- See:
-
Clavicular Frx in Children:
-
Congential Pseudoarthrosis of Clavicle:
-
Distal Clavicle Excision:
-
AC joint
-
Scapula Fracture:
-
Sternoclavicular Joint Injury:
- Discussion:
- serves as protector of
brachial plexus
- acts as a strut which provides th only bony connection between upper limb and the thorax.
-
embryology:
- first bone to ossify
- undergoes intra-membranous ossification w/o going thru prior enchondral stage;
- later in adolescence, secondary
enchondral ossification does occur at both its ends;
- in adolescents, usually a single ossification center develops at medial end of the clavicle, fusing with the shaft by age 25;
- occassionally, an ossification center may develop at the acromion process (os acromiale), and these should not be mistaken for fractures;
- references:
- The embryology of the clavicle. Gardner E: Clin Orthop 1968;58:9.
- Reflections upon the aetiology of congenital pseudarthrosis of the clavicle. Lloyd-Roberts GC: JBJS 1975;57B:24.
-
Edwin Smith Papyrus: A Fracture of the Clavicle -
- examination: if thou examinest a man having a break in his collar-bone (and) thou shouldst find his collar-bone short and separated from its fellow.
- diagnosis: thou shouldst say concerning him : "One having a break in his collar-bone. An ailment which I will treat."
- treatment: thou shouldst place him prostrate on back, with something folded between his two shoulder-blades; thou shouldst spread out with his two
shoulders in order to stretch apart his collar-bone until that break falls into its place. thou shouldst make for him two splints of linen, (and) thou
shouldst apply one of them both on the inside of his upper arm. thou shouldst bind it with yarn, (and) treat it afterward with honey every day, until he recovers.
- Fracture Classification:
-
frx of middle 1/3 (group I):
- most common clavicular frx in both adults and children (80%);
- frx usually occur in mid third region & have upward displacement of medial frag produced by sternocleidomastoid muscle.
- lateral fragment is pulled downward by wt of limb;
-
frx of distal 1/3 (group II)
- account for 10-15% of clavicle frx;
-
minimal displacement (type I)
-
frx medial to CC ligaments (type II)
-
articular surface fractures (type III)
- treatment:
- distal clavicle fractures may have a high incidence of non union but most of these are asymptomatic, and of these only a small number will
be severe enough to require surgery;
-
frx of medial 1/3 (group III):
- account for 5% of clavicular frx;
-
Fractures of the medial end of the clavicle.
- Radiology:
-
Serendipity View:
- best visualized w/ AP view & view w/ beam angled 30 deg. cephalad;
- w/ frx of clavicle, distal fragment & arm tend to sag, while proximal fragment,
held by the sternoclavicular joint tends to point upward;
- in any clavicular frx, carefully scutinize x-rays for presence of
scapular frx,
which represents a
floating shoulder;
- Non Operative Treatment:
- it is difficult to reduce and maintain the reduction of clavicle fractures;
- despite deformity, healing usually proceeds rapidly;
- union usually occurs rapidly & produces prominent callus;
- w/ midshaft fractures, there will also be some degree of malunion;
- in these patients be attentive to
medial cord nerve symptoms (more often
ulnar nerve);
- distal clavicle fractures may have a high incidence of non union but most of these are asymptomatic, and of these only a small number will
be severe enough to require surgery;
- references:
-
Treatment of clavicular fractures. Figure-of-eight bandage versus a simple sling.
-
Recovery following fractures of the clavicle treated conservatively.
-
Primary Nonoperative Treatment of Displaced Lateral Fractures of the Clavicle.
-
Closed treatment of displaced middle-third fractures of the clavicle gives poor results.
-
Estimating the Risk of Nonunion Following Nonoperative Treatment of a Clavicular Fracture.
-
Deficits Following Nonoperative Treatment of Displaced Midshaft Clavicular Fractures.
-
Shortening of clavicle after fracture: Incidence and clinical significance. A 5-year follow-up of 85 patients.
- Operative Treatment:
- indications for surgery:
- open fracture
- gross displacement of fracture w/ tenting of skin
- fractures w/ signficant medialization (causing medialization of the shoulder girdle);
- surgical considerations:
-
subclavian artery (axillary artery begins as it crosses the first rib)
-
brachial plexus (esp lower trunk damage (
C8,
T1);
- look for
posterior cord injury
- ref:
Injury to the brachial plexus by a fragment of bone after fracture of the clavicle.
