CLAVICLE FRACTURE

HARSHITA YADAVM.P.T (ORTHO)

CLAVICLE OSTEOLOGY

PECULARITIES OF CLAVICLE

Name derived from latin word – clavis & clavicula ( musical symbol)

Synonyms - Collar bone; beauty bone

Most superficial bone

Only long bone which lies horizontal in the body

MUSCLE ATTACHMENTS

PLATYSMA (Shaving muscle)1. Variable in terms of

thickness& extend

2. Usually envelopes the anterior & superior aspects of clavicle

3. Runs in subcutaneous tissue

4. Extending to mandible & deeper fascial muscle

5. Divided during surgical approach

LIGAMENTS

NEUROVASCULAR BUNDLE AROUND CLAVICLE

1. 1st bone to ossify2. Two Primary centers appears in the shaft during 6th wk of

fetal life and soon fuses with each other.3. The sternal end ossifies from a secondary centre that

appears between 15 & 20 yrs of age , & fuses with shaft by the age of 25 years.

4. An addinal center may appear in the acromian.5. It is the only long bone to ossify by the intramembranous

ossification.

OSSIFICATION

FUNCTION OF CLAVICLE

• Serves as bony link from thorax to shoulder.

• Stable linkage for shoulder movements & contibutes significantly to power & stability of shoulder girdle.

• Protective cover to vital neurovascular structure

• Also contributes to respiratory movements

Pathological #

Stress #

CLASSIFICATION :ON THE BASIS OF THEIR LOCATION

Rockwood classification : Type 2 -

Grp-1 fall on outstretched handGrp-2 fall on lateral shoulderGrp-3 due to indirect force applied on lateral shoulder

Robinson classification

CLINICAL FEATURES

Pain

Swelling

Tenderness

Subcutaneus lump

1. A-P View Radiographic beam should

be angled 20 degrees superiorly to eliminate the overlap of thoracic cage

IMAGING

2. Zanca view * A 10 -15 degree cephalic tilt of standard view of A-C joint .* Helps to delineate the fracture well, by removing the overlap of upper portion of thoracic cage.

A-P view Zanca view

3. CT scan * Mid shaft fracture – rarely done* Helpful in evaluating fractures of medial third of clavicle

Medial clavicular, Comminuted , intra – articular fracture

Type 1 clavicular fracture( middle fracture)

Type 1 comminuted clavicular fracture with skin tenting

Type 2 clavicular fracture (lateral third)

Type 3 clavicular fracture (medial fracture)

Distal clavicular fractureType 1 Type 2

ASSOCIATED INJURIES

1 . Vascular injuries requiring repair2 . Progressive neurological deficit3. Ipsilateral upper exterimity injuries4. Multiple ipsilateral upper rib fracture5. “Floating shoulder”6. Bilateral clavicle fracture

TREATMENT

Non – operative treatment

In children , the fracture is undisplaced and hence , a cuff and collar sling with strapping over the fracture site with elastoplast is adequate.

These are removed after 2 weeks and exercises of the shoulder are advised .

Stiffness of joint is unusual in children . It always unites in

children.

In adults , the undisplaced fracture is treated with traingular sling which supports the upper limb , with active exercises of fingers , wrist and elbow ( 50 times , thrice a day). The sling is removed after 3 weeks and shoulder exercises is advised .

If the fracture fragments are displaced, the distal fragment is lifted upwards and pulled backwards and figure of 8 bandage is applied with gud padding of both axilla with cotton .

Periodic check ups are important to look pressure sores in the axillary folds by figure of 8 bandage.

In elderly, the displacements are ignored and treated with traingular sling for 3 weeks followed by active exercises of the shoulder.

The elbow , wrist and fingers sholuld be exercised from day one of injury

Operative treatment

Indications for open reduction : Open # Neurovascular injuries Symptomatic non-unioun Soft tissue interposition Clavicle # associated with glenoid / scapular neck # # of the distal third with ligament Rupture Polytraumatized patient Non- union

Advantages Smaller, more cosmetic skin incision Less soft tissue stripping at the fracture site Decrease hardware prominance following fixation Technically, straightforward hardware removal & A possibly lower incidence of refracture or fracture at the

end of the implant

A small incision may be necessary to reduce vertically oriented communited fragments & “ tease” then back into alingment.

Partially threaded screws

Cannulated screws smooth screws

Use of precontoured plate for displaced Mid Shaft # of clavicle

Cerclage wires in isolation is inaequate to control the deforming forces at the site of a displaced clavicle fracture. It results in all of the risks of surgical intervention with few of benifts and is so avoided.

For sagittal plane obliquity or fracture comminution, AP lag screws are used with a superior plate placed in neutralization mode.

Lag screw Anatomical plate

clavicle_orif_640x360.mp4

Post- operative protocol The arm is placed in standard sling for comfort & gentle

pendulum exercises are allowed, & the patient is seen the # clinic at 10- 14 days postoperatively.

The wound is checked and radiographs are taken. The sling is discontinued & unrestricted ROM

exercises are allowed, but no strengthening, resisted exercises or sports activities are allowed .

At 6 wks postoperatively, radiographs are taken to ensure bony union. If acceptable , the patient is allowed to begin resisted & strengthening activites.

If delayed union is evident, then more aggressive activites are avoided.

It is generally advised that contact & / unpredictable sports should be avoided for 12 wks postoperatively.

Plate Or Hook Plate Fixation Of Displaced # Of Lateral clavicle

• The # site is reduced, & it may be held with either

k-wire or a lag screw.

• If the main # is in coronal plane, it may be possible to lag the # from anterior to posterior through a stab incision separate from the primary incision. Once the fracture is reduced & provisionally stabilized, the optimal type is chosen.

• Anatomical plate, fully threaded cancellous screws .

K -wire

Fully threaded, cancellous screw

Post- operative protocol The arm is placed in standard sling for comfort & gentle

pendulum exercises are allowed, & the patient is seen the # clinic at 10- 14 days postoperatively.

The wound is checked and radiographs are taken. The sling is discontinued & unrestricted ROM

exercises are allowed, but no strengthening, resisted exercises or sports activities are allowed .

At 6 wks postoperatively, radiographs are taken to ensure bony union. If acceptable , the patient is allowed to begin resisted & strengthening activites.

If delayed union is evident, then more aggressive activites are avoided.

It is generally advised that contact & / unpredictable sports should be avoided for 12 wks postoperatively.

Dynamic compression plate(DCP)

External fixation may be a method of choice

COMPLICATIONS

Infection Non-union (rare) Mal-union (common) Neurovascular injury Acute injuries (scapulothoracic dissociation) Delayed injuries (TOS) Iatrogenic injury Refracture Scapular winging