Lateral Clavicle Research Articles

Anatomic Reconstruction of Unstable Lateral Clavicular Fractures

Fractures of the lateral clavicle result in a high rate of nonunion compared with midshaft fractures. Many operative treatment methods of unstable lateral clavicle fractures have been described, but no single method has become generally accepted. This study reports our experience treating unstable lateral clavicle fractures with coracoclavicular ligament rupture. Within 7 years, 19 patients with acute unstable lateral clavicle fractures were treated using a 2.4-mm T-plate and a coracoclavicular polydioxanone cord. The follow-up averaged 5.3 years (range, 2.0-8.8). Shoulder function was assessed using the Constant score and Disabilities of the Arm, Shoulder and Hand score. General health of the patients was evaluated according to the Short Form 36 questionnaire. Eighteen of the 19 patients treated with our method achieved union at 8.8 weeks (range, 6-14), a Constant Murley score of 91.5 (range, 72-100) on the injured side versus 93.5 (range, 80-100) on the contralateral side, a Disabilities of the Arm, Shoulder and Hand score of 1.4 (range, 0-9.2), and a Short Form 36 Health Score of 85 (range, 89-100). One patient showed breakage of the plate and a delayed union at the radiologic follow-up 4 months after surgery. This study shows that treatment of unstable lateral clavicular fractures with an angular stable locking plate together with a polydioxanone cord ligament augmentation leads to excellent results with a 95% union rate. Additional coracoclavicular augmentation next to plate fixation of the clavicle may partially solve the problem of uncertain plate fixation if the lateral fragment is small and multifragmented, as often observed.

Comparing Hook Plates and Kirschner Tension Band Wiring for Unstable Lateral Clavicle Fractures

The purpose of this study was to compare outcomes and complications of clavicular hook plate and Kirschner tension band wiring for fixation of unstable lateral clavicle fractures. The surgical outcomes of 92 consecutive patients (mean age, 49.30 ± 15.54 years) with unstable fractures of the lateral clavicle treated using AO clavicle hook plates were compared with those of 24 patients (mean age, 50.67 ± 17.58 years) treated using K-wire tension banding. Patients in the hook plate and K-wire groups were followed up for 22.76 ± 2.22 and 25.67 ± 2.75 months, respectively (P<.001). The time to hardware removal was significantly shorter (P<.001) in the hook plate group (5.20 ± 1.93 months) compared with the K-wire group (7.58 ± 2.00 months), whereas the Constant-Murley score was significantly higher (P<.001) in the hook plate group (90.43 ± 4.78) compared with the K-wire group (85.63 ± 5.38) at final follow-up. There were 12 complications in the hook plate group and 7 in the K-wire group (P=.069). Complications in the hook plate group included 7 periprosthetic fractures, 4 plate removals, and 1 plate malposition. Complications in the K-wire group included 3 K-wire migrations, 3 losses of reduction, and 1 wire breakage. We found that hook plate fixation of unstable lateral clavicle fractures was associated with statistically better shoulder function and earlier implant removal than K-wire tension band fixation, with an equivalent rate of complications. Our findings suggest that hook plates are useful for treating unstable lateral clavicular fractures.

Clavicle hook plate fixation for displaced lateral-third clavicle fractures (Neer type II): a functional outcome study

Controversy exists with the use of the acromioclavicular hook plate for the treatment of lateral-third clavicle fractures (Neer type II). This is thought to stem from problems associated with the hook plate causing impingement symptoms, which can cause long-term limitation of movement and pain. Our aim was to evaluate the functional outcomes of patients with lateral-third clavicle fractures treated with the hook plate. We prospectively reviewed all patients who underwent surgery from July 2005 to August 2009 using our prospectively recorded electronic patient information database. All patients were assessed in the clinic to determine both Oxford and Constant shoulder scores. We identified 36 patients who underwent surgery with the hook plate, 26 men and 10 women. The mean age was 36.2 years (range, 22-60 years). Of the patients, 46% were smokers. The median length of hospital stay was 2 days (interquartile range [IQR], 1-3). The median follow-up was 28 months (IQR, 23-37). The median time from date of injury to surgery was 7 days (IQR, 4-76). The mean time to union was 3 months (IQR, 2-4), and the union rate was 95%. In total, 92% of plates were removed. The median time to removal was 4.5 months (IQR, 3-8.75). There were no complications. Two patients presented months later after falls with fractures around the medial end of the hook plate. Hook plates are an effective form of treatment for lateral third clavicle fractures. The best outcomes occur with plate removal before 6 months postoperatively, provided that the fracture has healed.

