A variant of a type V lateral clavicle fracture involving a posteriorly displaced medial segment. A case report

Clavicle fractures, particularly at the lateral end, are uncommon and pose diagnostic and management challenges. Bilateral lateral end clavicle fractures are rare, and surgical management is often necessary to restore shoulder function scenarios. A 52-year-old male presented with bilateral shoulder pain and restricted movements following a motorcycle fall. Clinical and radiological evaluation revealed a right undisplaced lateral clavicle fracture, a comminuted left lateral clavicle fracture, and associated right-sided rib fractures. Surgical fixation using the dog bone button technique was performed bilaterally. Post-operative rehabilitation involved early mobilization, and at 6 weeks, the patient demonstrated significant functional improvement, confirmed by disabilities of the arm, shoulder and hand and Oxford shoulder scores. Radiographs showed good fracture healing with bridging callus formation. Dog bone button fixation is an effective technique for managing bilateral lateral clavicle fractures, offering good functional and radiological outcomes.

Background:The management of lateral clavicle fractures is often challenging because of difficulties in identifying displacement patterns that indicate an unstable fracture.Hypothesis:The aim of this study was to evaluate displacement patterns through analysis using 3-dimensional (3D) rendering software for displaced lateral clavicle fractures. We hypothesized that most displaced lateral clavicle fractures would have posterior displacement and angulation as well as superior displacement of the medial fragment.Study Design:Cross-sectional study; Level of evidence, 3.Methods:Radiographs of 37 displaced lateral clavicle fractures were imported into the 3D rendering software to reconstruct the fracture model. For the computational simulation of fracture reduction, the medial fragment was manipulated and returned into place using the software’s moving tools. Two corresponding points were marked between the medial and lateral fragments to measure 3D spatial location in the x-axis (shortening), y-axis (horizontal displacement), and z-axis (vertical displacement). The displacement angle on the cranial view was also measured based on the medial end of the clavicle.Results:There were 32 cases (86.5%) of superior displacement of the medial fragment (mean, 5.8 mm; range, –6.5 to 19.0 mm), 35 cases (94.6%) of posterior displacement of the medial fracture fragment (mean, 8.8 mm; range, –3.2 to 18.3 mm), and 23 cases (62.2%) of distraction of the fracture site (mean, 2.1 mm; range, –9.2 to 12.2 mm). All 37 patients revealed posterior angulation of the fracture site (mean, 8.9°; range, 2.2°-39.4°).Conclusion:Most displaced lateral clavicle fractures have posterior displacement and angulation as well as superior displacement of the medial fragment. Our results revealed that 3D evaluation of lateral clavicle fracture displacement patterns is useful for assessing fracture stability and making treatment decisions.

Arthroscopy-assisted treatment of lateral clavicle fractures with coracoclavicular stabilization and an endobutton device have gained popularity over recent years. There is little evidence to support which types of lateral clavicle fractures are suitable for this treatment. The primary aim of this study was to evaluate the clinical und radiological outcomes of this treatment and to identify which fracture types are suitable. The secondary outcome was to evaluate potential risk factors for complications MATERIAL/METHODS: A retrospective single center review of 20 unstable lateral clavicle fractures treated with an arthroscopy-assisted CC stabilization technique and Endobutton device between September 2012 and August 2016. The functional outcome was evaluated using Constant and DASH Scores, VAS and SSV. Between September 2012 and August 2016, 20 patients were treated using this method (average age 45 years; male: female ratio 14:6). The DASH Score was on average 2.0 (0-9.82) and the Constant Score on average 81.8 points (range 68-93) with an average difference between the affected and the unaffected side of 4.1 points (range 0-15). Six patients had nonunion fractures of which two needed revision. Our study shows that arthroscopy-assisted CC stabilization using an endobutton technique delivers good functional results. Highly lateral unstable clavicle fractures seem to be especially suitable for this surgical technique. There was a high number of delayed unions. Analysis of risk factors showed that early mechanical stress, a lateral clavicular fragment larger than 3cm and a time delay to surgery could be risk factors for nonunions.

