Evaluation and Management of Clavicle Fractures: Midshaft, Lateral and Medial

The Problem

Clavicle fractures are common injuries, accounting for 8-15% of all fractures in children and adults. They are caused by direct trauma, falls on the shoulder, or falls onto an outstretched arm. Clavicle fractures occur at three locations:

• Mid-shaft clavicle fractures – most common, accounting for 85% of all clavicle fractures

• Lateral clavicle fractures – 10-15% of cases

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  Type 1 – Lateral to the coraco-clavicular (CC) ligaments (minimal displacement)

  Type 2 – Medial to the CC ligaments (may have significant displacement)

  Type 3 – Intra-articular fracture extending into the acromioclavicular (AC) joint

• Medial clavicle fractures – rare, <5% of cases

  Anterior displacement

  Posterior displacement

  Are often a fracture through the medial clavicle physis (e.g., Salter Harris type II injury), and may be associated with sternoclavicular dislocations

Clinical Presentation

Patients with clavicle fracture generally present with a clear history of trauma, pain over the affected clavicle, and deformity depending on the extent of displacement that is present. Patients may present with associated injuries and other symptoms, such as: dyspnea (from pneumothorax), weakness, paresthesia or paralysis (from brachial plexus injury), and difficulty swallowing or speaking (from injury to trachea or esophagus in medial clavicle fractures with displacement).

It is important to examine the clavicle for deformity, crepitus, or motion in poly trauma patients who are unable to communicate (e.g., intubated patients). There is a high prevalence of clavicle fractures in these patients, which may be missed if not property examined.

Diagnostic Workup

Physical examination

Physical exam findings are based on location of fracture:

• Mid-shaft clavicle fractures – generally there is pain and deformity in the middle aspect of the clavicle. The deformity is more appreciated with severe displacement. (The proximal fragment displaces superiorly, the distal fragment inferiorly).

• Lateral clavicle fractures – Lateral clavicle fractures may present similar to AC joint separation injuries, with superior displacement of the proximal fragment. The extent of deformity depends on the amount of displacement at the fracture site.

• Medial clavicle fractures – These patients may complain of sternal pain. They should have detailed examination of the mediastinal contents, to rule out injuries to the lung, esophagus, trachea, or great vessels. Any difficulty in breathing or swallowing should alert the physician to further investigation.

In all cases is important to examine the entire affected extremity, assess the neurovascular status of the limb, and look for associated injuries (pneumothorax, associated fractures). Physical examination should include assessment of the following:

• Pain – Patients with clavicle fractures have focal pain with palpation over the fracture site.

• Deformity – It may be possible to appreciate obvious deformity, motion, or crepitus depending on the extent of displacement and injury severity.

• Vascular – The vascular status of the limb should be examined, and compared to the contralateral side. Any sign of arterial injury should be further investigated with appropriate workup (e.g., CT angiogram) and vascular surgery consultation.

• Neurologic – Neurologic assessment of brachial plexus should be assessed and documented, and compared to the contralateral side.

• Respiratory – Patient should have assessment of their respiratory function. Any sign of respiratory distress or abnormality should be further worked up, to rule out possible pneumothorax or other intra-thoracic injury.

• Mediastinal contents – Injury to the esophagus, trachea or great vessels should be assessed in cases of medial clavicle fractures, especially if there is posterior displacement of the fragment.

Radiographic Assessment

• Appropriate X-ray views include:

  Upright antero-posterior (AP) clavicle view – Ensure upright views are obtained. Supine radiographs may underestimate the amount of displacement at the fracture site. The deformity is more pronounced when the patient is upright sitting or standing.

  Zanca view – For distal clavicle/AC joint. AP X-ray centered over AC joint, with 10° cephalic tilt.

  Serendipity View – For medial clavicle or sterno-clavicular (SC) joint. AP view centered over SC joint, with 40° cephalic tilt. It is best to compare this to the contralateral side.

  AP chest – If there are any concerns regarding pneumothorax.

• CT scan

  Medial clavicle fractures are difficult to appreciate with plain radiographs. A CT scan can better delineate the injury, the direction of displacement (anterior versus posterior), and possible injuries to mediastinal contents.

  CT angiogram can assist with delineating injury to the vascular structures, especially if there is concern regarding arterial injury.

• EMG, nerve conduction studies

  In rare instances with brachial plexus injuries, further testing with EMG and nerve conduction studies can assist with extent of involvement, and prognosis.

Non-Operative Management

Indications for non-operative treatment

Non-displaced or minimally displaced fractures, in any location are typically managed non-operatively. This includes fractures of the mid-shaft, medial or lateral clavicle.