Minimally invasive plate osteosynthesis using anterior–inferior plating of clavicular midshaft fractures

This study evaluated the clinical and radiological outcomes of acute displaced clavicular midshaft fractures treated with minimally invasive plate osteosynthesis (MIPO). Fifteen patients with acute displaced clavicular midshaft fractures underwent MIPO. A locking reconstruction plate was applied on the anterior aspect of the clavicle through two small incisions. Functional outcomes were assessed using range of shoulder motion and University of California Los Angeles (UCLA) shoulder score. Radiological evaluation included time to union, fracture healing, and clavicular length difference measured as proportional length difference with the unaffected side. All fractures healed within a mean of 15.1 weeks postoperatively. The mean proportional length difference was 0.66 ± 2.2% compared with the unaffected arm. Shoulder motion recovered to pre-injury activity level in all patients. The UCLA shoulder scores showed excellent results in 13 patients and good results in two patients. Nonunion and implant failures were not found in any patients. One patient complained of temporary hypoesthesia around the lateral clavicle area. MIPO using anterior-inferior plating for acute displaced clavicular midshaft fractures provided satisfactory clinical outcomes without serious complications and could be an effective alternative option to conventional operative treatments.

Report of a Rare Case of Gorham-Stout Disease of Both Shoulders: Bisphosphonate Treatment and Shoulder Replacement

Massive osteolysis known as Gorham-Stout disease is a rare idiopathic disorder typically affecting long bones in a unifocal pattern. Angiomatosis is strongly connected to the osteolysis. Weather angiomatosis is the cause or the result of osteolysis is subject of intense discussion (Kawasaki et al. (2003), Möller et al. (1999), Radhakrishnan and Rockson (2008)). There are about 200 cases described since 1955. Our patient is a 77-year-old female patient with osteolyses of both shoulders involving the proximal humerus, lateral clavicle, and the glenoid. Under bisphosphonate therapy, the progressive osteolysis stopped on the right side and showed progression on the left. With the patient complaining about severe rest pain and impaired function, we performed surgical reconstruction by implantation of total shoulder prosthesis three months after onset of symptoms. Our case shows a possibility of primary and early surgical reconstruction with good clinical outcome.

Mid-term results after operative treatment of rockwood grade III-V Acromioclavicular joint dislocations with an AC-hook-plate

Acromioclavicular joint dislocations often occur in athletic, young patients after blunt force to the shoulder. Several static and dynamic operative procedures with or without primary ligament replacement have been described. Between February 2003 and March 2009 we treated 313 patients suffering from Rockwood III-V lesions of the AC joint with an AC-hook plate. 225 (72%) of these patients could be followed up. Mean operation time was 42 minutes in the conventional group and 47 minutes in the minimal invasive group. The postoperative pain on a scale from 1 to 10 (VAS-scale) was rated 2.7 in the conventional group and 2.2 in the minimal invasive group. Taft score showed very good and good results in 189 patients (84%). Constant score showed an average of 92.4 of 100 possible points with 89% excellent and good results and 11% satisfying results. All patients had some degree of pain or discomfort with the hookplate in place. These symptoms were relieved after removal of the plate. The overall complication rate was 10.6%. There were 6 superficial soft tissue infections, 1 fracture of the acromion, 7 redislocations after removal of the hook-plate. We observed 4 broken hooks which could be removed at the time of plate removal, 4 seromas and 2 cases of lateral clavicle bone infection, which required early removal of the plate. We can conclude that clavicle hook plate is a convenient device for the surgical treatment of Rockwood Grade III-V dislocations, giving good mid-term results with a low overall complication rate compared to the literature. Early functional therapy is possible and can avoid limitations in postoperative shoulder function.

