Diafise Clavicula

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A c u t e M i d s h a ft

C l a v i c u l a r F r a c t u r e

A b str a ct

Clavicular f ractures represent 2.6% to 5% of all f ractures, and

middle third f ractures account f or 69% to 82% of f ractures of the

clavicle. The junction of the outer and middle third is the thinnest

part of the bone and is the only area not protected by or reinf orced

with muscle and ligamentous attachments. These anatomic

f eatures mak e it prone to f racture, particularly with a f all on the

point of the shoulder, which results in an axial load to the clavicle.

Optimal treatment of nondisplaced or minimally displaced

midshaf t f racture is with a sling or f igure-of-8 dressing; the

nonunion rate is very low. However, when midshaf t clavicular

f ractures are completely displaced or comminuted, and when they

occur in elderly patients or f emales, the risk of nonunion, cosmetic

def ormity, and poor outcome may be mark edly higher. Thus, some

surgeons propose surgical stabilization of a complex midshaf t

clavicular f racture with either plate-and-screw f ixation or

intramedullary devices. Further randomized, prospective trials are

needed to provide better data on which to base treatment decisions.

The clavicle is one of the most

commonly f ractured bones; cla-

vicular f ractures represent 2.6% to

5% of all f ractures.1,2 The incidence

of clavicular f racture in adults is es-

timated to be 71 in 100,000 f or men

and 30 in 100,000 f or women, with

the incidence of midshaf t f ractures

decreasing with increasing age. Mid-

shaf t f ractures account f or 69% to

82% of all clavicular f ractures.1-5

Midshaf t f ractures are more common

in children and young adults. The in-

cidence of high-energy clavicular

f ractures with comminution, dis-

placement, and shortening appears to

be increasing.2

Traditionally, f ractures of the

clavicle have been treated with

closed reduction. More than 200

methods have been described f or

closed reduction, yet a classic text-

book recognizes that “reduction is

practically impossible to maintain,

and a certain amount of def ormity is

to be expected, generally compatible

with satisf actory return of f unction

in the shoulder.”6 The same text-

book states that even completely

displaced f ractures “generally do

well with non-operative manage-

ment....”6

However, most previous studies

describing the results of clavicular

f racture have used surgeon-based or

radiographic outcome measures that

equate union with success. Very f ew

studies on clavicular f racture have

been published using patient-based

outcomes such as the Medical Out-

comes Study 36-Item Short Form

(QualityMetric, Lincoln, RI) or the

Disabilities of the Arm, Shoulder

and Hand questionnaire (DASH; In-

stitute f or Work and Health, Toron-

ta, Canada, and the American Acad-

Kyle J. Jeray, MD

Dr. Jeray is Program D irec tor,

O rthopaedic Surgery Education,

G ree nvill e Hospital System, G ree nvill e,

S C .

Ne ither Dr. Jeray nor the department

with which he is aff ili ated has rec eived

anything of value from or owns stock in a

commercial company or institution

related direc tly or indirec tly to the

sub jec t of this article.

Re print requests: Dr. Jeray, G ree nvill e

Hospital System, University Me dica l

C enter, O rthopaedic Surge ry Education,

701 G rove Road, 2nd Floor E R C

Support Tower, G ree nvill e, SC 2 9 6 0 5.

J Am Acad O r t hop Su r g 2007;15 :23 9-

24 8

C opyright 2007 by the American

Academy of O rthopaedic Surgeons.

Volume 15 , Numbe r 4, Ap ril 2007 23 9





that a direct in jury f rom the shoul-

der (rather than the hand) that pro-

duces a f orce equal to the body

weight would exceed the critical

buck ling load and result in a mid-

shaf t clavicular f racture.16 Several

stu

dies

have de

mo

ns

tr

at

edth

at

a di-

rect f all or blow onto the point of the

shoulder accounts f or 85% to 94% of

the in juries.2,3,5,16,17 When the f orces

are transmitted through the arm, as

with a f all on an outstretched hand,

the f orces are not directly delivered

to the clavicle; thus, they are unlik e-

ly to produce a midshaf t f racture.

