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ClavicularClavicular
fracturesfractures
Dr. Rutuj KamdarDr. Rutuj Kamdar
SIORSIOR

Relevant anatomyRelevant anatomy
Weakest part is where change of curvatureWeakest part is where change of curvature
occursoccurs
the superomedialthe superomedial clavicleclavicle serves as an origin ofserves as an origin of
the sternocleidomastoid. In a midshaftthe sternocleidomastoid. In a midshaft clavicleclavicle
fracture, the sternocleidomastoid elevates thefracture, the sternocleidomastoid elevates the
medial fragmentmedial fragment
Anterior to the clavicleAnterior to the clavicle lie the supraclavicularlie the supraclavicular
nervesnerves

FractureFracture
BiomechanicsBiomechanics

MECHANISM OF INJURYMECHANISM OF INJURY
87%

PATHOLOGICALPATHOLOGICAL
FRACTURESFRACTURES

CLASSIFICATIONSCLASSIFICATIONS
Possibly the most commonly used systemPossibly the most commonly used system
is that of Allman .He separatedis that of Allman .He separated clavicleclavicle
fractures into three groups:fractures into three groups:
Group I—middle third fracturesGroup I—middle third fractures
Group II—lateral third fracturesGroup II—lateral third fractures
Group III—medial third fracturesGroup III—medial third fractures

RELATIVE INCIDENCESRELATIVE INCIDENCES
MIDSHAFT FRACTURES MOST COMMONMIDSHAFT FRACTURES MOST COMMON
MEDIAL FRACTURES RAREMEDIAL FRACTURES RARE
The medialThe medial clavicleclavicle is also the most frequentis also the most frequent
site of pathologic fracture, owing to its proximitysite of pathologic fracture, owing to its proximity
to the head and neck. In cases of fractureto the head and neck. In cases of fracture
displacement combined with spinal accessorydisplacement combined with spinal accessory
palsy, operative fixation of thepalsy, operative fixation of the clavicle shouldclavicle should
be consideredbe considered

Clinical historyClinical history
Young adultsYoung adults
Incidence decreases from 20 to 50 yrsIncidence decreases from 20 to 50 yrs
ageage
Direct fallDirect fall
Skin tenting and echymosisSkin tenting and echymosis
Scapula / rib #Scapula / rib #
Pneumothorax 3% - standingPneumothorax 3% - standing
chest xray mandatory in highchest xray mandatory in high
Velocity traumaVelocity trauma
Traction brachial plexus inj / vascularTraction brachial plexus inj / vascular
inj when displacement more than 1 cminj when displacement more than 1 cm

X-raysX-rays
To obtain this view, a bump or roll is placedTo obtain this view, a bump or roll is placed
under the contralateral scapula, whichunder the contralateral scapula, which
places the involved scapula flat against theplaces the involved scapula flat against the
radiographic cassette (a true AP). Theradiographic cassette (a true AP). The
beam is then angled 20 degrees cephalad,beam is then angled 20 degrees cephalad,
which brings the clavicular image away fromwhich brings the clavicular image away from
the thoracic cagethe thoracic cage
Normal AP
Apical oblique

Other XRAYSOther XRAYS
For lateral fractures, a 10-pound stressFor lateral fractures, a 10-pound stress
view to analyze for integrity of theview to analyze for integrity of the
coracoclavicular ligaments may becoracoclavicular ligaments may be
necessary.necessary.
For intraarticular fractures of theFor intraarticular fractures of the
acromioclavicular joint, an axillaryacromioclavicular joint, an axillary
radiograph or Zanca 15-degree apicalradiograph or Zanca 15-degree apical
oblique view of the shoulder may be usefuloblique view of the shoulder may be useful

TREATMENT : MEDIALTREATMENT : MEDIAL
1/3RD1/3RD
CONSERVATIVECONSERVATIVE
OPERATIVE IF PATHOLOGICALOPERATIVE IF PATHOLOGICAL
FRACTUREFRACTURE