-
floating shoulder:
- multiple authors have reported excellent results with healing rates greater than 99% for variety of immobilization techniques;
- incidence of nonunion, malunion, NV complications total < 1%;
- single disruptions of SSSC have uniformly good results with nonoperative treatment;
- double disruptions of SSSC are a combination of innocuous injuries which create instability for UE best surgically treated
- ORIF simpler fracture reduces other injury satisfactorily
- intra-medullary clavicular fixation:
- references:
- Non-union of fractures of the mid-shaft of the clavicle. Treatment with a modified
Hagie intramedullary pin and autogenous bone-grafting.
- plate fixation: (Synthes Clavicle Products
- consider unicortical fixation with a Synthese 3.5 mm pelvic reconstruction locking plate (unicortical screws
will not risk injury to the deep neurovascular structures;
- post op exam should include a neurovascular check - check for full abduction and external rotation (inorder to test for thoracic outlet syndrome);
- advantages of anteroinferior plating:
- include less hardware prominence and the ability of the surgeon to direct instrumentation away from infraclavicular neurovascular structures;
- references:
- Anteroinferior plating of midshaft clavicular nonunions.
- Anterior-inferior plate fixation of middle-third fractures and nonunions of the clavicle.
- superior plate fixation:
- provides better stability at the fracture site;
- ref: Effects of plate location and selection on the stability of midshaft clavicle osteotomies: a biomechanical study.
- references:
Open reduction and internal fixation of ipsilateral fractures of the scapular neck and clavicle
Open reduction and internal fixation of clavicular fractures.
Low-contact dynamic compression plating of the clavicle.
Fractures of the distal clavicle: a case for fixation.
Osteosynthesis of irreducible fractures of the clavicle with 2.7-MM ASIF plates.
Plating of fresh clavicular fractures: results of 122 operations.
Late-onset brachial plexus paresis caused by subclavian pseudoaneurysm formation after clavicular fracture.
Nonoperative Treatment Compared with Plate Fixation of Displaced Midshaft Clavicular Frx. A Multicenter, Randomized Clinical Trial.
Minimally invasive intramedullary nailing of midshaft clavicular fractures using titanium elastic nails.
- Non Union and Malunion of the Clavicle:
- defined as absence of radiographic healing by 4 months;
- non unions occur in more severe traumatic injuries;
- occurs most often in the central third where the clavicle lacks abundant muscular coverage;
- in mid-clavicular region, deforming forces include the pectoralis major (pulls the distal fragment inferiorly and medially) and sternocleidmastoid
(which is pulled superiorly);
- note that the diagnosis of clavicular non union can sometimes be difficult (because 2 orthogonal views cannot be obtained), and the supermposed
ends of the clavicle on the AP view can give the false impression of union;
- exam:
- note function of
brachial plexus (esp lower trunk);
- r/o presence of
thoracic outlet syndrome;
- management:
-
intra-medullary clavicular fixation:
-
iliac crest bone grafting;
- internal or external bone stimulator;
- references:
-
Nonunion of the clavicle and thoracic outlet syndrome.
-
Non-union of fractures of the mid-shaft of the clavicle. Treatment with a modified Hagie intramedullary pin and autogenous bone-grafting.
-
Non-union of the clavicle. Associated complications and surgical management.
-
The operative treatment of mid-shaft clavicular non-unions.
-
Surgery for ununited clavicular fracture.
- The treatment of nonunion fractures of the midshaft of the clavicle with an intramedullary Hagie pin and autogenous bone graft.
Boehme D. Curtis RJ Jr. DeHaan JT. Kay SP. Young DC. Rockwood CA Jr. Instructional Course Lectures. 42:283-90, 1993.
-
Midshaft Malunions of the Clavicle.
-
Short malunions of the clavicle: An anatomic and functional study
-
Brachial Plexus Palsy Secondary to Clavicular Nonunion.
Condensing osteitis of the clavicle. A review of the literature and report of three cases.
Current concepts in the treatment of fractures of the clavicle.
Osteolysis of the distal part of the clavicle in male athletes.
Injuries to the clavicle and acromioclavicular joint. x
Atlanto-axial rotatory fixation and fracture of the clavicle. An association and a classification.
Outcome of clavicular fracture in 89 patients.
The mechanism of clavicular fracture. A clinical and biomechanical analysis.
Transcutaneous reduction and external fixation of displaced fractures of the proximal humerus. A controlled clinical trial.
INJURY TO THE BRACHIAL PLEXUS BY A FRAGMENT OF BONE AFTER FRACTURE OF THE CLAVICLE