This mechanism accounts f or 2% to

5% of all midshaf t f ractures. A direct

blow to the clavicle, such as f rom a

hock ey stick or a seat belt shoulder-

strap in jury, also may produce a f rac-

ture and accounts f or 10% to 13% of

midshaf t f ractures in most stud-

ies.16 Although rare, direct f orce on

the top of the shoulder may drive the

midshaf t clavicle against the f irst

rib, resulting in a f racture.

C l a s s i f i c ati o n

Clavicular f ractures have been

classif ied b y Allman18 into three ana-

tomic regions, with the middle third

being group I. The classif ication sys-tem of the O rthopaedic Trauma As-

sociation separates diaphyseal cla-

vicular f ractures into three types:

06-A (simple), 06-B (wedge) and 06-C

(complex).19 Each type is f urther bro-

k en down into three groups.

The system developed by Robin-

son3 divides midshaf t clavicular f rac-

tures into type 2A (cortical align-

ment f racture) and type 2B (displaced

f racture). In an eff ort to provide di-

rection f or treatment and prognosis,

Robinson f urther divides these into

subgroup types 2A1 (nondisplaced),

2A2 (angulated), 2B1 (simple or

wedge comminuted), and 2B2 (isolat-

ed or comminuted segmental) (Fig-

ure 2). Robinson’s classif ication sys-

tem has demonstrated satisf actory

levels of interobserver and intraob-

server reliability and reproducibility.

However, additional studies are

needed to determine whether this

classif ication system will reliablypredict treatment and f unctional

outcomes.

C l i n i c a l E v a l u ati o n

Of ten with clavicular f racture, a

bruise or abrasion is seen, either over

the point of the shoulder (indicating

a direct blow) or over the midline

(suggesting a seat belt shoulder-strap

in jury). The shoulder has a droop,

the scapula appears slightly internal-

ly rotated, and the shoulder appears

shortened relative to the opposite

side. This characteristic def ormity is

produced by the pull of muscles at-

tached to the clavicle. Immediate

swelling may obscure the def ormity

of the bone, which will be seen on

radiographs if the f racture is dis-

placed. Palpation over the area will

reveal tenderness, and gentle manip-

ulation may produce crepitus and

motion at the f racture site. A non-displaced or minimally displaced

f racture may be suspected when pain

and / or sk in changes are present over

the clavicle.

Because middle third f ractures

f requently occur with high-energy

trauma, a complete examination

should be perf ormed to avoid miss-

ing associated in juries. Sk eletal in ju-

ries include f racture-dislocations of

the SC and AC joints or, in younger

patients, physeal in juries. Chest wall

trauma may result in high rib f rac-

tures, scapular neck and body f rac-

tures, and a pneumothorax or he-

mothorax. Although acute brachial

plexus in jury is rare, the ulnar nerve

is at highest risk because of its loca-

tion ad jacent to the middle third of

the clavicle. When a nerve in jury is

identif ied, a thorough vascular ex-

amination and evaluation of the

scapulothoracic articulation should

Figure 2

Robinson’s class ifica tion system for midshaft clavicular frac tures . (Re produced with

pe rmission from Robinson CM: Frac tures of the clavicle in the adult: Epide miology

and class ifica tion. J Bone J o i n t Su r g B r 1998;80:476-484.)

Kyle J. Jeray, M D

Volume 15 , Numbe r 4, Ap ril 2007 241



be undertak en to avoid missing an

associated in jury. Penetrating trau-

ma is typically the cause of vascular

in jury. However, vascular in jury canoccur f rom blunt trauma, resulting

in spasm or thrombosis of the sub-

clavian vessels.

R a d i o g r a p h i cE v a l u ati o n

To determine the f racture pattern

and displacement, radiographs in

two pro jections are necessary. A

standard anteroposterior view should

be accompanied by a 45° cephalic tilt

view (Figure 3). The shoulder girdle

and upper lung f ields should be

caref ully assessed to avoid missing

associated f ractures or a subtle pneu-

mothorax. The radiographic evalua-

tion should assess the f racture pat-

tern, presence of comminution,

displacement, and shortening or dis-

traction of the f racture.

