FRACTURE CLAVICLEWhen to Operate?

DR.K.ANJANEYULUConsultant Orthopaedic Surgeon

Anatomy

• strut bet. the the Axial Skeleton & the Upper Extremity

• Muscle attachments

• Ligamentous attachments

• Protects Neurovascular stru.

Muscular attachments

• Sternomastoid & Pectoralis Major medially

• Trapezius & Deltoid laterally

• Subclavius inferiorly

Neurovascular Structures

• Subclavian Vein

• Subclavian Artery

• Brachial Plexus

Mechanism of Injury

CLINICAL EXAMINATION

• Ideally in standing position - shoulder translates & rotates forwards• From behind - inf.angle of scapula prominence• Swelling, Bruising, Ecchymosis, Blanching skin• Deformity, Stepping• Shortening• Neurovascular examination

Local Examination

Shoulder asymmetryDifferent levels of A/C Joint

Prominence of inf.angle of Scapula

X RAY EXAMINATION

AP X Ray of Shoulder for Clavicle in standing position - gravity – max deformity

Chest Radiograph – Compare with opp. Clavicle for any shortening -- assoc. injury to Rib, Glenoid Scapula -- Haemo / Pneumothorax

Displaced # Clavicle, multiple Rib #s Pneumothorax

CT SCAN• Medial 1/3 clavicle # cannot be visualised properly

in Plain radiographs

• Fractures of Glenoid in “Floating Shoulder”

• Midshaft #s – rarely required – can demonstrate complex three dimensional deformity

• Lat 1/3 #s with intra articular extension

Clavicle # & Glenoid #

Angiography

• Although displaced #s can’t be reduced & maintained in good reduction by cons.Rx

*Cosmesis is acceptable*Functional results are excellent

• Bony prominence resorbed with time

• Throwing athlets – malunion did not significantly alter their throwing ability

• Traditionally clavicle #s have been managed non operatively, but recent studies have shown that union rate for displaced midshaft #s may not be as favourable as described

• No obvious dif. in the outcome bet. Rx by a sling or figure of 8 bandage

IS THERE A NEED TO OPERATE A CLAVICLE

FRACTURE ?

Indications for Surgery

1. Fracture specific

2. Associated injuries

3. Patient factors

Fracture specific1. Displacement > 2 cms2. Shortening > 2 cms3. Increasing comminution > 3 fragments4. Segmental fractures5. Open fractures6. Impending open #s with soft tissue comprom7. Obvious clinical deformity ( 1 & 2)8. Scapular malpositioning & winging

ASSOCIATED INJURIES

1. Vascular injury requiring repair2. Progressive neurological deficit3. Ipsilateral Upper Extremity injuries / fractures4. Multiple ipsilateral upper rib #s5. “Floating shoulder”6. Bilateral clavicle fractures

PATIENT FACTORS

1. Polytrauma with requirement for early upper limb weight bearing / arm usage

2. Patient motivation for rapid return of function - elite sports - self employed professionals

SURGICAL APPROACH

• Anterosuperior

• Anteroinferior

Anterosuperior approach

Advantages: 1. familiar to many 2. extendibility 3. clear fracture view – postop.xray

Disadva: 1. trajectory of screw placement difficult 2. inadvertent plunging of drill may

injure lung & neurovasc. Structures 3. clavicle is narrow in superoinf. direct. 4. hardware prominence - requires removal

Anteroinferior approach

Advantages: 1. easier screw trajectory 2. less likely iatrogenic injury

3. wider AP dimension – longer screws 4. less hardware prominence 5. easier to contour a plate along

ant.bord

Disadvantages: 1. lack of general familiarity 2. plate obscures # site on x ray

Methods of fixation

1. Plate & Screw fixationanatomic reduction, stable fixationsugical morbidity is more

2. Intramedullary Pinningsmaller cosmetic skin incision, minimal soft tissue stripping, decreased hardware prominence

3. External Fixationintrinsic healing, no scar, no morbidity,

no retained hardware

Plate & Screw Fixation

Fracture medial end

Plate crossing onto the sternum

Badly displaced midshaft #

Open Reduction

Pre op & Post op X rays

Union of # & Implant Removal

Fracture Lateral End fixed with Hooked Plate

Malunion (symtomatic)

Intra operative Picture

Intra op &

Post op

# Clavicle with Head InjuryAbundant Callus, Venous Obstruction & Brachial

Plexus compression

Abundant callus Excision and PlatingRelief of symptoms

Transthoracic displacementPseudoaneurysm of Subclavian Art.

ORIF WITH PLATE & SCREWS

Intramedullary Pinning

Comminuted displaced midshaft # Intramedullary Pinning

Intramedullary Pinning

Cerclage Wire – Inadequate purchase

Implant failure

POSTOPERATIVE PROBLEMS

1. Scar2. Sensitive or Painful # site3. Hardware irritation / prominence4. Incisional numbness

conclusions• Majority of fractures heal with non operative Rx with

prompt return of near normal funct.• Poor prognostic signs – increasing displ.of frag

- increasing commi.with number of fragments

• Young active pts. – completely displaced midshaft #s – superior results-primary fixation

• Operative plate fixation - more rapid return to a superior level of function - low compli.rate

conclusions• Antero inferior plating better than superior plating in

terms of soft tissue irritation

• Intramedullary fixation has many theoritical adv. and high rate of success in skilled hands

• Scapular winging – conservative Rx - symptomatic

• Malunion is a definite clinical entity – benefits from corrective osteotomy

THANK YOU