Treatment of distal clavicle fractures usingan arthroscopic technique

Sergio Luiz Checchia, PhD, Pedro S. Doneux, MD, Alberto N. Miyazaki, PhD, Marcelo Fregoneze, MD,and Luciana A. Silva, MD, Sao Paulo, Brazil

Whenever indicated, distal clavicle fractures can betreated with a double loop of a nonabsorbable, #5 suturearound the clavicle and under the coracoid. Wedeveloped an all arthroscopic technique to perform thisprocedure. From January to September 2004, 7 patientswere treated. The mean age was 46 years. The coracoidis identified through the rotator interval. Using a specialneedle, a double #5 suture is passed around thecoracoid. A hole is created at the clavicle and, throughanother guide wire, is sent to the anterior portal. Thedouble #5 suture is transported to the clavicle. After thereduction of the fracture the sutures are tightened. All 7cases have healed. The surgical treatment of thesefractures is well established, and with the aid ofarthroscopy, the morbidity can be decreased. Thetechnique has been shown to be safe with nocomplications. (J Shoulder Elbow Surg 2008;17:395-398.)

Fractures of the clavicle comprise about 4% of all frac-tures of the human body. Because of the S shape of theclavicle, the great majority of fractures of this bone(80%) are in the middle third. Distal clavicle fractures(DCF) account for approximately 15% of the remain-ing fractures of the clavicle.15

The muscles of the shoulder girdle contribute to thedynamic stability of the upper limb;12,13,16 however,stability of the lateral cavicle is provided mostlyby the acromioclavicular and coracoclavicular liga-ments.1,3,6,7,18 These ligaments have statisticallybeen proven to enhance stability, especially the supe-rior acromioclavicular ligament, which is responsiblefor the vertical stability (suspensory mechanism) ofthe shoulder girdle.

From the Shoulder and Elbow Group, Department of Orthopedics,Santa Casa Hospitals and School of Medicine of Sao Paulo.

Reprint requests: R. Cesario Motta, Jr, 112 Sao Paulo-SP-Brazil,01221-900.

Copyright ª 2008 by Journal of Shoulder and Elbow SurgeryBoard of Trustees.

1058-2746/2008/$34.00doi:10.1016/j.jse.2007.08.011

Neer proposed a classification of distal claviclefractures (DCF) fractures with 3 distinct types, basedon the presence or absence of integrity of the coraco-clavicular ligaments and on the degree of involvementof the acromioclavicular joint.12,13 Later, Craig added2 additional sub-types to the original classification.4

DCF have a high rate of nonunion, accounting forup to 50% of all cases of nonunion in clavicle frac-tures. This complication is considered to result fromthe number of forces that act on the shoulder girdlepreventing adequate contact between the frag-ments.16 Surgical treatment is the treatment of choicefor fractures types II and V.

Thebasic principal of the surgery is to reconstruct thesuspensory mechanism in order to avoid anterior-infe-rior displacement of the lateral fragment of the clavi-cle.14,17 This can be achieved directly by fixation ofthe bone fragments11,12,14 or indirectly by fixatingtheclavicle to thecoracoidprocess,either witha screw2

or by coracoclavicular cerclage13 These techniques al-low approximationof the fractured fragments andboneconsolidation.Once consolidationhas takenplace, thesuperior acromioclavicular ligament will guarantee thesuspensory mechanism of the shoulder.2,3,13 Neer12

reported that a double coracoclavicular cerclagewould suffice for stabilization in most cases, reportinggood results with this technique (Figure 1).

Based on these principles, and on the arthroscopicanatomy of the coracoid process, we developed anarthroscopic cerclage device to pass sutures aroundthe coracoid, enabling an arthroscopic approach toDCF. This new technique combines all the advantagesof an arthroscopic approach to the fact that the deltoidmuscle and fractured site need not be manipulatedduring the procedure.

The objective of the current study is to describe thetechnique and to evaluate the results of treatment ofDCF with a double arthroscopic cerclage of theclavicle and the coracoid process. This technique is sim-ple, causes minimal damage to the soft tissues, and al-lows indirect reduction and stabilization of the fracture.