Several radiographic f indings can

help guide the surgeon’s choice of

treatment. Displacement without

bony contact, especially with a

transversely displaced f ragment, is a

risk f actor strongly predictive of long-term sequelae.7 Additional ra-

diographic parameters predictive of

increased risk f or pain, limitation of

motion, or nonunion include an

overall displacement of the f racture

ends >1.5 cm. This displacement in-

cludes shortening, distraction, or

separation of the ends in the anteri-

or or posterior direction in any radio-

graphic view.20-22 A second view, at

least 45° off plane f rom the f irst,

helps to f urther delineate the dis-

placement. Of ten, the displacement

is diff icult to assess on a single radio-

graph. For example, as seen in Figure

3, both views reveal distraction at

the f racture site of at least 1.5 cm.

M a n a g e m e nt

I n d i c a ti o n s

The primary goal in treatment is

to restore shoulder f unction to the

prein jury level. By allowing the clav-

icle to heal with minimal def ormity,

loss of motion and pain can be min-

imized. Indications f or nonsurgicaltreatment include a nondisplaced or

minimally displaced midshaf t clav-

icular f racture. Indications f or surgi-

cal treatment include open f ractures

and f ractures associated with sk in

compromise or with neurologic or

vascular in jury.

Relative surgical indications in-

clude certain multiple-system trau-

matized patients, a f loating shoulder,

and a painf ul malunion or nonunion.

More recently, relative indications

f or surgical treatment have been ex-

panded to include high-energy closed

f ractures with >15 to 20 mm of

shortening, f ractures with complete

displacement, and f ractures with

comminution.23-26 Although these re-

cently adopted indications have re-

ceived attention in the current liter-

ature, articles dating as f ar back as

the 1960s have described similar sur-

gical indications—including Neer’s

Figure 3

Standard rad iographic anteroposterior view (A) and 45° cephalic tilt view (B). B oth are necessary to de termine the ext ent of

frac ture disp lac ement.

Ac ute Midshaft C lavicular Frac ture

242 Journa l of the American Academy of O rthopaedic Surgeons



article,17 which is of ten cited as sup-

port f or nonsurgical management.

Randomized controlled trials, one of

which has recently been complet-

ed,11 and another that is currently

under way, are necessary to deter-

mine w

he

the

r these

r

ela

tive

ind

ica-

tions should be considered routine

and, if so, in which patients with

which f racture types.

N o n s u r g i c a l T r e atm e nt

Historically, nonsurgical treat-

ment has been the mainstay f or

clavicular f ractures. It has varied

f rom plaster shoulder spica casts to

benign neglect. Most commonly, a

sling or f igure-of-8 brace is applied

in the acute setting. With either de-

vice, immobilization is typically f or

2 to 6 week s, based on the patient’s

level of comf ort. Of ten, mild dis-

comf ort can linger in adults f or

3 months. Return to athletics or

heavy labor is permitted 4 to 6

week s af ter clinical and radiograph-

ic union has occurred. Light work

with restricted overhead activity

can begin once the patient’s comf ort

allows, usually in 2 to 4 week s af ter

f racture healing.

In a prospective, randomizedstudy,27 26% of patients treated with

a f igure-of-8 bandage were dissatis-

f ied compared with 7% of those

treated with a sling. The patients

treated with a sling reported less dis-

comf ort. There was no diff erence in

overall healing and alignment of the

f ractures, indicating that a f igure-

of-8 bandage does little to obtain or

maintain reduction.

S u r g i c a l Te c h n i q u e s

Pl ate s

Open reduction and internal f ixa-

tion using plates and screws can be

done with the patient in either the

supine or the beach-chair position,

with the head and neck tilted away

f rom the surgical site. A bump is

placed behind the scapula to aid in

the reduction. The arm is prepped in

the f ield to allow f or traction and

manipulation to assist in the reduc-

tion. Traditionally, a sk in incision is

made over the clavicle f ollowing

Langer’s lines, as the sk in permits. A

newly described alternative is to in-

cise the inf erior sk in af ter pulling it

over the f racture site.28 As the sk in is

released, it will f all 1 to 2 cm below

the clavicle and prevent the woundf rom being in contact with the plate

on the clavicle. The aim is to im-

prove cosmesis and prevent wound

complications. The dissection is

tak en down to bone with care to

identif y the cutaneous supraclavic-

ular nerves. When necessary, they

can be sacrif iced. It is important to

inf orm the patient bef ore surgery of

the possibility of a patch of numb-

ness in the sk in inf erior to the clav-

icle.

