Midshaft clavicle fracture

>Trauma Surgery >Midshaft clavicle fractureAuthor: J. Sprakel. MD - Latest update: 12-05-2014

Midshaft clavicle fracture

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Cause

  • - Direct blow to the shoulder or indirect by fall on an outstretched arm
  • - Incidence increase by cyclists and mountain bikers
  • - Incidence of clavicle fractures is 2,6%-10% of all fractures 1,2
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Clinical presentation

  • - Deformity of clavicle (diffence between right and left)
  • - Abnormal motility of two bones relative to each other, sometimes with crepitations
  • - Pain
  • - Assess whether the skin is endangered
  • - Dislocation of the fracture is caused by traction on the lateral part of the m. pectoralis major ventrocaudal to the medial part of the m. stenocleidomastoideus to dorsocranial
Associated injuries (rare):
  • - Ipsilateral scapulafracture
  • - Ribfracture
  • - Nerve injury, brachial plexus (radial, median or ulnar nerve palsy)
  • - Vascular injury of the subclavian artery and vein, running under the collarbone
  • - Pneumo-/hematothorax
  • - Scapulothoracic dissociation
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Imaging

  • Radiographs: standard X-rays
  • - X-shoulder AP view (X-clavicle)

  • Additional/optional X-rays:
  • - 45° cephalic tilt (Serendipity view)
  • - 45° caudal tilt (Garth view / apical oblique)

Midshaft claviclefracture: Hover over the image to see the findings

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Classification

Classification according to Robinson 1

Type 1: Medial 1/5th of clavicle
Incidence 5-8%, medial of a vertical line drawn from the center of the first rib
Type 2: Middle 3/5th of clavicle
Incidence 80-85%
Type 3: Lateral 1/5th of clavicle
Incidence 10-15%, laterally from a vertical line drawn from the basis of the coracoid process, normally marked by tubercle conoideum, subclassfication according to Neer
Subdivision:
Group A Undisplaced
Group B Displaced, more than shaft width of dislocation
Groep 1 Extra-articular
Groep 2 Intra-articular


Type 2: Midshaft claviclefracture
Type 2A1 - Midshaft undisplaced
- Nonoperative treatment
Type 2A2 - Midshaft angulated
- Nonoperative treatment
Type 2B1 - Type2B1: Midshaft, displaced, simple or with comminuted wedge fragment
- Type2B2: Midshaft, displaced, isolated segmental or comminuted segmental

- Nonoperative treatment:
      - Chance of non-union: 15–18 % 3-6
      - In the short term, reduced function and objective loss of strength in the shoulder from 18 tot 33% 3-5
      - 30-50% of the patients are dissatisfied with the appearance and function of the shoulder 5,7

- Operative treatment:
     - Chance of non-union: 1-2% 3-6
     - Benefits: Short-term pain relief and improved function 5,7
     - Disadvantages: The risk of complications of surgery (infection, irritation of osteosynthesis material)5,7

- At this time there is no evidenec that surgical treatment is better for the function in the long run.6
- If a patients has no consolidation after 8 weeks and the patient has symptoms. There is always the possibility for a pseudo-arthrosis treatment.
Type 2B2
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Nonoperative treatment

Choice of therapy:
The classification has limited clinical applicability. Of importance is the degree of dislocation, the degree of shortening of the clavicle and the degree of comminution. These factors contribute to the risk of a poor outcome. In the majority of cases a nonoperatieve treatment is chosen. There is a relative operation indication, wherein the patient characteristics, the characteristics of the fracture and the wishes of the patient are taken into account. Chance of nonunion increases in cases of old age, female gender,> 1 shaft width dislocation and comminution. The risk of symptomatic malunion increases when there is more than 1.5cm shortening of the clavicle. In general, when nonoperatieve management is performed there is a chance of 75-80% of a painless consolidated clavicle, compared to 99% in operatieve treatment group. However, the surgical treatment has the risk of complications, and the need of removing the osteosynthesis. In addition, the advantage of surgical therapy is that patients are more likely to have a good shoulder function in the first 6 months. In the long run, this difference has not been established.

Indication:
  • - Non-displaced and displaced midshaft claviclefractures (Robinson: 2A1, 2A2, 2B1 en 2B2)


Treatment:
  • - Functional
  • - Sling immobilization for a maximum of 3 weeks
  • - 1th week rest
  • - 2th week gentle ROM exercises in the sling untill 90 -90 degrees
  • - 3th week practice in the sling guided by the pain without restrictions, possibly without sling
  • - 4th week removal of sling


Follow-up:
  • Outpatient follow‐up
    After 2 weeks After 6 weeks After 3 months After 6 months (optional)
    - Control with X-ray
    - Control of function
    - Practice instructions     		- Control of function
    - Physiotherapy (optional)
    - Control with X-ray in case of persistent complaints
    		 - Optional outpatient visit in case of persistent complaints
    - Control of function
    - Control with X-ray in cased of persistent complaints
    		 -


Time to recovery:
  • - The duration of the bone healing is 6-12 weeks.
  • - The functional recovery is 3-6 months.


