Middle-third Clavicle Fractures Research Articles

Stability of mid-shaft clavicle fractures after plate fixation versus intramedullary repair and after hardware removal

Operative treatment for middle-third clavicle fractures has been increasing as recent data has demonstrated growing patient dissatisfaction and functional deficits after non-operative management. A controlled biomechanical comparison of the characteristics of locked intramedullary (IM) fixation versus superior pre-contoured plating for fracture repair and hardware removal is warranted. Therefore, the purpose of the present study was to investigate potential differences between these devices in a biomechanical model. Thirty fourth-generation composite clavicles were randomized to one of five groups with 6 specimens each and tested in a random order. The groups tested were intact, repair with plate, repair with IM device, plate removal, and IM device removal. The lateral end of the clavicles was loaded to failure at a rate of 60 mm/min in a cantilever bending setup. Failure mechanism, energy (J), and torque (Nm) at the site of failure were recorded. Failure torque of the intact clavicle (mean ± standard deviation) was 36.5 ± 7.3 Nm. Failure torques of the IM repair (21.5 ± 9.0 Nm) and plate repair (18.2 ± 1.6 Nm) were not significantly different (n.s.) but were significantly less than the intact group (P < 0.05). Failure torque following IM device removal (30.2 ± 6.5 Nm) was significantly greater than plate removal (12.9 ± 2.0 Nm) (P < 0.05). No significant differences were observed between the intact and IM device removal groups (n.s.). The results of the current study demonstrate that IM and plate devices provide similar repair strength for middle-third clavicle fractures. However, testing of the hardware removal groups found the IM device removal group to be significantly stronger than the plate removal group.

Middle-Third Clavicle Fracture With Associated Type IV Acromioclavicular Separation: Case Report and Literature Review

Review of available English literature suggests that combined injuries involving a clavicle shaft fracture and an acromioclavicular (AC) separation are rare. The force dissipation after the occurrence of either a midshaft clavicle fracture or an AC separation typically renders the injuries mutually exclusive. This article presents a review of literature on this combined injury pattern. A variety of treatment approaches have been put forth, including nonoperative, operative, and hybrid management of the two distinct injuries. The most appropriate treatment rendered depends on the degree of AC joint instability. This case report involves a midshaft clavicle fracture associated with a type IV AC separation in a patient ejected during a high-speed motor vehicle collision. Internal fixation of each injury was chosen and the patient had a successful final result. Other reported treatment options and recommendations are reviewed.

Evolving Management of Middle-Third Clavicle Fractures in the National Football League

Background Clavicle fractures have historically been managed nonoperatively. Recent literature suggests a subset of clavicle fractures may be best treated with primary surgical treatment. Purpose To review the National Football League (NFL) experience in the management of middle-third clavicle fractures over a 5-year period. Study Design Case series; Level of evidence, 4. Methods A retrospective review of clavicle fractures that occurred during a 5-season period was obtained from the NFL Injury Surveillance System. A detailed questionnaire was also sent to the medical staff of all 32 NFL teams. Results Nineteen players sustained a middle-third clavicle fracture over the 5-year period. Six fractures were nondisplaced or minimally displaced. All 6 healed at an average time of 7.3 weeks. Thirteen fractures were 100% displaced. Six of the 13 underwent acute surgical fixation that resulted in fracture healing without complication at an average of 8.8 weeks. The remaining 7 players with a completely displaced fracture were initially treated nonoperatively. Three of these 7 healed clinically without sequela at an average of 13.3 weeks after injury; however, 4 players sustained a refracture within 1 year of the initial injury. Conclusion Over the past 5 years, nearly 50% of NFL players with a completely displaced middle-third clavicle fracture were treated successfully with acute surgical fixation without sequela and healed at an average of 8.8 weeks. Three of these players were able to return to play during the same season. In addition, 4 of 7 players initially treated nonoperatively for a completely displaced middle-third clavicle fracture refractured their clavicle within a 1-year period from their initial injury. The 4 players missed an average of 1.5 seasons because of their clavicle injury and subsequent clinical course. Based on this review, it may be reasonable to consider acute surgical treatment of this injury in the NFL player to enable a successful clinical outcome in a predictable time frame.

Anterior-inferior plating of middle-third fractures of the clavicle

IntroductionVarious techniques have been reported for the treatment of middle-third clavicle (collar bone) fractures. This prospective study was conducted to evaluate the results of anterior-inferior plating using a 3.5-mm reconstruction plate for the treatment of middle-third clavicle fractures.Patients and methodsTwenty-six patients with middle-third clavicle fractures were treated with anterior-inferior plating. The indications for surgery included complete displacement, severe comminution, and marked shortening of the clavicle (>2 cm).ResultsThe mean time to union was 14 weeks (range 8–20 weeks). At the time of latest follow-up, all of the patients had returned to their pre-injury activity level. The plates were removed in ten patients after the fractures healed. No patients required plate removal due to implant-related problems.ConclusionAnterior-inferior plating is an effective treatment modality for middle-third clavicle fractures, with few complications and early return of shoulder function. The procedure provides stable fixation, avoids risk to vital structures below the clavicle, and is associated with a low rate of implant-prominence problems.