Minimizing subperiosteal strip-

ping with gentle handling of the sk in

and sof t tissue helps avoid complica-

tions. The plate usually is placed on

the tension side of the bone—f or the

clavicle, the anterosuperior position

(Figure 4). Biomechanically, this

position provides the best stabili-

ty.29 However, clinically successf ul

treatment with anteroinf erior place-

ment also has been described.30 The

anteroinf erior position, although

less f avorable biomechanically,29 al-

lows f or drilling in a direction away

f rom the subclavian vessels and

lung. It also k eeps the plate f rom be-

ing placed under the incision. This

position theoretically is less lik ely to

cause irritation, thereby decreasingthe need f or plate removal. However,

the anteroinf erior position demands

additional sof t-tissue stripping and a

more diff icult contouring of the

plate compared with the anterosupe-

rior position.

Ideally, a 3.5-mm dynamic com-

pression plate or plate of similar

strength should be used, with at

least six cortices on each side. Semi-

tubular plates are not as rigid and

should not be used.24,31 Reconstruc-

tion plates are more easily contoured

and have been used with success;

however, they account f or several

f ailures to obtain union and would

not be the author’s f irst choice.24,31

Precontoured plates of suitable

thickness off er the advantage of ease

of placement without manipulation

of the plate. Lock ed plates are not

necessary f or the acute plating of

nonosteoporotic clavicular f ractures;

Figure 4

An teroposterior rad iog raph demons trating clavicle plating in the anterosuperior

position , us ing a 3.5-mm limited-con tac t dynamic compress ion plate.

Kyle J. Jeray, M D




there is no signif icant advantage

over conventional plating, and the

cost is higher.

Once plating is completed, the

f ascia is repaired over the plate, if

possible, and the sk in incision is

closed. Suture closure is pref erable

to staples. With a suff iciently stableconstruct, unrestricted shoulder mo-

tion is allowed, with the exception

of overhead lif ting f or 6 week s. Of-

ten, the pain relief associated with

stabilizing the f racture is dramatic,

and eff orts to limit the patient’s ac-

tivity may be needed. Pain relief is

cited as one of the potential benef its

of surgical intervention.

In tr a m e d u l l a r y F i x ati o n

An

alt

ern

ativ

eto pl

ating i

sin-

tramedullary (IM) f ixation. Many

variations of IM implants have been

described over the past 40 years, in-

cluding Hagie pins, modif ied Hagie

pins, Knowles pins, Herbert screws,

Steinmann pins, elastic nails, can-

cellous screws, and Kirschner

wires.32-36 Modif ications in the tech-

nique have led to a resurgence of in-

terest in IM f ixation of these f rac-

tures. The potential benef its of IM

f ixation compared with plate f ixa-

tion include less sof t-tissue stripping

at the f racture site, better cosmesis

with a smaller sk in incision, easier

hardware removal, and less weak -

ness of the bone af ter hardware re-

moval. Biomechanically, however,

the ability to resist torsional f orceswith IM f ixation is much less than

that with a plate. Migration of the

pins also has been a ma jor concern.

Newer designs, which include lock -

ing nuts on the lateral end of the IM

devices, prevent medial pin migra-

tion. Newer techniques that avoid

penetration of the medial f ragment

cortex also prevent medial migration

of the devices.34

Patient positioning is similar to

th

at f or pl

at

ef ix

ation.

A sm

all in

ci-

sion is made over the f racture site,

exposing the f racture ends. The me-

dial segment is prepared by drilling

into the medullary canal, but the an-

terior medial cortex is not violated.

The distal segment is drilled retro-

grade through the canal, exiting the

posterior lateral cortex. The pin is

inserted retrograde through the ca-

nal and exits through the posterolat-

eral hole and out the sk in. Next, the

f racture is reduced, and the pin is ad-

vanced antegrade across the f racture

into the medullary canal of the me-

dial segment. The Rock wood Clavi-

cle Pin (DePuy Orthopaedics, War-

saw, IN) has two nuts that go over

the

thr

eaded en

d of th

ein

sert

ed pin

posterolaterally. Once the pin is

across the f racture, the f irst nut is in-

serted posterolaterally, compressing

the f racture, f ollowed by the second

nut, which is cold-welded to the

f irst. Figure 5 shows the Rock wood

Clavicle Pin in place. Some of the IM

techniques vary slightly depending

on the device, and not all of the tech-

niques allow f or f racture compres-

sion.