An anatomic study of the coracoid process as it relates to bone transfer procedures

The Latarjet and Bristow procedures address recurrent anterior shoulder instability in the context of a significant bony defect. However, the bony and soft tissue anatomy of the coracoid as they relate to coracoid transfer procedures has not yet been defined. The purpose of this study was to describe the soft tissue attachments of the coracoid as they relate to the bony anatomy and to define the average amount of bone available for use in coracoid transfer. Ten paired fresh frozen shoulders from deceased donors were dissected, exposing the coracoid, lateral clavicle, and acromion, along with the coracoid soft tissue attachments. The bony dimensions of the coracoid and the locations and sizes of the soft tissue footprints of the coracoid were measured. The mean maximum length of the coracoid available for transfer (ie, distance from the coracoid tip to the anterior border of the coracoclavicular ligament) was 28.5 mm. The mean distance from the coracoid tip to the anterior pectoralis minor was 4.6 mm, to the posterior pectoralis minor was 17.7 mm, to the anterior coracoacromial ligament was 7.8 mm, and to the posterior coracoacromial ligament was 25.7 mm. Average dimensions of the bony coracoid and average locations and sizes of coracoid soft tissue footprints are provided. This anatomic description of the coracoid bony anatomy and its soft tissue insertions allows surgeons to correlate the location of their coracoid osteotomy with the soft tissue implications of the coracoid transfer as the native anatomy is manipulated in these nonanatomic procedures.

Anatomically contoured locking plate fixation for unstable fractures of the lateral clavicle

Anatomically contoured locking plate fixation for unstable fractures of the lateral clavicle

Double-Plate Fixation in Lateral Clavicle Fractures—A New Strategy

Lateral clavicle fractures Neer type II often lead to the dislocation of the medial fragment and an increased rate of nonunion after conservative treatment. Therefore, most authors recommend an open reduction and internal fixation. Double-plate fixation is a common technique in the treatment of complex radius fractures. The authors use it as a routine procedure in the treatment of lateral clavicle fractures Neer type II. In this article, we present our experiences. From January 2006 to June 2008, 11 patients with lateral clavicle fractures of Neer type II were treated with an open reduction and internal fixation using the double-plate technique. All patients showed osseous union on radiographs after 10 weeks to 16 weeks. In eight of nine cases, the operated shoulder regained full range of motion. In all patients, we observed immediate postoperative recovery without severe complications. One female patient complained about slight pain and restricted motion in abduction of > 90°. In two patients, we observed the migration of one screw. It was removed under local anesthesia 9 weeks and 26 weeks after surgery. This study, for the first time, describes the technique of double-plate fixation for the treatment of lateral clavicle fractures. This technique provides a stable fixation even in small and comminuted distal fragments.

Early Acromial Erosion with the Synthes Hook Plate: An Unusual Complication and Its Treatment

We report an unusual case of early erosion of acromion with a Hook-plate used for fixation of lateral clavicle fracture. The management options and treatment is discussed further.

Local and nerve block techniques for analgesia after shoulder surgery

Local and nerve block techniques for analgesia after shoulder surgery

Dynamic Radiologic Evaluation of Horizontal Instability in Acute Acromioclavicular Joint Dislocations

