Clavicle Fractures

Question 1

What are the deforming forces on a clavicle fracture?

Answer 1

SCM pulls medial fragment posterosuperiorly while the pec major and weight of arm pull the lateral fragment inferomedially

Question 2

How are most pediatric distal clavicle fractures treated?

Answer 2

In contrast to adults, non-operatively; great osteogenic capacity of the intact inferior periosteum

Question 3

Where do the coracoclavicular ligaments attach to the clavicle?

Answer 3

Conoid- 4.5cm from end of clavicle (strongest)

Trapezoid- 3cm from end of clavicle

Question 4

What is the classification for clavicle fractures?

Answer 4

Allman (three groups based on location)
Group I (middle; 80%)
  displaced vs non-displaced
Group II (lateral 1/3; 10-15%)
  type I- fx lateral to intact CC lig
  type IIa- fx medial to CC lig 
  type IIb- fx lateral to torn CC, or btw CC lig with conoid   torn
  type III- fx through AC joint
  type IV- physeal fx 
  type V- comminuted
Group III (medial 1/3; 5-10%)
  anterior (non-op) or posterior (operative) displacement

Question 5

Which clavicle fractures have a high non-union rate with non-operative management?

Answer 5

Group II Type IIa (56%) and Type IIb (30-45%)
Other risk factors for non-union:
1) comminution
2) fracture displacement >100%; shortening (>2 cm)
3) advanced age and female gender

Question 6

What are absolute indications for ORIF of clavicle fractures?

Answer 6

1) unstable Group II fractures (Type IIA, Type IIB, Type V)
2) open fxs
3) displaced fracture with skin tenting
4) subclavian artery or vein injury
5) floating shoulder (clavicle and scapula neck fx)
6) symptomatic nonunion (esp atrophic)
7) posteriorly displaced Group III fxs
8) displaced Group I (middle third) with >2cm shortening

Question 7

What are relative indications for ORIF of clavicle fractures?

Answer 7

1) brachial plexus injury (questionable b/c 66% have spontaneous return)
2) closed head injury
3) seizure disorder
4) polytrauma patient (help mobilize)

Question 8

When does the clavicle ossify and fuse?

Answer 8

Ossify- 5 weeks gestation

Fuse- sternal end 22yrs

Question 9

How does superior plating compare to anterior plating?

Answer 9

1) superior plating biomechanically higher load to failure and bending
2) superior plating better for inferior bony comminution
3) superior plating has higher risk of neurovascular injury during drilling

Question 10

What are the findings of multiple studies comparing non-operative management versus plate fixation of midshaft clavicle fractures with >2cm shortening and 100% displacement?

Answer 10

1) improved functional outcome / less pain with overhead activity
2) faster time to union (16wks vs 28wks)
3) decreased symptomatic malunion rate
4) improved cosmetic satisfaction
5) improved overall shoulder satisfaction
6) increased shoulder strength and endurance
7) increased risk of need for future procedure (i.e implant removal, debridement for infection)

Question 11

What is the post-op rehab for clavicle fractures?

Answer 11

sling for 7-10 days followed by active motion
strengthening at ~ 6 weeks when pain free motion and radiographic evidence of union
full activity including sports at ~ 3 months