Clavicular Clavicular

fracturesfractures

Dr. Rutuj KamdarDr. Rutuj Kamdar

SIORSIOR

Relevant anatomyRelevant anatomyWeakest part is where change of curvature Weakest part is where change of curvature occursoccurs

the superomedial the superomedial clavicleclavicle serves as an origin of serves as an origin of the sternocleidomastoid. In a midshaft the sternocleidomastoid. In a midshaft clavicleclavicle fracture, the sternocleidomastoid elevates the fracture, the sternocleidomastoid elevates the medial fragmentmedial fragment

Anterior to the clavicleAnterior to the clavicle lie the supraclavicular lie the supraclavicular nervesnerves

Fracture Fracture BiomechanicsBiomechanics

MECHANISM OF INJURYMECHANISM OF INJURY

87%

PATHOLOGICAL PATHOLOGICAL FRACTURESFRACTURES

CLASSIFICATIONSCLASSIFICATIONS

Possibly the most commonly used system Possibly the most commonly used system is that of Allman .He separated is that of Allman .He separated clavicleclavicle fractures into three groups: fractures into three groups:

Group I—middle third fractures Group I—middle third fractures

Group II—lateral third fractures Group II—lateral third fractures

Group III—medial third fractures Group III—medial third fractures

RELATIVE INCIDENCESRELATIVE INCIDENCESMIDSHAFT FRACTURES MOST COMMONMIDSHAFT FRACTURES MOST COMMON

MEDIAL FRACTURES RAREMEDIAL FRACTURES RARE

The medial The medial clavicleclavicle is also the most frequent is also the most frequent site of pathologic fracture, owing to its proximity site of pathologic fracture, owing to its proximity to the head and neck. In cases of fracture to the head and neck. In cases of fracture displacement combined with spinal accessory displacement combined with spinal accessory palsy, operative fixation of the palsy, operative fixation of the clavicle should clavicle should be considered be considered

Clinical historyClinical historyYoung adultsYoung adults

Incidence decreases from 20 to 50 yrs Incidence decreases from 20 to 50 yrs ageage

Direct fallDirect fall

Skin tenting and echymosisSkin tenting and echymosis

Scapula / rib #Scapula / rib #

Pneumothorax 3% - standingPneumothorax 3% - standing chest xray mandatory in highchest xray mandatory in high Velocity traumaVelocity trauma

Traction brachial plexus inj / vascular Traction brachial plexus inj / vascular inj when displacement more than 1 cminj when displacement more than 1 cm

X-raysX-rays

To obtain this view, a bump or roll is placed To obtain this view, a bump or roll is placed under the contralateral scapula, which under the contralateral scapula, which places the involved scapula flat against the places the involved scapula flat against the radiographic cassette (a true AP). The radiographic cassette (a true AP). The beam is then angled 20 degrees cephalad, beam is then angled 20 degrees cephalad, which brings the clavicular image away from which brings the clavicular image away from the thoracic cagethe thoracic cage

Normal AP

Apical oblique

Other XRAYSOther XRAYSFor lateral fractures, a 10-pound stress For lateral fractures, a 10-pound stress view to analyze for integrity of the view to analyze for integrity of the coracoclavicular ligaments may be coracoclavicular ligaments may be necessary.necessary.

For intraarticular fractures of the For intraarticular fractures of the acromioclavicular joint, an axillary acromioclavicular joint, an axillary radiograph or Zanca 15-degree apical radiograph or Zanca 15-degree apical oblique view of the shoulder may be useful oblique view of the shoulder may be useful

TREATMENT : MEDIAL TREATMENT : MEDIAL 1/3RD1/3RD

CONSERVATIVECONSERVATIVE

OPERATIVE IF PATHOLOGICAL OPERATIVE IF PATHOLOGICAL FRACTUREFRACTURE

TREATMENT MIDDLE 1/3DTREATMENT MIDDLE 1/3D

•There are, however, no well-controlled studies that demonstrate a difference in outcome with any specific technique of immobilization •Dominant hand : figure of 8 as then he can write•Non dominant hand : sling support 4 to 6 weeks •Counsel : some deformity, no functional impairment

CLOSED REDUCTIONCLOSED REDUCTION

In the supine technique, a pillow is placed In the supine technique, a pillow is placed between the scapulae while the shoulders are between the scapulae while the shoulders are manipulated superiorly and laterally (35,159). In manipulated superiorly and laterally (35,159). In the sitting technique, a knee is placed between the sitting technique, a knee is placed between the scapulae and a sheet is used, in a the scapulae and a sheet is used, in a configuration similar to a figure-of-eight configuration similar to a figure-of-eight bandage, to pull the scapulae outward. The use bandage, to pull the scapulae outward. The use of a hematoma block aids in the technique of a hematoma block aids in the technique

OPERATIVE TREATMENTOPERATIVE TREATMENT

CLOSED REDUCTION CLOSED REDUCTION INTRAMEDULLARY PINS OR WIREINTRAMEDULLARY PINS OR WIRE

OPEN REDUCTION AND FIXATION OPEN REDUCTION AND FIXATION WITH A PLATE ( PLATE FELT WITH A PLATE ( PLATE FELT SUBCUTANEOUSLY)SUBCUTANEOUSLY)

LATERAL 3LATERAL 3RDRD FRACTURES FRACTURES

Type I and type III distal clavicle Type I and type III distal clavicle fractures are treated nonoperativelyfractures are treated nonoperatively

Both groups, but particularly those with Both groups, but particularly those with type III injuries, are warned of the type III injuries, are warned of the possibility of late acromioclavicular possibility of late acromioclavicular arthrosis with the possible need for arthrosis with the possible need for subsequent distal clavicle excisionsubsequent distal clavicle excision

Surgical optionsSurgical options

plethora of surgical plethora of surgical options that include options that include fixation of the ligament fixation of the ligament with screws, wires, fascia, with screws, wires, fascia, conjoint tendon, coraco-conjoint tendon, coraco-acromial ligament, and acromial ligament, and the use of synthetic the use of synthetic sutures, Dacron tape, sutures, Dacron tape, autologous gradts from autologous gradts from CA ligament.CA ligament.

Coraco-clavicular screwCoraco-clavicular screw

Complications of # clavicleComplications of # clavicle

MalunuionMalunuion

Non unionNon union

Brachial plexus traction injuriesBrachial plexus traction injuries

Post traumatic arthritisPost traumatic arthritis

ConclusionConclusionClavicle fractures usually heal uneventfully, even in the Clavicle fractures usually heal uneventfully, even in the presence of treatment noncompliance.presence of treatment noncompliance.

For most of these fractures, initial patient counseling as For most of these fractures, initial patient counseling as to the expected result is probably the most important to the expected result is probably the most important aspect of treatment. aspect of treatment.

In contrast, certain fracture types, such as the displaced In contrast, certain fracture types, such as the displaced and shortened midshaft fracture or the type II distal and shortened midshaft fracture or the type II distal clavicle fracture, require special attention. When clavicle fracture, require special attention. When necessary, operative intervention should be based on necessary, operative intervention should be based on counterbalancing the deforming forces, specifically the counterbalancing the deforming forces, specifically the weight of the arm. In the face of symptomatic nonunion, weight of the arm. In the face of symptomatic nonunion, bone grafting and plate fixation is an effective option.bone grafting and plate fixation is an effective option.

BibliographyBibliography

Rockwood and GreenRockwood and Green

internetinternet

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