Background: Biplane radiologic evaluation is indispensable for the correct diagnosis of acute acromioclavicular (AC) joint injuries. Thus far, no functional radiographic techniques have been quantified to evaluate horizontal instability in acute AC joint dislocations. Hypothesis: Supine dynamic axillary lateral shoulder views detect horizontal instability of the distal clavicle in patients with acute AC joint dislocations. Study Design: Cohort study (Diagnosis); Level of evidence, 2. Methods: Twenty-five consecutive patients with a mean age of 39 ± 14 years with acute AC joint injury underwent biplane radiologic evaluation, including a conventional Zanca view and an axillary lateral view in a sitting position. In addition, supine axillary lateral views with the arm in 90° of abduction and 60° of flexion and extension were taken to evaluate the horizontal dynamics of the distal clavicle. The gleno-acromio-clavicular angle (GACA) was introduced and used to quantify the horizontal clavicular dynamics in terms of angle differences. The unaffected shoulders served as the control group. Results: Superior dislocation of the lateral clavicle in the Zanca view was classified as Rockwood type II in 7 patients, type III in 15, and type V in 3. The axillary lateral view in a sitting position showed posterior dislocation of the distal clavicle in 8 patients (Rockwood type IV injury). Dynamic radiologic evaluation revealed an average GACA difference between the neutral and anterior position of the arm of 7.1° ± 5.5° for the unaffected shoulder. In the injured AC joints, 11 patients showed no radiologic evidence of horizontal instability (group A) with a GACA difference of 7.1° ± 4.8°. Increased anteroposterior translation was evident in 14 patients (group B) with a GACA difference of 30.3° ± 14.3° (P < .001). Conclusion: Functional axillary radiologic evaluation seems to represent a simple imaging tool to reveal dynamic horizontal instability. Clinical Relevance: Horizontal instability of the distal clavicle in acute AC joint injuries represents an indication for surgical treatment. Dynamic axillary radiologic evaluation may detect previously missed unstable injuries. This evaluation might be relevant when deciding on surgical AC joint stabilization.

Analgesic Effectiveness of a Continuous Versus Single-Injection Interscalene Block for Minor Arthroscopic Shoulder Surgery

The utility of continuous perineural infusions for lesser painful shoulder procedures is not well established. We hypothesized that the addition of a continuous interscalene ropivacaine infusion to a single-injection interscalene block would improve analgesia after minor arthroscopic shoulder surgery. An ultrasound-guided interscalene catheter targeting the C5-C6 roots/superior trunk was placed preoperatively in patients undergoing arthroscopic subacromial decompression, excision lateral clavicle, or stabilization. Ropivacaine 0.5% 30 mL was administered via this catheter before surgery was conducted under general anesthesia. All patients received dexamethasone and ondansetron antiemetic prophylaxis. At surgery conclusion, patients were randomly assigned to catheter removal in the postanesthesia care unit ("SS," n = 30) or to an elastomeric infusion of ropivacaine 0.2% 2 mL/hr with patient-controlled 5-mL boluses every hour ("Continuous," n = 31). Multimodal analgesia (acetaminophen, diclofenac, and rescue tramadol) was administered in both groups. Patients were questioned on postoperative days 1 and 2 for numerical rating pain score (0-10), supplemental tramadol consumption, and adverse effects of treatment. Median (quartiles) worst numerical rating pain score was lower in the Continuous group on day 1 on movement (SS = 4 [3-6], Continuous = 2 [0-4], P = 0.008) and at rest (SS = 2 [2-5], Continuous = 1 [0-3], P = 0.007) but was similar between groups on day 2. Median (quartiles) tramadol tablet consumption was lower in the Continuous group on both day 1 (SS = 1 [0-2], Continuous = 0 [0-0], P < 0.001) and day 2 (SS = 1 [0-2], Continuous = 0 [0-1], P = 0.017). Adverse effects of treatment were similar between groups except for numerically rated arm numbness, which was higher for the Continuous group. One patient in the SS group required 2 nights of hospitalization for intravenous opioid. After minor arthroscopic shoulder surgery, the addition of a continuous interscalene ropivacaine infusion to a single-shot interscalene block reduces pain, especially with movement, during the first 24 hrs.

Die Fraktur der lateralen Klavikula

Fractures of the lateral clavicle end account for 12-15 percent of all clavicle fractures. In contrast to the clear treatment of midshaft fractures the therapy of the distal third is still open to controversy. The high non-union rate up to 40 percent that occurs with the lateral end fractures shows the special biomechanical mechanisms. The role of the coracoclavicular ligaments is comparable to the acromioclavicular joint disruption. To make a clear decision about the therapy we need a treatment based classification such as the one by Jäger and Breitner, which distinguishes four different fracture types. The treatment options reach from conservative therapy up to numerous different operative techniques. The aim of this article is to demonstrate a simple and save way for the diagnosis and therapy of that special kind of fracture.

