nature.

3.6. Deformity

None of the patients in either group had a clinicaldeformity or was concerned over the appearance ofthe shoulder.

4. Complications

The one patient in the non-union group, who under-went plating, required the removal of the plate due tosuper®cial irritation. Two patients in the acute grouprequired removal of the Dacron graft, one due to low-grade infection and one due to a sinus, which provedto be sterile. Both settled after removal of the graft.

5. Discussion

The high incidence of non-union in these fractures islikely to be related to the button-holing of the medialfragment through the trapezius, coupled with theweight of the dependent limb, which acts to maintaindisplacement at the fracture site. Periosteal strippingdid not appear to be a signi®cant problem intra-opera-tively and, hence, is also unlikely to be a major causefor non-union.

In acute injuries (up to 1 month old) Dacron slingstabilisation was found to be a simple and e�ectivetechnique in which bone grafting is not required.

The Dacron sling method is not a rigid type of ®x-ation and allows some overlapping of the fracturefragments, maintaining adequate fracture reduction,but without allowing any clinically signi®cant shorten-ing of the clavicle. When the Dacron aortic graft is

M.C.B. Webber, J.F. Haines / Injury, Int. J. Care Injured 31 (2000) 175±179178

split longitudinally in half, it is found to give su�cientstrength without excessive bulk.

Following union it is felt that the sling allows thereturn of function of the coraco-clavicular ligaments,leading to bio-mechanically normal function of theshoulder. At this point the Dacron sling becomesredundant.

A recently published variation of this technique [10]has suggested that a Dacron sling be passed through adrill hole in the clavicle. We feel that this does not addany security and potentially weakens the clavicle.

If the presentation is late, the combination of inter-fragmentary ®xation, Dacron sling stabilisation, andbone grafting will generally produce union and excel-lent shoulder function. At this stage the distal claviclefragment has united to o�er good lag-screw purchase.In a few non-union cases, however, plating may berequired.

When the Dacron sling is used, slight erosion of theclavicle may appear within the ®rst year after ®xationbut this does not appear to be progressive. The likelycause for these erosions is friction between the clavicleand the Dacron sling prior to full union.

Nordqvist et al. [6] reported that in the long term(15±20 years) very few non-unions remained sympto-matic, but many fractures had still not united.

However, we have found that late presenters, andthose patients treated non-operatively for protractedperiods, were inadvertently subjected to considerablediscomfort and time o� work (especially in the case ofheavy manual workers).

It is the authors' belief that ®xation of Neer type IIfractures with a Dacron sling allows rapid rehabilita-tion and should be considered for all acute fractures.

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Fig. 3. Clavicular erosion 3 years post-sling ®xation.

M.C.B. Webber, J.F. Haines / Injury, Int. J. Care Injured 31 (2000) 175±179 179