MATERIALS AND METHODS

From January to September 2004, 7 patients (7 shoul-ders) with DCF were treated with arthroscopic surgery. The

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396 Checchia et al J Shoulder Elbow SurgMay/June 2008

patients’ ages ranged from 29 to 67 years (mean, 42 years);4 were males and 3 were females. The dominant limb wasaffected in 4 patients. Fractures were classified, based onCraig’s criteria, as 3 type II’s and 4 type V’s.4

Figure 1 Double coraco-clavicular cerclage.

Figure 2 ‘‘coracoid-hook’’, flat 90� and helical 110�.

Figure 3 The ‘‘coracoid-hook’’ around the coracoid and the suture-grasper from the anterior border of the clavicle.

Surgical technique

The anatomic parameters (acromioclavicular joint andthe site of the fracture) are carefully drawn and markedwith needles before beginning the procedure. Traditional

Figure 4 Two #5 FiberWire� around the coracoid.

Figure 5 The suture passer through the clavicle and the nitinol wirebeen sent to the anterior portal.

J Shoulder Elbow Surg Checchia et al 397Volume 17, Number 3

Figure 6 The reduction of the DCF.

Figure 7 The double coraco-clavicular cerclage accomplished.

Table I Presentation of the 7 patients with distal clavicle fractures treated arthroscopically from January to September 2004

Patient No. Age Gender Type Post-op ROM Follow-up Complications UCLA

1 53 M V 150,60,T12 24 352 45 F V 150,10,T4 19 Frozen shoulder 283 67 F V 120,60,T7 14 Bleeding 344 40 F II 160,70,T12 15 315 29 M II 160,30,T6 12 326 44 M V 150,45,T7 12 337 46 M II 160,60,T8 15 35

Age expressed in years.Follow-up expressed in months.Post-op ROM, post-operative range of motion; UCLA, University of California at Los Angeles scoring system.

joint arthroscopy through a posterior portal is then carriedout, followed by the placement of an anterior portal (slightlymore lateral than the traditional one). The rotator interval isapproached and opened using a full radius blade, and thecoracoid process is identified. A coracoid hook is then intro-duced through the anterior portal and passed around thecoracoid. This instrument has been specially designed forthis purpose and has 2 distinct angulations: 90� (flat) or110� (helical) (Figure 2). The latter format of the hook ismost widely used. A transport wire is then passed throughthe coracoid hook. At this point, arthroscopy is suspended,and a 1 cm incision is made at the anterior-superior aspectof the medial fragment of the clavicle, approximately 1.5cm from the fracture site. A suture-grasping device is intro-duced through the anterior deltoid at its attachment and,returning to arthroscopic visualization, the transport wire is

retrieved and directed to the superior incision (Figure 3).Two #5.0 FiberWire� sutures (Arthrex Inc., Naples, FL,USA) are guided through the transport wire and aroundthe coracoid process to the anterior portal (Figure 4). Thenext step involves creating a hole in the clavicle, using an an-gled guide anchored to the posterior aspect of the clavicleand introduced through the same superior incision. Anotherspecially designed guide is then introduced through the cla-vicular hole and directed toward the coracoid; through thisguide, a transport wire is introduced arthroscopically andled to the anterior portal (Figure 5). This second transportwire will carry the two # 5.0 FiberWire sutures to the upperpart of the clavicle and through the hole in the clavicle. Thearthroscopic part of the procedure ends at this point. The re-duction of the fracture is carried out using an open reductiontechnique, where the surgeon exerts an upward force with

398 Checchia et al J Shoulder Elbow SurgMay/June 2008

the humerus while the assistant holds down the medial frac-ture fragment (Figure 6). Only one of the two #5.0 FiberWire sutures is tied down at first, and reduction is verifiedby fluoroscopy before tying down the second cerclage (Fig-ure 7).

Final results were evaluated using the UCLA5 and AAOSscores9 for function and ROM assessment, respectively.

RESULTS

The mean postoperative follow-up period was 15months (range, 12-24 months). Results were satisfac-tory in all 7 cases, where 4 were considered excellentand 3 good (Table I). All fractures healed after a meanperiod of 7 weeks. Only 1 patient (case 3) had a lon-ger consolidation time of 12 weeks.

Two patients had complications, where 1 devel-oped a frozen shoulder (case 2) and another, withan underlying leukemia, bled through the portalsand developed a superficial infection (case 3).