Impact of work-related compensation claims on surgical outcome of patients with rotator cuff related pathologies: A matched case-control study

The purpose of this matched case-control study was to examine the impact of an active compensation claim following a work-related shoulder injury on reporting disability, as measured by subjective and objective outcomes at 1 year postoperatively. Data of 517 consecutive patients who had undergone a decompression or rotator cuff repair were reviewed. One-hundred and ten patients were on compensation related to their shoulder problems. These patients were matched with a historical control group (patients without a compensation claim) based on age, sex, and level of pathology. Outcome measures used were the Western Ontario Rotator Cuff Index, the American Shoulder and Elbow Score, and the Constant-Murley score. Nonparametric Wilcoxon and Ranked sign tests were conducted to examine the difference between and within groups. Data of 220 patients were used for analysis (mean age, 48+/-10; range, 20-69). Out of 110 patients in each group, 45 patients (41%) had undergone a repair and 65 (59%) had undergone a decompression surgery (acromioplasty with or without resection of lateral clavicle). Both groups improved significantly regardless of their claim status (P < .0001). There was a significant difference between injured and noninjured workers at baseline, 1-year postoperatively, and in overall improvement with the compensation group having a significantly higher level of disability. Our results show that although injured workers report a statistically significant higher level of disability before and after rotator cuff surgery, they still show significant improvement 1 year following decompression or repair of the rotator cuff tendon(s).

Analysis of the Capsule and Ligament Insertions About the Acromioclavicular Joint: A Cadaveric Study

The purpose of this study was to analyze the capsular and ligamentous insertions about the acromioclavicular (AC) joint to determine the amount of bone that can be removed without destabilizing the joint. We dissected 28 cadaveric shoulders. The AC ligament insertions were measured under loupe magnification with a digital caliper on the acromial and clavicular sides on the anterior, posterior, superior, and inferior edges. We measured the distance to the coracoacromial (CA) and coracoclavicular ligaments. In addition, the axial and coronal angle of the AC joint was measured. The AC joint capsular insertion on the acromion begins, on average, 2.8 mm (range, 2.3 to 3.3 mm) from the medial acromion and begins on the lateral clavicle a mean of 3.5 mm (range, 2.9 to 3.9 mm) from the distal clavicle. The mean capsular width ranged from 1.6 to 2.9 mm. The mean distance from the medial acromion to the CA ligament insertion was 3.5 mm. The mean axial angle of the AC joint was 51 degrees , with a 12 degrees coronal angle. The mean distance from the lateral clavicle to the start of the trapezoid ligament was 14.7 mm, and that to the conoid ligament was 32.1 mm. An anatomic-based recommendation for safe AC joint resection is that 2 to 3 mm of the medial acromion and 3 to 4 mm of the distal clavicle can be resected without removing the AC capsular insertions. The trapezial and CA attachments are in close proximity to the AC capsular insertions. Medial resections greater that 15 mm will begin to take down the trapezoid ligament. Arthroscopic bone resection should be directed into the AC joint at approximately 50 degrees in the axial plane and 12 degrees in the coronal plane for safe symmetric resection. These anatomic measurements suggest that AC joint resections (5 to 7 mm) with 2 to 3 mm from the acromial side and 3 to 4 mm from the clavicular side will not disrupt the stabilizing ligaments of the AC joint after distal clavicle resection.

The Clavicle Hook Plate for Neer Type II Lateral Clavicle Fractures

To evaluate functional and radiologic outcome in patients with a Neer type II lateral clavicle fracture treated with the clavicle hook plate. Multicenter retrospective study. Five level I and II trauma centers. Forty-four patients, average age 38.4 years (18-66 years), with a Neer type II lateral clavicle fracture treated with the clavicle hook plate between January 1, 2003, and December 31, 2006. Open reduction and internal fixation with the clavicle hook plate. Removal of all 44 implants after consolidation at a mean of 8.4 months (2-33 months) postoperatively. At an average follow-up of 27.4 months (13-48 months), functional outcome was assessed with the Constant-Murley scoring system. Radiographs were taken to evaluate consolidation and to determine the distance between the coracoid process and the clavicle. The average Constant score was 92.4 (74-100). The average distance between the coracoid process and the clavicle was 9.8 mm (7.3-14.8 mm) compared with 9.4 mm (6.9-14.3 mm) on the contralateral nonoperative side. We observed 1 dislocation of an implant (2.2%), 2 cases of pseudarthrosis (4.5%), 2 superficial wound infections (4.5%), 2 patients with hypertrophic scar tissue (4.5%), and 3 times an acromial osteolysis (6.8%). Thirty patients (68%) reported discomfort due to the implant. These implant-related complaints and the acromial osteolysis disappeared after removal of the hook plate. With all the patients, direct functional aftercare was possible. The clavicle hook plate is a suitable implant for Neer type II clavicle fractures. The advantage of this osteosynthesis is the possibility of immediate functional aftercare. We observed a high percentage of discomfort due to the implant; therefore, we advise to remove the implant as soon as consolidation has taken place.

