distal clavicle fractures
TRANSCRIPT
Distal Clavicle
Fractures
2013 AOSSM Meeting
Chicago, IL - July 13, 2013
J.R. Rudzki, MDWashington Orthopaedics & Sports Medicine
Clinical Assistant Professor, Dept. of Orthopaedic Surgery
George Washington University School of Medicine
Disclosure
Arthrex – Consultant
AJSM, JBJS, CORR – Reviewer
AAOS – Evaluation Committee, BOC
AOSSM – Enduring Education Committee
Group I – middle-third fractures
Group II – distal-third fractures
Group III – proximal-third fractures
Type I – minimal displacement
(interligamentous)
Type II – medial to CC ligaments
A. Conoid & trapezoid attached
B. Conoid torn, trapezoid attached
Type III – articular surface fractures
Distal Clavicle Fractures Introduction
Reproduced with permission from
Nuber & Bowen, JAAOS 1997
Type IV–ligaments intact to periosteum
(children), with displacement of
proximal fragment
Type V–comminuted, ligaments not
attached proximally or distally, but
to inferior, comminuted fragment
Similar Concepts to
A-C Injuries
The Critical Concept
Which injuries need to be
treated as fractures by:
• ORIF/osteosynthesis
Which injuries need to be
treated as ligament injuries by:
• Ligament repair/reconstruction
The Critical Concept
Which injuries need both:
• ORIF/osteosynthesis
• Ligament repair/reconstruction
Several methods can achieve
successful outcomes
Limitations of Literature
Difficult to define optimal management
Numerous• Small sample sizes; variable inclusion/exclusion criteria
• Short Follow-Up
• Retrospective Reviews, Case Series, Surveys…• Recall Bias • Selection Bias
• Non-validated Outcomes Instruments• Detection Bias
• Susceptibility Bias
Newer Studies
Better Data
Enhanced Understanding of
Anatomy & Biomechanics
2013
Broader Array of Repair
& Reconstructive Options
Technological
Advances
More impt than ever to be clear on
indications for surgery &
best approach for each patient
Type I• Interligamentous fracture
• Minimally displaced
• Treated non-op with
typically excellent results• Nordqvist, Act Orth Scand,1993
Distal Clavicle Fractures Classification
• Neer described incidence of
osteolysis & AC arthrosis
• Arthroscopic distal clavicle
resection may be performed
if symptoms persistent
Type II - A & B
• Type A: trapezoid & conoid ligaments
are attached to distal fragment
ConoidTrapezoid
Distal Clavicle Fractures Classification
• Type B: fracture plane is between
trapezoid & conoid ligaments, & medial
fragment is displaced.
• Greater risk for non-union due to loss of
restraint of C-C ligament
Type III• Intra-articular AC fracture
• No ligamentous injury
• Potential confusion w/
1st degree AC separation
Distal Clavicle Fractures Classification
Type IV• Displaced fracture, C-C ligaments
remain intact attached
to periosteal sleeve
(childhood injury)
Distal Clavicle Fractures Classification
• Displaced, comminuted
fracture with ligaments
attached to butterfly fragment
Type V
Type IV15 y/o elite male hockey player
Distal Clavicular Physeal Closure
Age 19
- XR ~ 4wks after presumed
AC separation
Indications for Treatment:
Controversy regarding Type II
• Classically, type II injuries
associated with higher rates
of nonunion
• 33% - Neer, J Trauma, 1963
• Several authors have
reported increased rates of
non-union for this injury
pattern:• Edwards DJ, Injury, 1992
• Nordqvist, Acta Orth Scan, 1993
• Robinson, JBJS, 2004~30-40%
Indications for Treatment:
Controversy regarding Type II
• Several authors have advocated
surgical intervention based on:• Degree of displacement
• Age & Activity-Level
• Edwards DJ, Injury, 1992
• Nordqvist, Acta Orth Scan, 1993
• Rokito, Bull HJD, 2002-3
• Robinson, JBJS, 2004
~2-50%
• Despite higher rates of non-
union, incidence of symptoms
& need for delayed surgical
reconstruction is controversial
Ballmer, JBJS-Br, 1991; Edwards, Injury, 1992; Yamaguchi, Int Orth, 1998; Flinkkila, Acta Orth
Scand, 2002; Nourissat, Arthroscopy, 2007; Kalamaras, JSES, 2008; Checchia, JSES, 2008
More data
is needed
20 years, 21 articles, 425 cases: 365 surgical cases & 60 nonop tx
Surgical Tx: Nonop Tx:• CC Stabilization – 105
• Hook Plate – 162
• IM Fixation – 16
• K Wire/Tension Band – 40
1.6% Nonunion
22% Complications
33% Nonunion
6.7% Complications
Complication rate with hook plate or K wire (40 vs 20%)
Complication rate with CC
stabilization (4.8%)
JSES, 2010
38 patients treated with hook plate or locked plate & suture
• Union achieved in 95%
• Complication rate 15.8%
Hook plate patients treated in
delayed fashion had higher rate
of complications P = <0.05
Type IIA&B Operative
Surgical Treatment Options:
• Modified Weaver-Dunn
• Transacromial K-wire fixation
• Knowles Pins/Malleolar Screws
• CC Ligament Slings– Mersilene Tape, PDS Braids, FiberTape
• Bosworth CC Screw Fixation
• Plate Fixation
• Arthroscopic Endobutton FixationNourissat, Arthroscopy, 2007
Kalamaras, JSES, 2008
Checchia, JSES, 2008
Type IIA&B Operative Outcomes
Treatment
Clavicular plates for large
distal fragments• Flinkkila, 2002: compared K-wire versus hook
plate fixation - same union rate; higher
complication rate with K-wires
• Tambe, 2005: 10% non-union rate with plate
fixation & 28% rate of acromial osteolysis
• Muramatsu, 2007: 100% union rate @ 4 mos.
