Clavicle Fractures KTH Ortho Home

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					       Fractures of the Clavicle (Dr Zahid)
@ Mechanism of Injury
        1.    Moderate or high-energy direct traumatic impacts to the shoulder (87%).
        2.    Direct impact to clavicle. (07%)
        3.    Fall on outstretched hand . (06%)
        4.    Vigorous muscle contractions, seizures (Rare).
        5.    Atraumatic ,pathologic (Rare).

@ Radiographic Evaluation Clavicle #:
        1) Anteroposterior View

         2) 30-degree Cephalic tilt view.
            No thoracic overlap.

         3)     Chest X-ray for comparison.

         4)     CT scan usually indicated to best assess degree and direction of
                displacement. And to differentiate sternoclav joint dislocation from
                epiph. Injury in children.
@ Fractures Classification
 * Group I : Middle third (80% )
 * Group II: lateral third (10-15%)
         Type I:
           - Minimal displacement
           - Interligametous # ,i.e b/w conoid &
             trapezoid or b/w AC & CC ligaments.
            - Ligamets still intact.

         Type II (Unstable)
           Typically displaced secondary to # medial to the
           coracoclavicula ligaments, keeping the distal
           fragment reduced while allowing the medial
           fragment to displace superiorly.
            Type II A
                        Both conoid and trepezoid remain
                   intact and atteched to distal segment.# is
                   medial to conoid tubercle on x-ray.
            Type II B
                        Conoid torn, trepezoid attached to distal
                   fragment. # is in line with conoid tubercle on
  Type III:(Stable)
       Extension to Acromioclav joint (Articular surface),
       Intact ligaments.
  * Group III: Medial third (5%)
          Type I- Minimal displacement.
          TypeII- Displaced.
          TypeIII- Intraarticular.
          Type IV-Epiphyseal separation.
          Type V- Comminuted

@ Treatment Options for Group I (Middle third):
                      Sling / Brace (Immobilization till pt. becomes pain free).

            Surgical (2 wks immobilization)
                      Recon Plating .
                      Ex-Fix can be used in rare cases.(Remove after 8 wks ).

            Indications for surgical treatment:
                      1) Open #                          6) Floating shoulder
                      2) Neurovascular injury             7) Multiple trauma
                      3) Shortening of >2cm              8) Cosmetic
                      4) Soft tissue interpositioning     9) Quick recovery
                      5) Seizures disorders
@ Treatment of Distal-Third (Type II) Clavicle Fractures

     1) Nonoperative treatment
                   Chances of non-union or delayed union are much more as
                   Compared to ORIF. Opted in undisplaced #.
     2) Operative treatment
                    Fractures healing occures within 6 to 10 weeks after surgery.
                    Opted in all displaced #.

   Techniques for Acute Operative Treatment of Distal Clavicle #:
          - K-wires fixation.
           -   Tension band wiring (Most prefered) / PDS sutures.
           -    Plate and screw fixation.
           -    Single transacromial knowel pin.
           -    Coracoclavicular ligament reconstruction.

  Techniques for Late Operative Treatment of Distal Clavicle #
     1) Excision of distal clavicle
                With or without reconstruction of coracoclavicular ligaments
                (Modified Weaver-Dunn procedure)
     2) Reduction and fixation of fracture
@ Complications of Clavicular # & its Treatment:
 1) Non-union (o.1% – 7%):
         Risk factors include,         1) Location of # (distal third).
                                       2) Degree of displacement (Marked).
                                       3) Primary ORIF (Periostel stripping).
                                       4) Open #.
         Principles of treatment:      * Restore length of the clavicle.
                                        * Rigid fixation with plate.
                                        * Bone graft.
  2) Clavicular Malunion
         - Initially treat with strengthening, especially of scapulothoracic stabilizers.
         - Consider osteotomy, internal fixation if non-operative treatment fails.

  3) Neurological Sequele:
     - Occasionally, fracture fragments or abundant callus can cause brachial
       plexus symptoms.
     - Treatment is reduction and fixation of the fracture, or resection of callus
       with or without osteotomy and fixation for malunions.

 4) Post-traumatic arthritis

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