Referral for physiotherapy:
  • - Refer patients to a physiotherapist if the range of motion is insufficient, despite good practice guidance, or if the patient doesnt understand the instructions.
  • - Mention in the referral to the physiotherapist which exercises (loaded / unloaded) can be preformed.
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Operative treatment

Relative indications:
  • - Displaced midshaftfractures (Robinson: 2B1 en 2B2)
  • - Fracture with 3 or more fragments
  • - Extreme pain
  • - (Top)atheletes
  • - Pseudartrosis with complaints


Absolute indications:
  • - Injury of neurovascular bundle
  • - Open fractures
  • - Endangered skin
  • - The presence of a ipsilateral scapulafracture (floating shoulder)


Treatment:
  • - Midshaft claviclefracture: Open reduction and internale fixation with a Locking Compression Plate (LCP) clavicle plate
  • - Midshaft claviclefracture: An option with fresh fractures and young patients is the medial intramedullar approach with Titanium Elastic Nail (TEN)
  • - There is no difference in functional outcome between plate or intramedullary fixation 8


Post-operative treatment:
  • - Sling immobilization for a maximum of 2 weeks untill woundhealing
  • - 3th week ROM exercises
  • - Removal of osteosynthesis material, not within 6 months after surgery
  • - Always remove TEN nail (approximatly 3 months after surgery


Follow-up:
  • Outpatient follow‐up
    After 2 weeks After 6 weeks After 3 months After 6 months (optional)
    - Removal of stitches
    - Practice instructions     		- Control with X-ray
    - Control of function
    - Fysiotherapie op indicatie     		- Control with X-ray
    - Functiecontrole
    - Physiotherapy (optional)
    - Define policy concerning removal of osteosynthesis     		- Optional outpatient visit in case of persistent complaintsn
    - Control with X-ray


Time to recovery:
  • - The duration of the bone healing is 6-12 weeks.
  • - The functional recovery is 3-6 months.


Referral for physiotherapy:
  • - Refer patients to a physiotherapist if the range of motion is insufficient, despite good practice guidance, or if the patient doesnt understand the instructions.
  • - Mention in the referral to the physiotherapist which exercises (loaded / unloaded) can be preformed.
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Complications

Complications of treatment with displaced midshaftclaviclefractures 6
Operative Non-operative
- All of the following complications 29% 42%
- Pseudoartosis / non-union (non-healed fracture 52 weeks after accident) 1,4% 14,5%
- Delayed union (not healed fracture 24 weeks after accident) 2,4% 3,5%
- Symptomatic malunion 0% 9%
- Infection 4,2% 0%
- Irritatieon of osteosynthesis material 13,2% 0%
- Failure of osteosynthesis material (breach) 1,4% 0%
- Neurological symptoms (irritation and compression of brachial plexuss) 5,6% 14%
- Re-fracture 0,9% 1,5%
- Pneumothorax + -
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Patient education

Practice flyer shoulder exercises (Word)
Practice flyer shoulder exercises (PDF)
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References

  • 1. Robinson CM (1998) Fractures of the clavicle in the adult. Epidemiology and classification. J Bone Joint Surg Br 80(3):476–484
  • 2. Postacchini F, Gumina S, De Santis P, Albo F (2002) Epidemiology of clavicle fractures. J Shoulder Elbow Surg 11(5):452–456
  • 3. Neer CS 2nd (1960) Nonunion of the clavicle. J Am Med Assoc 172:1006–1011
  • 4. Rowe CR (1968) An atlas of anatomy and treatment of midclavicular fractures. Clin Orthop Relat Res 58:29–42
  • 5. Hill JM, McGuire MH, Crosby LA (1997) Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg Br 79(4):537–539
  • 6. McKee RC, Whelan DB, Schemitsch EH, McKee MD (2012) Operative versus nonoperative care of displaced midshaft clavicular fractures: a meta-analysis of randomized clinical trials. J Bone Joint Surg Am 94(8):675–684. doi:10.2106/jbjs.j.01364
  • 7. McKee MD, Pedersen EM, Jones C, Stephen DJ, Kreder HJ, Schemitsch EH, Wild LM, Potter J (2006) Deficits following nonoperative treatment of displaced midshaft clavicular fractures. J Bone Joint Surg Am 88(1):35–40. doi:10.2106/jbjs.d.02795
  • 8. Houwert RM, Wijdicks FJ, Steins Bisschop C, Verleisdonk EJ, Kruyt M. (2012) Plate fixation versus intramedullary fixation for displaced mid-shaft clavicule fractures: a systematic review. Int. Orthop. 2012 Mar; 36(3):579-85.