w/ hook-plate, Mean Constant Score = 89
CC ligament slings• Mersiline tape: associated w/ clavicle & coracoid fx
• PDS suture: associated w/ loss of reduction Clayer, 1997
• Suture Anchor/Ethibond Sling & K-Wires: Bezer, 2005
Bosworth Screw• Yamaguchi, 1998:
• 11 pts, 100% union @ 10 wks
• 100% return of shoulder fxn to
pre-injury level
• Requires Screw Removal
Type IIA&B Operative Outcomes
Treatment
Modified Weaver-Dunn
• Removal of distal fragment
• Transfer of CA ligament to
clavicle
• Can reinforce with palmaris
or semi-tendonosis graft,
suture anchor, or screw
Type IIA&B Operative Outcomes
Treatment
Non-anatomic Procedure
Severely displaced
5mm;
no bony contact
Mild to moderate
displacement
Acute fixation/stabilization
Large distal fragment
ORIF
Small fragment
• Locking or Hook Plate ORIF• Consider Tendon Graft, suture or
endobutton CC reinforcement
• Open Anatomic Reconstruction
• Arthroscopic Endobutton
• Modified Weaver-Dunn
Union Non-union
Asymptomatic
Mod Weaver-Dunn,
Anatomic, or Arthroscopic
CC Reconstrxn
+ Graft
Pain
or limited
function
Conservative Mgmt
Type II Distal Clavicle Fractures
Better understanding of anatomy, numerous techniques
available, better plates, arthroscopic approaches
Why not fix all of them?
Operative Management Complications
• Loss of Reduction
• Implant Migration
• Clavicle & Coracoid Fracture
• Articular Injury
• Nonunion, Malunion
• Infection
• Neurovascular Injury
• Stiffness
• Hardware Prominence?
• Need for Removal?
Why not fix all of them?
Operative Management Complications
55 y/o RHD male physician went over handlebars of bike
Treatment Options:
• Hook Plate
• Combined Clavicle/Coracoid
Fixation Device
• Transacromial Fixation
• ? +/- Graft Augment ?
Arthroscopic Procedure
4 week follow-up
JSES, 2013
21 specimens: • 7 tightrope
• 7 locking plate
• 7 plate & tightrope
Increased: - stiffness
- max. resistance to compression
Decreased displacement
Further Study is Needed
Arthroscopic Endobutton Fixation
Checchia SL, et al. J Shoulder Elbow Surg, 2008
Nourissat G, et al. Arthroscopy, 2007
5 year follow-up
Sling for 4-6 Weeks
Passive Supine ER & ER with
elbow supported begin immediately
Passive Supine Fwd Elev
Pendulums at 6 wks
Pulleys when Passive Fwd Elev =
90°
Operative Management Rehab Considerations
Key Take-Home Points
Distal Clavicle Fractures Summary
• Distal clavicle fractures are less common• Important to consider in young athletes when
assessing AC joint injury
• Majority can be treated conservatively
• Some displaced type IIb fractures may
warrant surgical intervention • Important to consider potential complications,
need for hardware removal, & re-injury when
choosing surgical approach
2013 AOSSM Meeting
Chicago, IL - July 13, 2013
J.R. Rudzki, MDClinical Assistant Professor, Dept. of Orthopaedic Surgery
George Washington University School of Medicine
Thank You
Distal Clavicle Fractures
JSES, 201112 pts, 100% union
JSES, 2003