The anatomic relationship of the axillary artery and vein to the clavicle: A cadaveric study

Clavicle fractures are common, accounting for 5% to 12% of all fractures. 2 Basamania C.J. Craig E.V. Rockwood Jr., C.A. Fractures of the clavicle. in: Rockwood C.A. Matsen III, F.A. Wirth M.A. Lippitt S.B. The shoulder. 3rd ed. Saunders, Philadelphia2004: 455-519 Google Scholar , 31 Rowe C.R. An atlas of anatomy and treatment of midclavicular fractures. Clin Orthop Relat Res. 1968; 58: 29-42 Crossref PubMed Google Scholar Eighty percent of fractures occur in the middle third. 25 Neer II, C.S. Nonunion of the clavicle. J Am Med Assoc. 1960; 172: 1006-1011 Crossref PubMed Scopus (446) Google Scholar Traditionally, the results of nonoperative management for these middle-third clavicle fractures have been thought to be good, with a rate of nonunion between 0.1% and 5%. 2 Basamania C.J. Craig E.V. Rockwood Jr., C.A. Fractures of the clavicle. in: Rockwood C.A. Matsen III, F.A. Wirth M.A. Lippitt S.B. The shoulder. 3rd ed. Saunders, Philadelphia2004: 455-519 Google Scholar , 25 Neer II, C.S. Nonunion of the clavicle. J Am Med Assoc. 1960; 172: 1006-1011 Crossref PubMed Scopus (446) Google Scholar , 28 Robinson C.M. Fractures of the clavicle in the adult. Epidemiology and classification. J Bone Joint Surg Br. 1998; 80: 476-484 Crossref PubMed Scopus (644) Google Scholar However, there is increasing recognition of functional impairment after malunion of these fractures, especially where the clavicle is significantly shortened. 1 Altamimi S.A. McKee M.D. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. Surgical technique. J Bone Joint Surg Am. 2008; 90: 1-8 PubMed Google Scholar , 9 Chan K.Y. Jupiter J.B. Leffert R.D. Marti R. Clavicle malunion. J Shoulder Elbow Surg. 1999; 8: 287-290 Abstract Full Text PDF PubMed Scopus (91) Google Scholar , 21 Ledger M. Leeks N. Ackland T. Wang A. Short malunions of the clavicle: an anatomic and functional study. J Shoulder Elbow Surg. 2005; 14: 349-354 Abstract Full Text Full Text PDF PubMed Scopus (145) Google Scholar , 24 McKee M.D. Wild L.M. Schemitsch E.H. Midshaft malunions of the clavicle. J Bone Joint Surg Am. 2003; 85: 790-797 Crossref PubMed Scopus (235) Google Scholar As a result of this and the identification of groups of patients with a high risk of nonunion, 7 Brinker M.R. Edwards T.B. O'Connor D.P. Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. J Bone Joint Surg Am. 2005; 87: 676-677 PubMed Google Scholar , 12 Gossard J.M. Closed treatment of displaced middle-third fractures of the clavicle gives poor results [letter]. J Bone Joint Surg Br. 1998; 80: 558 PubMed Google Scholar , 14 Hill J.M. McGuire M.H. Crosby L.A. Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg Br. 1997; 79: 537-539 Crossref PubMed Scopus (560) Google Scholar , 29 Robinson C.M. Court-Brown C.M. McQueen M.M. Wakefield A.E. Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. J Bone Joint Surg Am. 2004; 86: 1359-1365 PubMed Google Scholar , 35 Wick M. Muller E.J. Kollig E. Muhr G. Midshaft fractures of the clavicle with a shortening of more than 2 cm predispose to nonunion. Arch Orthop Trauma Surg. 2001; 121: 207-211 Crossref PubMed Scopus (109) Google Scholar there has been increased interest in internal fixation of selected clavicle fractures. The availability of site-specific locking plates and intramedullary fixation devices has facilitated this change in practice. Neurovascular complications have been reported from both plate osteosynthesis 8 Casselman F. Vanslembroek K. Verougstraete L. An unusual cause of thoracic outlet syndrome. J Trauma. 1997; 43: 142-143 Crossref PubMed Scopus (29) Google Scholar , 16 Johnson B. Thursby P. Subclavian artery injury caused by a screw in a clavicular compression plate. Cardiovasc Surg. 1996; 4: 414-415 Crossref PubMed Scopus (33) Google Scholar , 32 Shackford S.R. Connolly J.F. Taming of the screw: a case report and literature review of limb-threatening complications after plate osteosynthesis of a clavicular nonunion. J Trauma. 2003; 55: 840-843 Crossref PubMed Scopus (45) Google Scholar and intramedullary fixation of midshaft clavicle fractures. 27 Ring D. Holovacs T. Brachial plexus palsy after intramedullary fixation of a clavicular fracture. A report of three cases. J Bone Joint Surg Am. 2005; 87: 1834-1837 Crossref PubMed Scopus (46) Google Scholar