TREATMENT MIDDLE 1/3DTREATMENT MIDDLE 1/3D
•There are, however, no well-controlled studies that demonstrate a
difference in outcome with any specific technique of immobilization
•Dominant hand : figure of 8 as then he can write
•Non dominant hand : sling support 4 to 6 weeks
•Counsel : some deformity, no functional impairment

CLOSED REDUCTIONCLOSED REDUCTION
In the supine technique, a pillow is placedIn the supine technique, a pillow is placed
between the scapulae while the shoulders arebetween the scapulae while the shoulders are
manipulated superiorly and laterally (35,159). Inmanipulated superiorly and laterally (35,159). In
the sitting technique, a knee is placed betweenthe sitting technique, a knee is placed between
the scapulae and a sheet is used, in athe scapulae and a sheet is used, in a
configuration similar to a figure-of-eightconfiguration similar to a figure-of-eight
bandage, to pull the scapulae outward. The usebandage, to pull the scapulae outward. The use
of a hematoma block aids in the techniqueof a hematoma block aids in the technique

OPERATIVE TREATMENTOPERATIVE TREATMENT
CLOSED REDUCTIONCLOSED REDUCTION
INTRAMEDULLARY PINS OR WIREINTRAMEDULLARY PINS OR WIRE
OPEN REDUCTION AND FIXATIONOPEN REDUCTION AND FIXATION
WITH A PLATE ( PLATE FELTWITH A PLATE ( PLATE FELT
SUBCUTANEOUSLY)SUBCUTANEOUSLY)

LATERAL 3LATERAL 3RDRD
FRACTURESFRACTURES
Type I and type III distal clavicleType I and type III distal clavicle
fractures are treated nonoperativelyfractures are treated nonoperatively
Both groups, but particularly those withBoth groups, but particularly those with
type III injuries, are warned of thetype III injuries, are warned of the
possibility of late acromioclavicularpossibility of late acromioclavicular
arthrosis with the possible need forarthrosis with the possible need for
subsequent distal clavicle excisionsubsequent distal clavicle excision

Surgical optionsSurgical options
plethora of surgicalplethora of surgical
options that includeoptions that include
fixation of the ligamentfixation of the ligament
with screws, wires, fascia,with screws, wires, fascia,
conjoint tendon, coraco-conjoint tendon, coraco-
acromial ligament, andacromial ligament, and
the use of syntheticthe use of synthetic
sutures, Dacron tape,sutures, Dacron tape,
autologous gradts fromautologous gradts from
CA ligament.CA ligament.

Coraco-clavicular screwCoraco-clavicular screw

Complications of # clavicleComplications of # clavicle
MalunuionMalunuion
Non unionNon union
Brachial plexus traction injuriesBrachial plexus traction injuries
Post traumatic arthritisPost traumatic arthritis

ConclusionConclusion
Clavicle fractures usually heal uneventfully, even in theClavicle fractures usually heal uneventfully, even in the
presence of treatment noncompliance.presence of treatment noncompliance.
For most of these fractures, initial patient counseling asFor most of these fractures, initial patient counseling as
to the expected result is probably the most importantto the expected result is probably the most important
aspect of treatment.aspect of treatment.
In contrast, certain fracture types, such as the displacedIn contrast, certain fracture types, such as the displaced
and shortened midshaft fracture or the type II distaland shortened midshaft fracture or the type II distal
clavicle fracture, require special attention. Whenclavicle fracture, require special attention. When
necessary, operative intervention should be based onnecessary, operative intervention should be based on
counterbalancing the deforming forces, specifically thecounterbalancing the deforming forces, specifically the
weight of the arm. In the face of symptomatic nonunion,weight of the arm. In the face of symptomatic nonunion,
bone grafting and plate fixation is an effective option.bone grafting and plate fixation is an effective option.

BibliographyBibliography
Rockwood and GreenRockwood and Green
internetinternet

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Claviclefrctures

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