IntroductionLateral clavicle fractures often need to be stabilized by a plate osteosynthesis and due to the acting high forces a cut-out of the screws of the lateral fracture fragment can occur. New plates enable to place anterior screws in addition to the screws placed from the top of the clavicle. This experimental in-vitro study will determine whether they have a substantial biomechanical effect.Materials and methodsIn synthetic bones, lateral clavicle fractures were created and stabilized in 4 different groups: In Group A, a lateral clavicle plate was fixed with 3 screws in the lateral fracture fragment. In group B, the same type of plate was fixed with additionally two screws from anterior in the lateral fragment. In group C, a coraco-clavicular banding was added to the fixation method of group B. A similar plate from another company was used in group D with a screw fixation method comparable to group A. In a material testing machine, the specimens were loaded by dynamic and static tests. The mode of failure and pull-out forces were analyzed.ResultsIn the dynamic testing phase, five specimens failed already in group A and B, whereas in group C 11 specimens survived the cyclic tests. Lateral fractures and screw cut-out appeared in the static tests mostly in group A and B. In contrast, in group C, ten of eleven specimens failed by a medial fracture at the plate end. No significant differences were determined in-between groups for the displacement recorded by the optical system, even, when group A revealed the highest values of the groups A-C. In group D, the specimens showed an early screw cut-out of the lateral fracture fragment, and all failed during the dynamic testing phase.ConclusionsThe use of additional screws from anterior led in a significant lower cut-out and higher biomechanical stability at the lateral clavicle regarding axial tensile forces. From a biomechanical point of view, plates for stabilization of lateral clavicle fractures with additional screw holes from anterior and restoring the cc-bands is favorable to standard plates with screws from the top of the clavicle only.

Background: Lateral end clavicle fractures are common to end up in nonunion if not surgically treated, many interventions are advised for the surgical management of lateral end clavicle fractures. Precontoured lateralend clavicle locking plates (PLCLP) and clavicle hook plates (CHPs) are among the commonly used techniques; nonetheless, no single procedure is deemed to be the benchmark treatment. Thus, the aim of the study is to compare the functional outcome of lateral end clavicle fractures treated with precontoured lateral end clavicle plates verses CHP. Objectives: This study involves evaluating the functional outcome of lateral end clavicle fractures treated with precontoured lateral end clavicle locking plates verses CHP. Materials and Methods: In 20 patients with lateral end clavicle fractures 10 patients were treated with open reduction and internal fixation with precontoured lateral end clavicle locking plate and 10 patients treated with CHP at the Department of Orthopaedics MMCR and I, Mysore, from December 2020 to May 2022 with age from 18 years to 65 years. Clinical assessments for functional outcome were performed at 3 weeks, 12 weeks and 24 weeks interval and results were analyzed using the Constant and Murley score. Results: Twenty patients were followed for 6 months the mean Constant–Murley score, and in the PLCLP group were, 82.1 ± 5.2, at 12 weeks postoperatively. Scores were significantly better than those in the HP group 72.5 ± 4.1 (P < 0.05). At 24 weeks postoperatively, mean Constant–Murley score was 90 ± 4 in the PLCLP group and 80 ± 5 in the CHP group. Functional outcome is better and lesser complications among the group treated with precontoured lateral end clavicle locking plates compared to the group treated with CHP. Conclusion: Open reduction and internal fixation with precontoured lateral end clavicle locking plates provide better functional outcomes and fewer complications than those treated with CHP in treating lateral end clavicle fractures.

BackgroundAlthough of great value in the management of lateral clavicle fractures, substantial variation in their classification exists. We performed a retrospective study to address the inter- and intraobserver reliability of three different classification systems for lateral clavicle fractures.MethodsRadiographs of 20 lateral clavicle fractures that represented a full spectrum of adult fracture patterns were graded by five experienced radiologists and five experienced trauma surgeons according to the Orthopaedic Trauma Association (OTA), the Neer, and the Jäger/Breitner classification systems. This evaluation was performed at two different time points separated by 3 months. To measure the observer agreement, the Fleiss kappa coefficient (κ) was applied and assessed according to the grading of Landis and Koch.ResultsThe overall interobserver reliability showed a fair agreement in all three classification systems. For the OTA classification system, the interobserver agreement showed a mean kappa value of 0.338 ranging from 0.350 (radiologists) to 0.374 (trauma surgeons). Kappa values of the interobserver agreement for the Neer classification system ranged from 0.238 (trauma surgeons) to 0.276 (radiologists) with a mean κ of 0.278. The Jäger/Breitner classification system demonstrated a mean kappa value of 0.330 ranging from 0.306 (trauma surgeons) to 0.382 (radiologists).The overall intraobserver reliability was moderate for the OTA and the Jäger/Breitner classification systems, while the overall intraobserver reliability for the Neer classification system was fair.The kappa values of the intraobserver agreements showed, in all classification systems, a wide range with the OTA classification system ranging from 0.086 to 0.634, the Neer classification system ranging from 0.137 to 0.448, and a range from 0.154 to 0.625 of the Jäger/Breitner classification system.ConclusionsThe low inter- and intraobserver agreement levels exhibited in all three classification systems by both specialist groups suggest that the tested lateral clavicle fracture classification systems are unreliable and, therefore, of limited value. We should recognize there is considerable inconsistency in how physicians classify lateral clavicle fractures and therefore any conclusions based on these classifications should be recognized as being somewhat subjective.

