Fractures of the Clavicle (Dr Zahid)

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

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):

Non-operative
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 # 2) Neurovascular injury 3) Shortening of >2cm 4) Soft tissue interpositioning 5) Seizures disorders 6) Floating shoulder 7) Multiple trauma 8) Cosmetic 9) Quick recovery

@ 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 #. * Restore length of the clavicle. * Rigid fixation with plate. * Bone graft.

Principles of treatment:

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