Middle 1/3rd clavicular fracture

Clavicle fractures are common accounting for 2- 4% of all adult fractures. They constitute 35% of the injuries to the shoulder.

Most midshaft clavicle fractures will go on to heal uneventfully with non operative treatment.

Overall clavicular fracture non union is rare, less than 2-5% when all types of clavicular fractures are combined including paediatric fractures.

However a certain subset of fractures are more prone to non union (female, increasing age, comminution, displacement) and approaches for example 35% in a 35 year old female with a displaced comminuted fracture.

It has also been shown that shortening of 1.5 - 2cm may lead to residual symptoms related to the shoulder and unsatisfactory outcome.(Hill)

Robinson et al looked at the non union risk following conservative management of clavicular fractures. They found that in diaphyseal clavicular fractures prognostic variables include:

• Age (older)

• Sex (female)

• Displacement of the fracture (lack of any cortical apposition)

• Comminution

They calculated the prognostic index which can be used to estimate probability of a diaphyseal fracture remaining ununited at six, twelve, or twenty-four weeks.

See prognostic index calculators (Prognostic index calculator for diaphyseal clavicular fractures)

Classification

Traditional

See overview

Traditionally clavicle fractures are divided into thirds, medial, middle and lateral.

They may be further described as:

    Displaced or undisplaced

    Simple or comminuted

Edinburgh Classification (Robinson)

• Type 1 - The medial 1/5, ie area of clavicle lying medial to a vertical line drawn upward from the centre of the first rib

• Type 2 - Middle 3/5ths

• Type 3 - Lateral 1/5th of the clavicle, ie. lateral to a vertical line drawn upward from the centre of the base of the coracoid process, a point normally marked by the conoid tuberosity.

Type 2 Middle 3/5th diaphyseal fractures are further broken down into

May require second radiograph with 30º caudal tilt to visualize displacement

Clinical

Patients often have obvious deformity with local tenderness. Evaluate integrity of overlying skin and make sure skin not threatened.

Deformity from downward displacement of lateral fragment due to gravity on shoulder and upward displacement on medial fragment from sternocleidomastoid muscle.

Very prominent fracture fragments just under the skin suggest they have ‘‘button-holed’’ through the platysma muscle.

Evaluate whole arm to exclude vascular or neurological injury (brachial plexus).

A difference in blood pressure between the two arms suggests a vascular injury, consider duplex ultrasound, angiography or CT angiography if the diagnosis is suspected.

If no axillary view in radiographs, ensure full relatively pain free passive external rotation to exclude the rare occasion of an associated posterior dislocation of the shoulder.
 

Radiology

Radiographs

Standard AP radiographs often make the diagnosis but an orthogonal view is needed to define displacement and comminution.

Various tilted views of different degrees have been suggested (Sharr), alternatively an axillary view for the clavicle can fully outline the clavicle.

Shortening is difficult to ascertain on a plain AP radiograph due to the "S" shape of the clavicle.

look closely at the shoulder/ scapula to exclude a "floating shoulder" in high energy injuries.

CT scans

CT scan +- 3D reconstruction accurately defines comminution, displacement and degree of shortening, but is not advocated in routine practice for acute fractures.

CT scans are very useful to demonstrate or exclude a non union.

Treatment

    Non operative

    Operative

Most undisplaced midshaft fractures are treated non operatively.

Operative treatment should be considered in adults with displaced, comminuted, shortened midshaft fractures.

Studies in the past have shown overall non union rates as low as 1% for non operative treatment, however they have included all fractures including children and undisplaced fractures. Two large retrospective studies from the 1960's by Neer and Rowe showed a higher rate of nonunion following ORIF than non operative treatment, once again both studies included fractures in children, which nearly always unite.

Recent studies have shown higher rates of nonunion and poorer functional outcomes after nonoperative treatment compared with ORIF. (COTS, Mckee1; Mckee2).

Non operative

MOST diaphyseal clavicular fractures should be treated non operatively, in certain circumstances however primary internal fixation may be considered.

See above, usually considered in high energy, displaced, shortened, comminuted fractures.

Broad arm sling for 2-6 weeks and symptomatic use. Patients should be advised to discard the sling once the acute pain settles, encouraging shoulder range of motion and normal activities as comfort allows.

