Clavicle Fractures


February 5, 2021 | By : OrthoFixar | Trauma
| Last updated on April 28, 2021


  • The clavicle fracture is one of the most frequently fractures in
    the body.
  • The clavicle fractures most often resulting from a direct blow or a fall on an outstretched arm.
  • The clavicle fractures can be divided into:
    • Midshaft clavicle fracture: the most common (80-85 %).
    • Distal third fractures: the second most common type (15% to 20%).
    • Medial third fractures: the rarest type (0% to 5%).

Pathophysiology

Mechanism of injury:

  • A direct blow on the point of the shoulder is the commonest reported mechanism of injury injury that produces a midshaft fracture of the clavicle.
  • Or it can result from fall on an outstretched arm.

Pathoanatomy:

  • The deforming forces in the displaced clavicle fractures are:
    1. The sternocleidomastoid muscle that pulls the medial fragment postero-superiorly.
    2. Weight of arm pull the lateral fragment inferiorly but is opposed by the trapezius.
    3. In addition, the pectoralis major and latissimus dorsi pull the lateral segment infero-medially with resultant shortening.

Associated Injuries

  1. Ipsilateral rib fractures.
  2. Scapular and/or glenoid fractures.
  3. Proximal humeral fractures.
  4. Hemo/pneumothoraces.

Classification of clavicle fractures

TypeDescriptionTreatment
NondisplacedLess than 100% displacementNonoperative
Displaced– Greater than 100% displacement
– Nonunion rate of 4.5%
Operative
Group I – Middle third clavicle fractures (80-85%)
TypeDescriptionTreatment
Type I– Fracture occurs lateral to coracoclavicular ligaments (trapezoid, conoid) or inter-ligamentous
– Usually minimally displaced
– Stable because conoid and trapezoid ligaments remain intact
Nonoperative
Type IIA– Fracture occurs medial to intact conoid and trapezoid ligament
– Medial clavicle unstable
– Up to 56% nonunion rate with nonoperative management
Operative
Type IIB– Fracture occurs either between ruptured conoid and intact trapezoid ligament or lateral to both ligaments torn
– Medial clavicle unstable
– Up to 30-45% nonunion rate with nonoperative management
Operative
Type III– Intraarticular fracture extending into AC joint
– Conoid and trapezoid intact therefore stable injury
– Patients may develop posttraumatic AC arthritis
Nonoperative
Type IV– A physeal fracture that occurs in the skeletally immature
– Displacement of lateral clavicle occurs superiorly through a tear in the thick periosteum
– Clavicle pulls out of periosteal sleeve
– Conoid and trapezoid ligaments remain attached to periosteum and overall the fracture pattern is stable
Nonoperative
Type V– Comminuted fracture
– Conoid and trapezoid ligaments remain attached to comminuted fragment
– Medial clavicle unstable
Operative
Group II – Neer Classification of Lateral third clavicle fractures (10-15%)

TypeDescriptionTreatment
Anterior
displacement
– Most often non-operative
– Rarely symptomatic
Nonoperative
Posterior
displacement
– Rare injury (2-3%)
– Often physeal fracture-dislocation (age < 25)
– Stability dependent on costoclavicular ligaments
– Must assess airway and great vessel compromise
– Serendipity radiographs and CT scan to evaluate
– Surgical management with thoracic surgeon on standby
Operative
Group III – Medial third clavicle fractures (5-8%)

Clinical Evaluation

Symptoms & Signs:

  • Pain around the shoulder.
  • Disability at the shoulder joint.
  • Deformity in the shoulder region.

Examinations:

  • Evaluate the neurovascular structures.
  • Look for tenting of skin.

Imaging Evaluation

  • AP view of bilateral shoulders for comparable purposes and to measure clavicular shortening.
  • 15-degree cephalad-oblique radiographic views.

Clavicle Fractures treatment

Non-Operative treatment:

  • It’s the first choice of treatment for most of the midshaft clavicle fractures.
  • Hand the limb in a sling or figure-eight bandage (There is No difference in outcome).
  • Indications:
    • Nondisplaced middle third fractures.
    • Lateral third Stable fractures (Group II) (NEER Type I, III, IV)
    • Nondisplaced medial third frctures.
    • Pediatric distal clavicle fractures (skeletally immature).
  • Risk factors for non-union in clavicle fractures treated non-operativley:
    1. Females
    2. Elderly
    3. Displaced fractures
    4. Shortening more than 2 cm
    5. Comminuted.
    6. Lateral third fractures have higher rates of nonunion compared with midshaft fractures.

Operative treatment

Indications:

  • Absolute indications:
    1. Unstable lateral third fractures (NEER Type IIA, Type IIB, Type V)
    2. Open fractures
    3. Displaced fractures with skin tenting.
    4. Vascular injuries.
    5. Floating shoulder (clavicle and scapula neck fractures)
    6. Symptomatic nonunion
    7. Posteriorly displaced of medial third fractures.
    8. Displaced middle third with >2cm shortening.
  • Relative indications:
    1. Brachial plexus injury (may have spontaneous improvement)
    2. Closed head injury
    3. Seizure disorder
    4. Polytrauma patient

Types of procedure in clavicle fractures:

  1. Open reduction internal fixation (ORIF) with plate and screw fixation (superior vs anterior plate position)
  2. Intramedullary screw or nail fixation
  3. hook plate (for lateral third fractures)
  4. Coracoclavicular ligament repair
  5. Coracoclavicular ligament reconstruction

Superior plating positioning has better biomechanical strength than anterior plating but it’s more prominent that require later hardware removal.

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