Neurofibroma With Clear Cell Change

Cutaneous clear cell proliferations and degenerative change have been seen in a variety of entities including nevi, dermatofibromas, fibrous papules, atypical fibroxanthomas, basal cell carcinomas, and squamous cell carcinomas, to name a few. However, there have been no reports of clear cells within neurofibromas. We received a biopsy and excision from a 61-year-old man with a papule on his right lateral clavicle. The initial biopsy showed a proliferation of clear cells that stained positive with S-100 and focally with CD68. A clear cell granular cell tumor was favored. Subsequent excision showed the same population of clear cells as seen on the initial biopsy. Interestingly, a neurofibroma was also present immediately beneath the clear cells with areas of transition. A p75 stain highlighted both populations of cells. This is the first case of neurofibroma with clear cells reported in the literature. We postulate that the clear cells are due to degenerative change.

Free Functional Gracilis Muscle Transplantation for Reconstruction of Active Elbow Flexion in Posttraumatic Brachial Plexus Lesions

Reconstruction of powerful active elbow flexion. Reconstruction of missing muscle unit by neurovascular pedicled functional muscle transplantation. Treatment of last choice for --secondary reconstruction of active elbow flexion in case of complete lesion of the brachial plexus or musculocutaneous nerve (M0 muscle function = replacement indication), partial but incomplete lesion of the brachial plexus or musculocutaneous nerve (M1-(3) muscle function = augmentation indication); --replacement of the elbow flexor muscles in case of primary muscle loss (tumor, trauma). Concomitant lesions of the axillary artery. No adequate donor nerve. Relative: no sensibility at all at the forearm and hand. Free functional biarticular myocutaneous transplantation of gracilis muscle. A myocutaneous gracilis flap is raised at the thigh. At the upper arm the flap is fixed proximally to the coracoid process or the lateral clavicle. The distal insertion is sutured to the distal biceps tendon. Vascular anastomoses are carried out in end-to-side fashion with the brachial artery and vein. Nerval coaptation is done in end-to-end technique using the muculocutaneous nerve. Complete immobilization for 6 weeks. Dorsal upper arm splint until sufficient muscle power (M(4)). Progressive increase of active range of motion for another 6 weeks. Continuation of physiotherapy for 12-18 months. Postoperative standardized compression therapy, combined with scar therapy (silicone sheet). Functionally useful results can be expected in 60-75% of patients, especially if there is some residual function (M1 or M2) left ("augmentation indication"). Early free functional muscle transplantation shows best results in patients with direct muscle defect, because all vascular and neuronal structures are still available, and no secondary changes such as fibrosis or joint stiffness are present yet. There are inconsistent results for patients with neurologic insufficiency (i.e., total brachial plexus palsy) or mixed neuromuscular insufficiency, such as compartment syndrome. Especially in complete brachial plexus lesion, free functional muscle transfer is often the only treatment option. Provided there is a good patient selection, satisfactory results can be achieved for elbow flexion. Whether a higher number of axons, as provided by the contralateral C7 transfer, will lead to better results is the topic of an ongoing study.

Bipolar segmental clavicle fracture

We present a case of a combined medial and lateral segmental clavicle fracture. Open reduction and internal fixation of both fractures was performed with a return to full activities. Combined medial and lateral fractures of the clavicle are exceptionally rare. The relevant medical literature and treatment of this injury is discussed.