Andersen et al showed no value in using a figure of 8 bandage over simple sling in terms of functional and cosmetic results and alignment of the healed fractures was unchanged from the initial displacement for both.

Figure of 8 bandaging risks axillary pressure sores, compression of the neurovascular bundle and in some studies a higher rate of non union.

Operative

Operative intervention should be considered and offered to adult patients in the presence of:

• Shortening > 1.5-2cm

• Comminution

• Displacement

• "Z" ed pattern or vertical fragment

• Open fractures or where the skin imminently threatened

• Association with floating shoulder injury

• Neurovascular injury/ compromise

As always counseling patients on the risks Vs the benefits of surgery Shen et al reviewed acute plate fixation of displaced midshaft clavicular fractures.

Considerations in consenting for surgery:

• Subcutaneous position of clavicle, Viz Wound breakdown, infection, tethering , damage to subcutaneous supraclavicular nerves

• Rare but potential complication of damage to underlyingstructures.

• The plate remains prominent and often needs removing with attendant risks.

• Still risk non union  (3–5% with surgery vs 10–15% with non operative management of high energy displaced comminuted fractures) (see prognostic index for diaphyseal fractures)

The Canadian Orthopaedic Trauma Society (COTS) recently demonstrated in a prospective randomised trial of non operative vs plate fixation, plate fixation provided:

• Better functional outcomes

• Lower rates of malunion

• Lower rates of nonunion

• Shorter time to union

The plate fixation group had a complication rate of 34% and a reoperation rate of 18%, mostly for removal of metalwork. (table below)

Table of complications in COTS study

Does delayed fixation matter?

Having a trial of non operative treatment and then correcting symptomatic non union and or malunion.

Rosenberg et al 2007 however showed that satisfactory osseous union can be achieved but only 46% of 13 patients returned to their previous professional and recreational activities after delayed internal fixation for symptomatic non union. Constant scores of the affected shoulders remained significantly lower than those of the normal contralateral side. Ten patients reported various degrees of pain, and only three patients were pain-free. They suggest surgeons offer a balanced prognosis when undertaking surgery for symptomatic non union.

Potter et al 2007 compared immediate fixation with delayed reconstruction, both groups rated their satisfaction with the procedure as excellent. They found late reconstruction of nonunion and malunion after displaced midshaft fractures of the clavicle to be a reliable and reproducible procedure that results in restoration of objective muscle strength similar to that seen with immediate fixation; however, there are subtle decreases in endurance strength and outcome compared with acute fracture repair.

Mckee the senior author on that paper, at an instructional course lecture AAOS 2009 summarised this as delayed surgery will "provide a good shoulder but perhaps not as good as if acute surgery was undertaken".

Operative Techniques

A wide variety of methods have been described for operative fixation of shaft fractures

    Plate fixation

    Intramedullary fixation

    External fixation

Plate Fixation
It is possible to place the plate superiorly or anteroinferior. Biomechanically a plate on the superior aspect of the clavicle is better. The superior approach may be associated with a greater risk of injury neurovascular structures during fracture reduction and drilling and is prominent superiorly. As such some surgeons advocate an antero inferior approach.
Pre contoured anatomical low profile locking plates are available to overcome the problems with standard DCP plates (straight plate on curved bone). Reconstruction plates should probably be avoided as they are prone to deformation and fatigue failure.

Intramedullary Fixation
The "S" shape of the clavicle and variable cross sectional diameter poses some problems for intramedullary devices.

Biomechanical studies have shown plate fixation provides a stronger construct but the mode of healing primary vs secondary healing is different in nail Vs plate fixation.

Several intramedullary devices have been used:

• Knowles pins

• Hagie pins

• Rockwood pins

• TENS nails

• Cannulated intramedullary screws

Insertion may be antegrade or retrograde, often an open reduction is undertaken to ensure safe passage of the device across th efracture site.

In the presence of comminution it is difficult to correct and prevent shortening. Implant fatigue failure, wound breakdown and brachial plexus injury have been reported. At present intramedullary fixation is therefore used less widely than plate fixation.

External fixation
External fixators have been used to treat clavicular fractures, rarely indicated in open fractures or septic non unions.