Clinical and radiographic outcomes of a transosseous suture technique for displaced lateral clavicle fractures

BackgroundLateral clavicle fractures account for 17% of all clavicle fractures and large studies comparing nonoperative and operative treatment are lacking. Therefore, patients cannot be properly informed about different treatment options and prognosis. We assessed long-term patient-reported and clinical outcomes in patients with lateral clavicle fractures.MethodsA multicenter cross-sectional study was performed in patients treated for lateral clavicle fractures between 2007 and 2016. Primary outcome included patient-reported outcome measures (PROMs) (DASH, EQ-5D, return to work, sports, cosmetics and satisfaction). Questionnaires were sent to 619 eligible patients, of which 353 (57%) responded after a mean follow-up of 7.4 ± 2.8 years. Secondary outcome included adverse events and secondary interventions. Outcomes after nonoperative vs. operative treatment (stratified by nondisplaced vs. displaced fractures) were compared using Student t tests and linear regression analysis.ResultsNondisplaced lateral clavicle fractures were treated nonoperatively and resulted in excellent PROMs. Six patients (3%) developed a nonunion. For displaced lateral clavicle fractures, no differences were found between nonoperative and operative treatment with regard to DASH score (7.8 ± 12.5 vs 5.4 ± 8.6), EQ-5D (0.91 ± 0.13 vs 0.91 ± 0.09), pain (0.9 ± 1.7 vs. 0.8 ± 1.6), patient satisfaction (90.1 ± 25.5 vs. 86.3 ± 20.4), return to work (96.4% vs. 100%) and sports (61.4% vs. 62.3%). The absolute risk of nonunion in patients with a displaced fracture was higher after nonoperative than operative treatment (20.2% vs. 2.9%; p = 0.002), with six patients needing treatment to avoid one nonunion.ConclusionsNondisplaced lateral clavicle fractures should be treated nonoperatively and result in good functional outcomes and high union rates. For displaced fractures, neither nonoperative nor operative treatment seems superior. Patients opting for nonoperative treatment should be informed that nonunion occurs in 20% of patients, but only half of these need additional operative treatment. Patients who opt for surgery should be told that nonunion occurs in only 3%; however, most patients (56%) will require secondary intervention for elective implant removal. Regardless of the type of treatment, no differences in functional outcome and PROMs should be expected at long-term follow-up.

Introduction Due to an increased risk of complications, lateral clavicle fractures are usually managed operatively. Unfortunately, there is no consensus on the optimal method of fixation. Method We assessed practice in our regional trauma unit by retrospectively identifying patients who underwent fixation of a lateral clavicle fracture between 1st August 2014 and 31st July 2019. Data was extracted from electronic care records and imaging systems. Results 44 patients were included, with the following demographics: mean age 26 years, 63.6% male, 65.9% high energy injury, and 68.2% Neer II fracture. The following operations were performed; hook plate fixation (HPF) = 10, locking plate fixation (LPF) = 16, coracoclavicular ligament reconstruction (CCLR) = 12, and LPF + CCLR = 6. Patients having LPF had a significantly larger post-operative coracoclavicular distance (7.6mm vs 13.5mm, p < 0.01), and a trend towards incomplete acromioclavicular joint reduction (50.0% vs 89.3%, p = 0.11). There was a significantly higher re-operation rate after HPF (100% vs 23.5%, p < 0.01). Conclusions In our unit there is no favoured method of fixation of lateral clavicle fractures. When LPF is used, there should be consideration of concomitant CCLR. The high rate of re-operation after HPF must be considered.

Lateral clavicle fractures comprise a minority of all clavicle fractures and are associated with high rates of nonunion when managed nonoperatively. Various fixation methods have been described, including augmentation with coracoclavicular (CC) ligament repair or reconstruction. Outcomes following the surgical treatment of lateral clavicle fractures are limited to small case series and systematic reviews, and the literature within physically demanding populations remains sparse. We sought to describe the characteristics and complications of operative lateral clavicle fractures treated with CC ligament repair or reconstruction within the Military Health System. We queried the U.S. Military Health System Data Repository for patients with a lateral clavicle fracture treated with CC ligament repair or reconstruction between October 2013 and March 2020. We reviewed electronic health records, including patient demographics, radiographs, operative reports, and clinical notes, to assess injury characteristics, surgical constructs, postoperative complications, and functional outcomes. A total of 40 patients underwent CC ligament repair (n = 20, 50%) or reconstruction (n = 20, 50%) for treatment of lateral clavicle fractures during the study period. Twenty-two (55%) patients underwent surgery within 6 weeks of injury, and 40% (n = 18) required concomitant open reduction and internal fixation. Complications included adhesive capsulitis (n = 3, 7.5%), unplanned return to the operating room (n = 4, 10%), and loss of CC reduction (n = 10, 25%). Twenty-six (65%) patients achieved a full, pain-free range of motion. There was a statistically significant association between postoperative complications and shoulder pain or diminished range of motion (P = .026). Seven of 32 (21.9%) active-duty service members required medical separation from military service. Female sex (P = .04) and distal clavicle plate fixation increase the risk of unplanned return to the operating room (P = .01). Nicotine use was predictive of eventual military separation (P = .004). In this case, a series of lateral clavicle fractures treated with CC ligament repair or reconstruction, all patients achieved fracture union and the majority of patients regained full, pain-free range of motion. Complications were common and portended a poor functional outcome. At the conclusion of their fracture care, 1 in 5 active-duty patients necessitated medical separation from military service.