Patients are allowed to begin

shoulder motion immediately post-

operatively. When rotational stabil-

ity is a concern, f orward elevation

should be restricted to 90° and ab-

duction to 90° f or the f irst 4 week s.

The Rock wood pin should be re-

moved at 8 to 14 week s. In some sit-

uations, this can be done under local

anesthesia in the off ice; however,

most Rock wood pins need to be re-

moved in the operating room. Some

of the other IM devices, such as Her-

bert screws, do not need to be re-moved.

As with plating, a ma jor benef it is

early return to activities. Several

studies have reported athletes’ re-

turning to their sport activities by

2 to 3 week s.35,37

C o m p l i c ati o n s

Complications can occur f rom non-

surgical treatment as well as surgical

treatment. Both can produce a cos-

metic def ormity (Figure 6). Both can

result in malunion, nonunion, pain,

local tenderness or irritation, and

limitation of motion. Other rare

complications f ollowing surgical or

nonsurgical treatment are residual

nerve paresthesia; subclavian ves-

sel compression, thrombosis, and

pseudoaneurysm; thoracic outlet

syndrome; and brachial plexus neu-

ropathy.

Figure 5

An teroposterior rad iograph demons trating the Rockwood C lavicle Pin (DePuy

O rthopaed ics). No te tha t the anteromed ial cortex is not violated , preventing the pin

from m igrating med ially.





Some complications are unique

to surgical intervention, such as in-

f ection and hardware problems. In-

f ection rates vary f rom 0% to 18%,with the lower rates reported in the

more recent studies.24,31,37,38 Painf ul,

irritating hardware requiring plate or

pin removal is reported to be as high

as 50% to 100%.24,39 Following plate

removal, the risk f or ref racture rang-

es f rom 0% to 8%.24,31 Adhesive cap-

sulitis of the shoulder has been re-

ported with surgical treatment in

0% to 7% of cases.24,28

IM devices are associated with

unique complications, including mi-

gration of the pin and hardware irri-

tation, resulting in local sk in break -

down that of ten requires antibiotics

and, ultimately, hardware remov-

al.39 Figure 7 illustrates sk in break -

down f rom an IM pin. Although

most of these complications are rare,

a second surgery f or plate or pin re-

moval is suff iciently f requent to be

considered when reviewing treat-

ment choices.

R e s u lts

Whether treated nonsurgically or

surgically, most clavicular f racturesheal without incident when length

and alignment are maintained. Ac-

ceptable cosmetic and f unctional re-

sults should be expected. Satisf acto-

ry results occur less consistently

when the f racture f ails to heal or

heals with a signif icant def ormity.

N o n u n i o n

Most cases of nonunion are symp-

tomatic, presenting with pain, loss

of f unction, neurologic changes,

and / or unsightly clavicular def ormi-

ty. Although clavicular nonunion

has not been clearly def ined in the

literature, most authors concur that

nonunion is present when healing

has not occurred by 16 week s.

Traditional think ing is that cla-

vicular f ractures treated nonsurgical-

ly almost always heal and that surgi-

cal treatment increases the risk of

nonunion. Rowe4reported a non-

union rate of 3.7% in patients who

underwent surgery compared with

0.8% in those treated without sur-

gery. Neer17 reported nonunion ratesof 0.1% with nonsurgical treatment

and 4.6% with surgical treatment.

Neer17 suggested that the most im-

portant causal f actor f or nonunion of

a midshaf t clavicular f racture is im-

proper open surgery. This may be

true to some extent; aggressive sof t-

tissue stripping, inability to reduce

the f racture, and inadequate internal

f ixation all can lead to poor results.