Displaced fractures of the clavicle may be treated non-operatively in selected cases. These include those with <100% displacement and ≤ 2 cm shortening on radiographs. Even if the radiographs meet the criteria for surgical fixation, patient factors are important to consider. The following patient factors should lead one to strongly consider non-operative treatment: older patients (> 65 years old), those with multiple medical co-morbidities, those with a high risk of surgical complications (diabetes, smoker), those likely to be non-compliant with postoperative care and rehabilitation (alcohol/drug use) those with a sedentary occupation and those with minimal symptoms.

Non-operative treatment protocol:

Regular arm sling applied to affected extremity for 1-2 weeks, patient may remove the sling and perform pendulum exercises of the shoulder to prevent stiffness. Wean off sling after 2 weeks, continue with range of motion exercises. Strengthening exercises after 6 weeks.

Indications for Surgery

Mid-shaft clavicle fractures

Prospective studies regarding surgical indications for clavicle fracture fixation are focused on mid-shaft clavicle fractures. The current indications include:

• Open fractures

• Fracture associated with vascular or neurologic injury

• Floating shoulder (associated fractures of scapula)

• 100% displacement

• >2 cm shortening

• Young, active, healthy patients

Lateral clavicle fractures

• Type 2 lateral clavicle fractures are known to have a higher rate of non-union (up to 50%), compared to type 1 and type 3.

• While there is no level I evidence present, type 2 fractures with 100% displacement may benefit from surgical fixation in select cases.

Medial clavicle fractures

• These injuries are rarely treated surgically.

• Surgical indications include: severe displacement, especially posterior displacement which may cause symptoms such as difficulty with swallowing or dyspnea.

Surgical Technique

Mid-shaft clavicle fractures

Necessary equipment/instrumentation

• Pre-contoured clavicle plates – Refrain from using pelvic reconstruction plates, especially in larger adults – there is a higher rate of hardware failure in adult patients (plate breakage, plate bending).

• Intramedullary nail devices – these may also be used, but generally they are better indicated for stable, non-comminuted fractures. There is an issue with lack of rotational stability (lack of distal locking in most models). Also many of these nails need to be removed after fracture union.

Patient set-up

• General anesthesia, with or without regional block.

• Beach chair semi-sitting position (Figure 1).

• The ipsilateral arm may be tucked in by the side (our preferred choice), or draped free.

• The involved shoulder is prepared and draped (Figure 2).

Figure 1.

Figure 2.

Surgical procedure

Our preferred technique is open reduction internal fixation (ORIF) with plate and screws: anterosuperior approach:

• Oblique incision is made centered over the clavicle.

• Supraclavicular nerve branches may be present, and should be protected and retracted away.

• Subcutaneous layer is developed all around.

• The myofascial later is split longitudinally over the clavicle, and the fracture site is identified. (In case of anterior plating, more soft tissue dissection of the pec muscles is required to expose the anterior aspect of the clavicle)

• Fracture site is cleared of debris and hematoma, and the fracture reduced anatomically.

• Provisional reduction is held with a K-wire or reduction clamp and definitive fixation applied.

• A lag screw may be used in lag fashion if possible.

• If there is comminution with an intervening Z fragment, this can be lagged to one of the main fragments, creating a simple fracture pattern for fixation. Ensure this Z fragment is reduced and secured while maintaining soft tissue attachments to the fragment.

• A pre-contoured clavicle plate is applied for fixation along the anterosuperior or anterior aspect of the clavicle, with a minimum of three screws in the distal and proximal fragments. (Screw lengths are usually 12-16mm) (Figure 3)

• Following fixation, a two-layer closure is performed: the myofascial later is closed with figure of eight No. 1 Vicryl absorbable sutures, and skin/subcutaneous tissues with non-absorbable 3-0 Prolene horizontal mattress sutures (Figure 4).

• A standard sterile dressing and sling is applied.

Figure 3.

Figure 4.

Lateral Clavicle Fractures

Necessary equipment/instrumentation

• Pre-contoured lateral clavicle plates – these plates have a distal flair with multiple screw options at the distal end of the plate, for improved fixation of the distal fragment.

• Hook plates – may be used if the distal fragment is too small to obtain adequate fixation with a plate.

  The decision to use the hook plate may be more apparent intra operatively after assessment of the distal fragment.

  The hook plate is placed in a similar fashion as when treating AC joint injury.

  The hook plate may need later removal after fracture healing.

Patient set-up

• General anesthesia, with or without regional block.

• Beach chair semi-sitting position.