A biomechanical comparison of two plating techniques in lateral clavicle fractures

For most types of acromioclavicular (AC) injuries, treatment is well established. For Neer type 2 lateral clavicle fractures and Rockwood types 3-5 AC dislocations, the ideal treatment is still a point of debate. The purpose of this study was to evaluate the functional and radiological outcome in patients treated for one of these two lesions in our hospital. Our study group consisted of 30 patients with a Neer type 2 lateral clavicle fracture (n=19) or Rockwood types 3-5 AC dislocation (n=11) treated with the clavicle hook plate. All implants were removed after healing. At a mean follow-up of 40months (12-92), data were collected by the analysis of questionnaires (DASH, NSST, OSS, SF-36), clinical examination (Constant-Murley score), and radiological evaluation (Zanca view). The mean Constant score was 88 [standard deviation (SD) 8] compared to 92 (SD 6) on the contralateral non-operated side. The questionnaires resulted in the following scores: median DASH: 4.5 (0-70); median NSST: 100 (8-100); mean OSS: 41 (SD 8); mean SF-36: 81 (SD 12). The mean coracoclavicular (CC) and AC distances were not significantly different. This study suggests that hook plate fixation is a reliable treatment for Neer type 2 lateral clavicle fractures and Rockwood types 3-5 AC injuries. It results in a good and comparable function of the shoulder when compared to the contralateral side, high union rate, good to excellent objective and subjective results, and allows early active motion with limited abduction. A disadvantage is the necessity to remove the plate.

Differentiating and treating lateral clavicle fractures: a new simple classification system.

To assess the total number of procedures in initially surgically and nonsurgically treated patients with lateral clavicle fractures and to compare patient-reported outcome measures (PROMs). Retrospective cohort study. Level 1 trauma center. One hundred twenty-two patients with lateral clavicle fractures treated at Uppsala University Hospital from 2013 to 2015 were included in a patient record review. A subgroup of 30 patients was assessed at a study follow-up visit at a median of 3 years postinjury. Comparisons between initially surgically and nonsurgically treated patients. Rates of surgical treatment, reoperations, and delayed surgeries. PROM subgroup: Constant score; Disabilities of the Arm, Shoulder and Hand score; and Visual Analog Scale over satisfaction with the cosmetic results and interview-based information on subjective complaints and reflections. Of 23 surgically treated patients (22 Neer type II and V fractures), 10 underwent subsequent implant removal, after which 1 developed symptomatic nonunion. Of 99 nonsurgically treated patients (36 Neer type II and V fractures), 2 underwent delayed surgery because of symptomatic nonunion. In the PROM subgroup, the surgically treated patients had worse Constant scores, complained of infraclavicular sensory deficits, and were less satisfied with the cosmetic result than the nonsurgically treated patients. Half of the surgically treated patients underwent implant removal, whereas delayed surgeries in nonsurgically treated patients were very rare. Nonsurgical treatment should be considered more often as an alternative to surgery even for the usually surgically treated Neer type II and V lateral clavicle fractures. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Purpose: The current investigation was designed to evaluate and validate a simple assessment system focusing on outcomes on clavicle fractures. Method: To examine the new scoring system focusing on outcomes post-midclavicular fracture and lateral clavicle fractures, 312 patients were studied on average 17 months post-injury. The cohort included 33 patients with lateral clavicle fractures, 46 non unions after midclavicular fracture and 233 patients with midclavicular fractures. As a control group, the same parameters in 45 healthy volunteers were examined. The Cologne Clavicle Score (CCS) is based on a system of three partnered objective/subjective items as well as radiographic assessment of fracture healing. To validate the system, linear regression analysis was performed comparing the Cologne Clavicle Score to two established assessment systems (Score of Constant and Murley and the DASH Score). Results: The correlation coefficients R=0.756 (Constant) and R=0.687 (DASH) post midclavicular fractures and R=0.780 (Constant and DASH) post lateral clavicle fractures indicated that the conclusions were comparable to two established assessment systems and therefore valid. The reliability coefficient Cronbach’s Alpha was calculated at 0.8324, indicating high reliability. Conclusion: The CCS is a simple, valid, and reliable instrument to assess outcomes post-midclavicular fracture and lateral clavicle fractures. It needs application in further studies to fully evaluate the quality of its conclusions.