Kirschner wires should be avoided due to wire breakage and migration to a variety of anatomic locations, with potentially catastrophic consequences.

Non union

Robinson et al defined union as the absence of mobility or pain on stressing the fracture site and evidence of bridging callus on radiographs.

Non-union can be defined as a fracture that remains unhealed according to these criteria at 24 weeks after injury.

Non union is rare about 2-5% of all midshaft clavicular fractures, and may not be symptomatic.

The incidence of non union is higher in comminuted displaced fractures approaching 10-15%.

Surgery for symptomatic midshaft clavicular non union generally has a good outcome with low risks.

However patients should be warned quoted complication rates in the literature are.

• Persistent non union following surgery 8%

• Soft tissue complications 15% (usually minor sensory changes)

• Metal related problems 6%

References

Andersen K, Jensen PO, Lauritzen J. Treatment of clavicular fractures. Figure of eight bandage versus a simple sling. Acta Orthop Scand. 1987;58:71-4.

C.M. Robinson, C.M. Court-Brown, M. M. McQueen, and A.E. Wakefield; Estimating the Risk of Nonunion Following Nonoperative Treatment of a Clavicular Fracture; JBJS - A 2004 86: 1359-1365

C.M. Robinson, Fractures of the clavicle in the adult. Epidemiology and classification. J. Bone Joint Surg. [Br] 80-B (1998), pp. 476–484

W.J. Shen, T.J. Liu and Y.S. Shen , Plate fixation of fresh displaced midshaft clavicle fractures. Injury 30 (1999), pp. 497–500

J.M. Hill, M.H. McGuire and L.A. Crosby , Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J.BJS 79-B (1997), pp. 537–539.

Late complications following clavicular fractures and their operative management, Injury, Volume 34, Issue 1, January 2003, Pages 69-74
C. K. Kitsis, A. J. Marino, S. J. Krikler and R. Birch
 

J Dertavitain, JNS Davison, JJ Dias. Clavicular fracture non-union surgical outcome and complications. Injury 2002;33: p135-143

Damien O'Connor, Satish Kutty, and John P. McCabe. Long-term functional outcome assessment of plate fixation and autogenous bone grafting for clavicular non-union. Injury 2003

FL Allman; Fractures and ligamentous injuries of the clavicle and its articulation; JBJS - Am., Jun 1967; 49: 774 - 784.

Jeremy R.P. Sharr, Khalid D. Mohammed; Optimizing the radiographic technique in clavicular fractures; Journal of Shoulder and Elbow Surgery; March 2003 (Vol. 12, Issue 2, Pages 170-172)
 

L.A. Kashif Khan, Timothy J. Bradnock, Caroline Scott, and C. Michael Robinson; Fractures of the Clavicle; JBJS - Am. 2009;91:447-460

Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized
clinical trial. J Bone Joint Surg Am. 2007;89:1-10.

McKee MD, Wild LM, Schemitsch EH. Midshaft malunions of the clavicle. J Bone Joint Surg Am. 2003;85:790-7

McKee MD, Pedersen EM, Jones C, Stephen DJ, Kreder HJ, Schemitsch EH, Wild LM, Potter J. Deficits following nonoperative treatment of displaced midshaft
clavicular fractures. J Bone Joint Surg Am. 2006;88:35-40

Nordqvist A, Petersson CJ, Redlund-Johnell I. Mid-clavicle fractures in adults: end result study after conservative treatment. J Orthop Trauma. 1998;12:572-6

Jeffrey M. Potter, Caroline Jones, Lisa M. Wild, Emil H. Schemitsch, Michael D. McKee; Does delay matter? The restoration of objectively measured shoulder strength and patient-oriented outcome after immediate fixation versus delayed reconstruction of displaced midshaft fractures of the clavicle; Journal of Shoulder and Elbow Surgery; September 2007 (Vol. 16, Issue 5, Pages 514-518)

Nahum Rosenberg, Lars Neumann, Angus W. Wallace; Functional outcome of surgical treatment of symptomatic nonunion and malunion of midshaft clavicle fractures; 
Journal of Shoulder and Elbow Surgery; September 2007 (Vol. 16, Issue 5, Pages 510-513)
 

Last updated 11/09/15