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Epidemiology
incidence
clavicle fractures make up 5-10% of all fractures
demographics
often seen in young active patients
Pathophysiology
mechanism
direct blow to lateral aspect of shoulder
fall on an outstretched arm or direct trauma
pathoanatomy
in displaced fractures SCM and trapezius muscles pull the medial fragment
posterosuperiorly, while pectoralis major and weight of arm pull the lateral fragment
inferomedially
open fractures buttonhole through platysma
Associated injuries
are rare but include
ipsilateral scapula fracture
scapulothoracic dissociation
should be considered with significantly displaced fractures
rib fracture
pneumothorax
neurovascular injury
Pediatric Clavicle fractures
fracture patterns include
medial/middle/lateral fractures (listed below)
Classification
Displaced
Greater than 100% displacement
Nonunion rate of 4.5%
Operative
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
x
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
x
Type V
Comminuted fracture
Conoid and trapezoid ligaments remain attached to comminuted fragment
Medial clavicle unstable
Operative
x
Group III - Medial third (5-8%)
Anterior displacement
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
Presentation
Symptoms
shoulder pain
Physical exam
deformity
perform careful neurovascular exam
examine skin
Imaging
Radiographs
standard AP view
45 cephalic tilt determine superior/inferior displacement
45 caudal tilt determines AP displacement
CT
may help evaluate displacement, shortening, comminution, articular extension, and
nonunion
technique
sling or figure-of-eight (prospective studies have not shown difference between sling
and figure-of-eight braces)
after 2-4 weeks begin gentle range of motion exercises
no attempt at reduction should be made
complications of nonoperative treatment
nonunion (1-5%)
treatment of nonunion
if asymptomatic, no treatment necessary
if symptomatic, ORIF with plate and bone graft (particularly atrophic nonunion)
Open Reduction Internal Fixation
surgical technique
plate and screw fixation
superior vs anterior plating
superior plating biomechanically higher load to failure and bending
superior plating better for inferior bony comminution
superior plating has higher risk of neurovascular injury during drilling
limited contact dynamic compression plate
3.5mm reconstruction plate
locking plates
precontoured anatomic plates
lower profile needing less chance for removal surgery
intramedullary screw or nail fixation
higher complication rate including hardware migration
hook plate
AC joint spanning fixation
postoperative rehabilitation