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Clavicle Fractures

- See: 
- Clavicular Frx in ChildrenCongential Pseudoarthrosis of Clavicle
- AC joint / Sternoclavicular Joint Injury / Scapula Fracture

Clavicle fractures are common accounting for around 4% of all fractures and up to 44% of fractures of the shoulder girdle of which the middle third is by far the most common site.  The management of such injuries can be difficult and outcome can be unsatisfactory.  There has been reported non-union rate of displaced mid-shaft clavicle fractures of between 15 and 20%.  This can be reduced significantly with surgical intervention.  Whilst there is risk and some potential complications with any surgical intervention the published results demonstrate that  plate and screw fixation can be performed safely to give a good outcome with improved patient satisfaction and a reduction in the non-union rate compared to conservatively managed fractures.

There are many implant companies with clavicle specific plates.  Described here is the use of the Stryker VariAx 2 clavicle locking plate system.  These contoured and sided plates are available for lateral injuries, superior shaft fractures and for use along the anterior face of the clavicle.  The plates and screws are made of different grades of titanium allowing the harder locking screws to cut their own thread within the softer material of the plate and their position can be adjusted up to three times.  Screws are available in sizes 3.5 and 2.7 in both non-locking and locked varieties.  The clavicle set also provides useful instruments to facilitate exposure with periosteal elevation, fracture reduction in terms of clamps and wires as well as plate holding clamps.

Readers will also find of interest the following OrthOracle instructional techniques:

Internal fixation of midshaft clavicle fracture using Synthes superior clavicle plate

Arthroscopic repair of acute Acromioclavicular Joint Separation with the Arthrex TightRope system

Read more »

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- Discussion and Classification

- Exam Findings:
    - brachial plexus
- ref: Injury to the brachial plexus by a fragment of bone after fracture of the clavicle

- Radiology: 
- Serendipity View
- best visualized sitting up w/ AP view & view w/ beam angled 30 deg. cephalad;
- w/ frx of clavicle, distal fragment & arm tend to sag, while proximal fragment, held by SC joint tends
to point upward;
- in any clavicular frx, carefully scutinize x-rays for presence of scapular frx, which represents
a floating shoulder;
- references:
- Upright versus supine radiographs of clavicle fractures: does positioning matter?

- Non Operative Treatment:
- it is difficult to reduce and maintain the reduction of clavicle fractures;
- despite deformity, healing usually proceeds rapidly;
- union usually occurs rapidly & produces prominent callus;
- w/ midshaft fractures, there will also be some degree of malunion;
- in these patients be attentive to medial cord nerve symptoms (more often ulnar nerve);
- distal clavicle fractures may have a high incidence of non union but most of these are asymptomatic, and of these
only a small number will be severe enough to require surgery;
- references:
- Treatment of clavicular fractures. Figure-of-eight bandage versus a simple sling.
- Recovery following fractures of the clavicle treated conservatively.
- Primary Nonoperative Treatment of Displaced Lateral Fractures of the Clavicle.
- Closed treatment of displaced middle-third fractures of the clavicle gives poor results.
- Estimating the Risk of Nonunion Following Nonoperative Treatment of a Clavicular Fracture.
- Deficits Following Nonoperative Treatment of Displaced Midshaft Clavicular Fractures.
- Shortening of clavicle after fracture. Incidence and clinical significance, a 5-year follow-up of 85 patients.
- Operative Versus Nonoperative Treatment of Midshaft Clavicle Fractures in Adolescents
              - Pediatric refracture rates after angulated and completely displaced clavicle shaft fractures.
- Arteriovenous Fistula Development After Nonoperative Treatment of a Clavicular Fracture
- Arteriovenous Fistula Development After Nonoperative Treatment of a Clavicular Fracture. A Case Report
- Dynamic Compression of the Subclavian Artery Secondary to Clavicle Nonunion. A Report of 2 Cases

- Operative Treatment / Intramedullary Pin Fixation

- Non Union and Malunion of the Clavicle:

- defined as absence of radiographic healing by 4 months;
- non unions occur in more severe traumatic injuries;
- occurs most often in the central third where the clavicle lacks abundant muscular coverage;
- in mid-clavicular region, deforming forces include pectoralis major (pulls distal fragment inferiorly and medially) and
sternocleidmastoid (pulled superiorly);
- note that the diagnosis of clavicular non union can sometimes be difficult (because 2 orthogonal views cannot be obtained), and
supermposed ends of the clavicle on the AP view can give the false impression of union;
- exam:
- note function of brachial plexus (esp lower trunk);
- r/o presence of thoracic outlet syndrome;
- management:
- intra-medullary clavicular fixation:
- iliac crest bone grafting;
- internal or external bone stimulator;
- references:
- Nonunion of the clavicle and thoracic outlet syndrome.
- Non-union of fractures of the mid-shaft of the clavicle. Treatment with a modified Hagie intramedullary pin and autogenous bone-grafting.
- Non-union of the clavicle. Associated complications and surgical management.
- The operative treatment of mid-shaft clavicular non-unions.
- Surgery for ununited clavicular fracture.
- The treatment of nonunion fractures of midshaft of the clavicle with an intramedullary Hagie pin and autogenous bone graft.
- Midshaft Malunions of the Clavicle.
- Short malunions of the clavicle: an anatomic and functional study
- Brachial Plexus Palsy Secondary to Clavicular Nonunion.

- References:

Osteolysis of the distal part of the clavicle in male athletes.
Condensing osteitis of the clavicle. A review of the literature and report of three cases.
Atlanto-axial rotatory fixation and fracture of the clavicle. An association and a classification.