Clavicle Fractures : Last Minute Revision

1. 80-85% are mid-shaft fractures (other 10-15% are lateral 3rd and 5% are medial 3rd fractures) because of:

• Narrow cross-section
• Scarce muscle attachment

2. Deforming forces:

• Medial (proximal) fragment: pulled postero-superiorly and into external rotation by sternocleidomastoid (can stretch the overlying skin)
• Lateral (distal) fragment: Pulled –
  • Inferiorly: by weight of arm and deltoid
  • Medially and into internal rotation: by pectoralis major and latissimus dorsi (also causes scapular protraction and prominence of inferior scapular angle as scapula moves along with lateral end of clavicle)

3. X-ray views:

• Standard AP view
• Mid-shaft fracture:
  • AP cephalic tilt view (20-30 degrees cephalad tilt; eliminates overlap of thoracic cage)
  • Apical oblique view (45 degrees oblique and 20 degrees cephalic tilt; useful in pediatric fractures where significant curvature is present in bone)
• Lateral third fractures and ACJ: Zanca view (15 degrees cephalad tilt with 50% penetration)
• Medial third fractures and SCJ: Serendipity view (40 degrees cephalad tilt)

4. Allman classification:

• Group 1: Middle 1/3
• Group 2: Lateral 1/3 (with Neer’s subdivision) –
  • Type I: Lateral to CC ligaments (stable)
  • Type IIA (Rockwood): Medial to CC ligaments; unstable (50% non-union; operative management recommended)
  • Type IIB (Rockwood): Between CC ligaments; unstable (30-45% non-union, operative management recommended)
  • Type III: Intra-articular (stable, but risk of ACJ arthritis)
  • Type IV: Physeal
  • Type V: Comminuted (operative management recommended)
• Group 3: Medial 1/3 (operative management recommended with posterior displacement)

Dameron and Rockwood classification for lateral 1/3 pediatric fractures:
Type I: Mild strains of ligaments or periosteal tears
Type II: Complete disruption of AC ligaments or lateral periosteal attachment with mild damage to superolateral periosteal sleeve
Type III: Type II + Large disruption of superolateral periosteal sleeve (CC interval >25-100% than normal side)
Type IV: Type III + Posterior displaced (often embedded in trapezius)
Type V: Type III + Superior displaced (occasionally splitting deltoid and trapezisu)
Type VI: Displaced inferiorly (inferior to coracoid)

* Displacement of the distal clavicle through this periosteum in children has been likened to having “a banana being peeled out of its skin.”

5. Non-union rate is 15% in conservative management and 1.5% in surgically treated patients.

6. Operative indications (relative):

• Open fractures and impending open fractures (skin tenting)
• Floating shoulder – with scapular fractures (double disruption of superior shoulder suspensory complex)
• Vascular injury requiring repair
• Brachial plexus palsy
• Displacement >100% or 2 cm (risk of nonunion)
• Shortening or overlap >2 cm (risk of nonunion; associated with poor function outcome and patient dissatisfaction; decreased shoulder strength and edurance)
• Comminuted (>3 fragments; risk of nonunion) and segmental fractures
• High activity level
• Polytrauma
• Patient preference
• Lateral clavicle fracture – Neer type II and V
• Pediatric lateral clavicle fracture – Dameron and Rockwood type IV, V and VI

7. Structures at risk during surgery:

• Superficially on clavicle (run from medial to lateral): 3 branches (anterior, middle, posterior) of supraclavicular nerves (C3,C4) – injury leads to numbness inferior to incision site
• Inferior to clavicle: Subclavian vein, Subclavian artery (more posterior), Brachial plexus (most risky in mid-clavicular fractures; avoid violating subclavicular space) in middle 1/3 and lateral 1/3
• Posterior to clavicle: Subclavian vessels in medial 1/3

8. Recommendations for the optimal treatment of displaced midshaft fractures of clavicle:

• Young active patients will have superior results with primary fixation
• Antero-inferior plating may reduce the risk of symptomatic hardware and breach of sub-clavicular space compared with superior plating
• No difference in outcome between a regular sling and a figure of 8 bandage (if snugged to tightly – can compromise skin and brachial plexus) when non-operative treatment is selected
• No difference in outcome between plating and intramedullary nailing
• Factors associated with poor outcome following non-operative treatment: shortening and increasing fracture comminution

9. Rehabilitation for non-operative treatment:

• Sling/NWB for 6 weeks
  • Elbow, wrist and finger ROM initiated immediately
  • Passive ROM once discomfort subsides in 7-10 days (ROM in 90 degrees shoulder flexion/abduction avoided for 2-3 weeks to avoid clavicular rotation)
  • At 6 weeks, WBAT and full ROM

10. Rehabilitation for operative treatment:

• Immediate postoperative: Sling and gentle pendulum exercises
• 2-6 weeks: Sling discontinued and unrestricted ROM
• 6-12 weeks: Resisted and strengthening exercises if X-rays shows adequate healing
• >12 weeks: Contact and adventurous sports