• The ipsilateral arm is tucked in (our preferred technique) or draped free.

• The involved shoulder is prepared and draped with stockinet over the arm.

Surgical procedure

• Antero-superior surgical approach centered over the fracture site (as described above for mid-shaft fractures).

• The AC joint is identified; a needle can be placed into the joint to confirm the location.

• The fracture fragments are then examined for best mode of fixation:

  ORIF with pre-contoured lateral clavicle plates:

  The fracture is reduced and reduction is held with use of K-wires.

  An anatomic plate designed for the distal clavicle is applied to the superior.

  Locking or cancellous screws are placed in the distal fragment (which is softer cancellous bone).

  Cortical screws are placed in the shaft.

  Fixation with hook plate (Figure 5):

  If the distal fragment is too small for optimal distal fixation, a hook plate may be used.

  The fracture is reduced in a similar fashion to that used for mid-shaft fractures.

  The appropriate length hook and plate size is selected based on patients anatomy.

  Ensure the hook is placed more posteriorly underneath the acromion.

  It is important to ensure the hook matches the contour of the acromion, and avoid over reduction of the distal clavicle at the AC joint.

  Minimum 2 cortical screws are placed in the shaft fragment.

  Single lag screw or suture fixation may augment the distal fragment fixation.

  Distal clavicle excision:

  This may be an option if the distal fragment is very small, especially in the presence of AC joint arthritis or delayed presentation.

  It is important to examine the stability of the shaft fragment; if the shaft is unstable, coraco-clavicular stabilization is needed.

• The wound closure is performed in two layers as for mid-shaft clavicle fractures.

• A standard sterile dressing and sling is applied.

Figure 5.

Medial Clavicle Fractures

Necessary equipment/instrumentation

• Sutures – Non-absorbable sutures (e.g., number 2 ethabond).

• Plate and screw sets – 1/3 tubular plates, or pelvic reconstruction plates.

• Hook plates – may be used if the displacement is in the anterior direction.

Patient set-up

• General anesthesia, with or without regional block.

• Beach chair semi-sitting position.

• Prep and drape the chest, including both SC joints, as well as the entire clavicle from AC to SC joints on the affected side, and including the contralateral SC.

• Place a bump between the scapula, for better visualization of the SC joints.

Surgical procedure

• There are complications associated with these techniques, and these procedures should be performed by advanced surgeons with expertise in the field.

• If there is a pure dislocation without a medial clavicle fracture, which is reducible and relatively stable, we choose to treat this with suture fixation, by placing figure of eight sutures from the medial clavicle to the sternum.

• If there is instability with sutures alone, we may augment this by placing a small plate (1/3 tubular plate, or pelvic reconstruction plate) across the SC joint, spanning the joint onto the sternum. The plate will need to be removed in 6-12 weeks time, after fracture union.

• If there is anterior displacement of the lateral fragment, we will consider the use of a hook plate, by placing the hook under the sternum, and placing at least two screws into the medial clavicle. Although there is no literature on this mode of fixation, we have found it to be effective in select cases. The hook plate needs removal in 6-12 weeks.

Pearls and Pitfalls of Technique

Pearls

• Majority of clavicle fractures can be treated non-operatively with good outcomes, surgical indication must be met for patients undergoing surgical fixation.

• The screw lengths are generally 12-16mm depending on the size of patient. If the screw length measures much longer than 18mm, this should be confirmed. An error is to drill into the first rib, and inserting a longer screw than is needed, with possible injury to lung and neurovascular structures.

• Avoid use of pelvic reconstruction or 1/3 tubular plates, these have higher rates of failure in most North American adult size individuals. If there is no pre-contoured clavicle plate available, a small fragment compression plate may be used with use of plate benders to contour to the desired shape. Pelvic reconstruction plates may be used in very select cases (e.g., small female patients), but have high rates of failure in larger patients.

• In case of hook plate use for distal clavicle fracture, ensure the AC joint capsule and ligaments are not violated during the approach. The hook is placed along the posterior aspect of the acromion, and most of the AC joint capsule should be left intact.

• The hook of the hook plate should be contoured appropriately to avoid over reduction of the clavicle at the AC joint.

• Two layer closure is important for adequate soft tissue coverage over the plate and screws, to help decrease wound complications and infection.

Pitfalls

• Avoid operative fixation in unreliable individuals (e.g., substance abuse, homeless, etc). Despite the strongest anatomic fixation, there is high rate of hardware failure in the acute period if the patient suffers a fall, a withdrawal seizure, or is involved in an altercation.

