Mechanism
Direct fall onto shoulder / FOOSH
Fall off bicycle / sports
Incidence
Fractures of the clavicle are common
- 70% male
- 5% of all fractures
- 80% involve the middle third
Anatomy
| Ossification | Shape | |
|---|---|---|
|
Intramembranus First bone to ossify / 5th week fetal life |
S shaped double curved bone Middle 1/3 is junction of 2 curves |
Rotates 40o with scapula is elevated |
| Most growth occurs at medial end | Medial convex anterior | Most rotation occurs with arm above shoulder height |
| Medial physis last to close at age 22 - 25 | Lateral convex posterior |
Classification clavicle fractures
Fractures may be divided into three regions of the clavicle
| Lateral | Midshaft | Medial |
|---|---|---|
|
Lateral 1/5 of clavicle Line drawn up from base of coracoid |
Intermediate 3/5 |
Medial 1/5 of clavicle Line drawn up from center first rib |
|
20% of clavicle fractures
|
70 - 80% | Rare |
 |
 |
Examination
Skin
- skin tenting / threatened skin
- compound wounds
Xray
Shortening
Displacement
- the proximal fragment elevated by sternocleidomastoid
- lateral fragment sags down with weight of shoulder
Management
Operative indications
| Absolute | Relative |
|---|---|
| Compound fracture | Shortened / displaced |
| Skin tenting / skin under threat | Multitrauma |
| Floating shoulder |
Compound clavicle fracture
Shorted / displaced midshaft clavicle fractures
Z shaped midshaft clavicle fracture
Operative versus Nonoperative management
Canadian Orthopedic Trauma Society JBJS Am 2007
- RCT of 62 operative v 49 nonoperative treatment of displaced midshaft clavicle fractures
- operative v nonoperative
- time to union: 16 v 28 weeks
- nonunion: 5% v 14%
- symptomatic malunion: 0 v 18%
- RCT of 200 patients with displaced clavicle fractures
- operative versus nonoperative
- nonunion: 1% v 15%
- no difference in outcome if union achieved
- RCT of 160 patients with displaced clavicle fractures
- operative versus nonoperative
- nonunion: 2% v 23%
- no difference in outcome if union achieved
Summary
Plate fixation of shorted displaced midshaft clavicle fractures reduces nonunion rates
Operative Management
Options
Plate fixation
Intramedullary screw
Plate fixation
Superior versus anteroinferior plates
Nourian et al J Orthop Trauma 2017
- systematic review of superior v anteroinferior plates
- no difference in outcome or union rates
- higher incidence sympomatic hardware with superior plates
Dual plating
- comparison of superior / inferior / dual plating with minifrag plates
- lowest rate of reoperation with minifrag plates
- reduced nonunion and reduced need to remove prominent hardware
Technique
Vumedi clavicle ORIF with plate video
Lazy beach chair
- square drape / free drape
- LA with Adrenalin
Transverse incision in Langer’s line
- ? identify and protect supraclavicular nerves
- divide platysmus as a layer to repair later
- clean and reduce fracture
- application contoured locking plate
- need 6 cortices each side
Supraclavicular nerve branches
Intramedullary screw
Indication
Displaced clavicle fractures
Minimal comminution
Results
- systematic review of plate versus IM screw fixation
- no difference in union rates / outcomes
- increased hardware removal with screw fixation
- increased refracture rate after plate removal
Fuglesang et al Bone Joint J 2017
- RCT of plate versus IM screw in 123 patients
- shorter duration of surgery with IM screw
- faster functional recovery with plate fixation
- slower function recovery with IM screw fixation in setting of increasing comminution
Technique
Vumedi surgical technique clavicle IM screw
Mini open approach to fracture
- drill medial fragment for screw
- pass cannulated wire through lateral fragment and out through skin
- reduce fracture and pass wire into medial fragment
- drill lateral fragment
- insert cannulated 6.5 mm screw
- needs to be between 80 and 110 mm
- check x-ray to ensure good medial fixation
Complications
Operative management
Painful hardware
Numbness
Pneumothorax
Infection / wound breakdown
Nonunion /malunion
Vascular injury
Subclavian vein injury
- can be adhered to periosteum medially
- careful with medial screws
- instrumentation medially and inferiorly must be subperiosteal
- may need clavicular osteotomy to control bleeding
Air embolus
- from subclavian vein injury
- patient must be put in immediate head down position
- prevent further air embolus with pressure / saline immersion
- aspirate air from right ventricle
- vascular repair
Subclavian artery pseudoaneurysm
- delayed presentation with intermittent claudication
- pulsatile mass
Infection / wound breakdown
Periprosthetic fracture
Nonunion
Technique
Vumedi dual plating clavicle nonunion
Results
Muhlenfeld et al J Clin Med 2024
- 44 patients with nonunion
- union rate with plate: 94%
- union rate with plate + bone graft: 96%
Malunion
Symptoms
- pain, weakness, fatigue, parasthesia
Theory
- clavicle shortening causes altered scapular mechanics
- scapular winging
- increased thoracic outlet symptoms
- disrupted ACJ and SCJ
Technique
Vumedi surgical technique video clavicle malunion
Results
- 15 patients with clavicle malunion
- average shortening 2.9 cm
- osteotomy + plate
- 1 non union
- 8/12 patients with weakness and pain improved