Several recent studies have re-

ported high union rates with surgical

intervention using a variety of inter-

nal f ixation devices, including plat-

ing and IM pin or rod f ixation.39,40 In

addition, there is evidence that the

nonunion rate af ter nonsurgical treat-

ment may be higher than previously

reported, particularly in certain f rac-

ture types and in certain patients. In

their review of 581 nonsurgically

treated f ractures, Robinson et al20re-

ported an overall nonunion rate of

Figure 6

A, Hea led clavicular frac ture managed nonsurgica lly. The bump, shortened shoulde r width, and subtle droop are evide nt.

B, A healed clavicu lar frac ture trea ted with plate and screw s, showing prominence of the anterior-superior–positioned plate.

Kyle J. Jeray, M D




4.5% f or diaphyseal f ractures. Strat-

if ication of Robinson’s data revealed

that women with displaced diaphy-

seal f ractures had a nonunion rate

ranging f rom 19% to 33%. When

comminution was combined with

displacement, the nonunion rate in

women increased to a range of 33%

to 47%.41 In addition to f racture f rag-

ment displacement, f emale sex, and

comminution, other risk f actorsidentif ied with nonunion include ad-

vancing age, lack of cortical apposi-

tion, severity of the initial trauma,

the extent of f racture f ragment dis-

placement,25 and, arguably, sof t-

tissue interposition.42 Early mobiliza-

tion has not been associated with the

development of a nonunion, whether

treated surgically or nonsurgically.

A recently published systematic

review of the literature on nonunion

af ter treatment of midshaf t clavicu-

lar f ractures revealed a 5.9% non-

union rate in nonsurgically managed

f ractures.8 In the completely dis-

placed f ractures, the rate increased to

15.1%. In surgically treated displaced

f ractures, plating of 460 f ractures re-

sulted in a nonunion rate of 2.2%,

and IM f ixation of 152 f ractures re-

sulted in a nonunion rate of 2.0%.8

These data should be interpreted

with caution, however, because most

were f rom evidence-based level III,

IV, and V studies (ie, observational,

retrospective, case series, and expert

opinion studies) rather than f rom

level I and II studies (ie, randomized,

prospective studies).

Surgical treatment of nonunion

has a high success rate. Techniques

include plate f ixation with bone

graf t, IM pin f ixation with bone

graf t, and external f ixation. Unionrates with each method have been

reported to be >92% and as high as

100%.42-45 Plate f ixation has the

largest support in the literature and

is currently the most predictable

and recommended treatment f or

symptomatic nonunion. Other

methods may be successf ul in the

hands of an experienced surgeon.

M a l u n i o n

Most nonsurgically treated cla-

vicular f ractures heal with some de-

f ormity. The literature does not

clearly def ine when a def ormity is

considered to be a malunion; howev-

er, the evidence strongly suggests

that some clavicular def ormities re-

sult in unsatisf actory outcomes. The

def ormity is a three-dimensional

problem; the most consistent char-

acteristic is shortening with inf erior

displacement of the medial f rag-

ment. Symptomatic patients help

def ine the malunion. Symptoms in-

clude weakness and pain in the in-

volved shoulder, loss of shoulder

motion, loss of endurance, neurolog-

ic symptoms consistent with thorac-

ic outlet syndrome and brachial

plexus impingement, and cosmetic

def ormity.46

In 1986, Esk ola et al21 noted in

89 patients that shortening >12 mmwas associated with increased pain.

Wick et al22 concluded in a retrospec-

tive study that shortening of 2 cm in

midshaf t clavicular f ractures was as-

sociated with an increased risk of

pain, limitation of motion, or non-

union. McKee et al9 assessed f unc-

tional outcome f ollowing displaced

clavicular f ractures and noted signif-

icantly inf erior scores f or both the

upper extremity–specif ic (DASH)

outcome scores (P = 0.02) and the

Constant scores (P = 0.01) compared

with the general population. They

concluded that f ractures with >2 cm

of shortening tended to be associated

with decreased abduction strength

and greater patient dissatisf action.

Hill et al25reported on completely

displaced middle third clavicular

f ractures and concluded that f inal

shortening ≥2 cm was associated

with an unsatisf actory result but not

Figure 7

H ea led clavicu lar frac ture trea ted with intramedullary pinning . A, No te inc ision size and loc ation over frac ture and posterolateral

prominence. B,

Ea rly breakdown of the skin resu lting from a prominent pin at the posterolateral inse rtion site.







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Diafise Clavicula