DISCUSSION

The elevating mechanism of the shoulder is essentialfor the proper functioning of the joint;3,8,10,14 there-fore, the objective of treating DCF is to re-establishthe integrity of this mechanism by reduction and fixa-tion. This may be achieved indirectly using a doublecoracoclavicular cerclage that allows approximationof the fractured clavicular fragments and provides thenecessary stability for healing.13 This technique doesnot require the use of hardware, thus providing theadditional advantage of avoiding re-operations forremoval of hardware.

In the current series, all patients achieved satisfac-tory results and healing of the fracture. Similar resultshave already been reported using an open tech-nique.2,3,8 Complications were reported in 2 of the7 cases. Case 2 was a female patient, who did notcomply with the exercises to maintain external rota-tion. Because this may have resulted from openingthe rotator interval, it is important to recommend exer-cises that aid in preserving external rotation. The othercomplication resulted from excessive bleeding andsecondary superficial infection in a patient with anunderlying leukemia that subsided after a few weeks(case 3).

If one can replicate a successful open procedurearthroscopically, the final results may be superior con-sidering that anatomy may be better preserved,thereby reducing complications.

REFERENCES

1. Allman FL Jr. Fractures and ligamentous injuries of the clavicle andits articulation. J Bone Joint Surg Am 1967;49:774-83.

2. Ballmer FT, Gerber C. Coracoclavicular screw fixation for unstablefractures of the clavicle: a report of five cases. J Bone Joint Surg Br1991;73:291-4.

3. Checchia SL, Doneux PS. Complicacoes apos a resseccao daextremidade distal da clavıcula. Rev Bras Ortop 1995;30:593-8.

4. Craig EV. Fractures of the clavicle. In: Rockwood CA, Matsen FA,editors. The Shoulder. Philadelphia: W.B. Saunders; 1990.p. 367-412.

5. Ellman H, Kay SP. Arthroscopic subacromial decompression forchronic impingement: two to five years result. J Bone Joint SurgBr 1991;73:395-8.

6. Flatow EL, Duralde XA, Nicholson GP, Pollock RG, Bigliani LU.Arthroscopic resection of the distal clavicle with a superiorapproach. J Shoulder Elbow Surg 1995;4:41-50.

7. Fukuda K, Craig EV, An KN, Cofield RH, Chao EY. Biomechanicalstudy of the ligamentous system of the acromioclavicularjoint. J Bone Joint Surg Am 1986;68:434-40.

8. Hawkins RJ, Bethune S, Noble JS. Type II clavicular fractures withcoracoclavicular disruption. J Shoulder Elbow Surg 1996;5(Suppl):S6.

9. Hawkins RJ, Bokor DJ. Clinical evaluation of shoulder problems. In:Rockwood CA Jr, Matsen FA III, editors. The Shoulder. Philadel-phia: WB Saunders; 1990. p. 149-77.

10. Heppenstall RB. Fractures and dislocations of the distal clavicle.Orthop Clin North Am 1975;6:477-85.

11. Neer CS. Fractures of the distal clavicle with detachment of thecoracoclavicular ligaments in adults. J Trauma 1963;3:99-110.

12. Neer CS. Fractures of the distal clavicle. Clin Orthop 1968;58:43-50.

13. Neer CS. Fractures. In: Neer CS, editor. Shoulder reconstruction.Philadelphia: W.B. Saunders; 1990. p. 403-12.

14. Neviaser RJ. Injuries to the clavicle and acromioclavicular joints.Orthop Clin North Am 1987;18:433-8.

15. Nordquist A, Peterson C. The incidence of fractures of the clavicle.Clin Orthop 1989;245:89-101.

16. Post M. Current concepts in the treatment of fractures of the clavi-cle. Clin Orthop 1989;245:89-101.

17. Stanley D, Trowbridge EA, Norris SH. The mechanism of clavicu-lar fractures. A clinical and biomechanical analysis. J Bone JointSurg Br 1988;70:431-64.

18. Urist MR. Complete dislocation of the acromioclavicular joint. Thenature of the traumatic lesion and effective methods of treatmentwith an analysis of forty-one cases. J Bone Joint Surg 1946;28:813-37.