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%)
- 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
Extension to Acromioclav joint (Articular surface),
* Group III: Medial third (5%)
Type I- Minimal displacement.
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
- Treatment is reduction and fixation of the fracture, or resection of callus
with or without osteotomy and fixation for malunions.
4) Post-traumatic arthritis