• If there is a worry about violation of the pleura/lung (e.g., while drilling): fill up the wound with saline irrigation and ask the anesthesiologist for a Valsalva maneuver. If air bubbles are seen coming up from underneath the clavicle, there has been a perforation of the pleura/lung. A chest x-ray is required immediately post-op, and a chest tube may be required depending on the size of pneumothorax and patient symptoms.

• There have been reports of Brachial Plexus injury after surgical fixation of clavicle fractures. While there is a potential of penetrating injury from drills/screws, there is also potential for stretch/neuropraxia injury from reduction techniques and traction on the distal fragment. Overly aggressive traction should be avoided, as should over distraction or lengthening.

• In case of profuse bleeding from underneath the clavicle, there may be an injury to the subclavian vein/artery (usually penetration from from drills/screws). It is important to pack the wound, apply pressure, alert the anesthesiologist, and ask for immediate vascular surgery consultation. This complication can be life threatening, leading to haemorrhagic shock, or air embolus.

Potential Complications

Non-operative complications

• Nonunion – 15%-20%

• Symptomatic malunion – 15% (including ongoing pain, weakness, fatigue)

• Thoracic outlet syndrome

• Shoulder asymmetry, deformity

• Pain with backpacks, clothing straps over malunion “bump”

• Scapular winging with scapulothoracic dyskinesia

Intra operative complications

• Vascular injury: subclavian vein or artery (may lead to aneurysm, pseudo aneurysm, air embolism, etc)

• Brachial plexus injury: from stretch/over distraction, or iatrogenic injury from deep dissection

• Pneumothorax

Post operative complications

• Hardware irritation, need for hardware removal (higher risk for shorter individuals, or use of non-contoured plates)

• Nonunion 1%, malunion <1%, hardware failure

• Infection, wound complications

• Heterotophic ossification, thoracic outlet syndrome

Post-operative Rehabilitation

• Sling x 2 weeks with gentle pendulum range of motion (ROM) exercises.

• At 2 weeks start ROM exercises.

• At 6 weeks start resistance/strength training (if evidence of radiographic fracture healing).

• Avoid contact activity or upper body strength training for minimum 8-12 weeks (e.g., pushups, weight training).

Outcomes/Evidence in the Literature

Hill, JM, McGuire, MH, Crosby, LA. “Closed treatment of displaced middle-third fractures of the clavicle gives poor results”. The Journal of bone and joint surgery British volume. vol. 79. 1997. pp. 537-9. (The first study which used patient based outcome measures when assessing patients with clavicle fractures. This study reported poor outcomes of displaced clavicle fractures, a discrepancy compared to accepted knowledge. Patients had 15% rate of nonunion, 32% of patients were dissatisfied.)

McKee, MD, Pedersen, EM, Jones, C, Stephen, DJ, Kreder, HJ, Schemitsch, EH. “Deficits following nonoperative treatment of displaced midshaft clavicular fractures”. The Journal of bone and joint surgery American volume. vol. 88. 2006. pp. 35-40. (This study conducted strength testing of patients with malunion of the mid-shaft clavicle fractures. They reported significant decreases in maximal and endurance muscle strength testing (compared to the uninjured side), especially in abduction. The results were worst in cases with > 2cm shortening of the clavicle.)

“Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial”. The Journal of Bone and Joint Surgery American volume. vol. 89. 2007. pp. 1-10. (The first randomized controlled trial of mid-shaft clavicle fractures, reporting improved outcomes and decreased nonunion and symptomatic malunion rates in patients treated with surgical fixation compared to non-operative treatment. Inclusion criteria were: young healthy adults, > 100% displaced clavicle fractures with >2cm shortening.)

McKee, RC, Whelan, DB, Schemitsch, EH, McKee, MD. “Operative versus nonoperative care of displaced midshaft clavicular fractures: a meta-analysis of randomized clinical trials”. The Journal of bone and joint surgery American volume. vol. 94. 2012. pp. 675-84. (Meta analysis of 6 RCTs of mid-shaft clavicle fractures, demonstrating improved outcomes and lower complications with surgical fixation, as compared to sling treatment.)

Summary

Clavicle fractures are common injuries, and the majority should be treated non-operatively. In select young adult patients who are active, and have >100% displaced clavicle fractures, with >2cm shortening, surgical fixation leads to improved outcomes, compared to non-operative treatment. There is little high-quality evidence regarding the best treatment strategy for medial and lateral clavicle fractures. Lateral clavicle fractures with >100% displacement may benefit from surgical fixation. Medial clavicle fractures may be associated with SC dislocation, and in select cases with severe posterior or anterior displacement these may benefit from surgical fixation.

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