ANATOMY – WHAT IS THE CLAVICLE?
The clavicle is the shoulder bone that connects the torso with the upper limb. It is a long, S-shaped, wavy bone located just below the skin (subcutaneously). The middle part of the clavicle protects significant structures, such as the brachial plexus and the axillary artery. It also plays an important role in abduction and upper extremity adduction. On the outer side it is articulated with the scapula and on the inner side with the sternum and the first rib. Many times, due to its location and form, it is vulnerable to injuries.
ETIOLOGY – HOW IS THE CLAVICLE INJURED?
Fractures of the clavicle are often caused by a direct strike on the shoulder. This can happen during a simple fall on the shoulder or after a car accident. Frequently, the fractures of the clavicle can be caused by a fall with the upper extremity extended.
Overall, the clavicle injury mechanisms mentioned in the literature include simple falls, falls from height, various sports injuries, traffic accidents and violence. Injuries associated with clavicle fractures sometimes include neovascular injuries (brachial plexus, axillary artery), rib fractures, lung compression and other skeletal injuries (acromioclavicular and sternoclavicular distention or separation).
CLASSIFICATION – TYPES OF CLAVICLE FRACTURES
Fractures of the clavicle may be open or closed, simple or complex with multiple pieces, dislocated or not. Fracture localization can also be important. Topographically, they are classified as fractures of the outer third (15%) of the medial (80%) and the inner third (5%) of the clavicle.
In particular, the fractures of the outer third of the clavicle are classified as follows:
Type I: Between the coraco-clavicular ligaments (conoid-trapezoid). Minimum dislocation
Type II: Fracture in the joint. Dislocated
Type III: Ligaments intact. Fracture at the level of the acromio-coracoid joint.
SYMPTOMATOLOGY – WHAT ARE THE SYMPTOMS AFTER A CLAVICULAR FRACTURE?
Usually the fracture of the clavicle is accompanied by severe pain and nausea or bruising. The patient, depending on the type of fracture, exhibits obvious shoulder deformity or asymmetry due to the displacement of the fractured pieces. In addition, the shoulder may appear comparatively shorter or visibly enlarged due to bleeding edema (hematoma). The swelling is absorbed over time and the bruising disappears in a few weeks. Usually, the patient reports severe pain when trying to move the limb with “clicking” due to friction of the fractured parts.
TREATMENT – HOW DO THE CLAVICLE FRACTURES ARE TREATED?
Clavicle fractures account for 2.6% of all fractures while the incidence rate is 64 per 100,000 fractures per year. Recent studies have been able to offer valid therapeutic options for the most common type of clavicle fracture, the medial third.
In summary, the results of these studies show that when a fracture has a high degree of displacement, internal osteosynthesis (ORIF) surgery is recommended. In this way, patients exhibit better functional outcomes and a lower rate of complications, such as nonunion and malunion.
Fractures of the clavicle can be treated conservatively or surgically depending on the type of fracture and the case. Fractures that do not exhibit significant displacement or comminution are treated conservatively. Fractures that are highly dislocated, open fractures with puncture and damage to the skin or comminuted fractures may need to be treated surgically. Also, fractures at the distal end of the clavicle may affect the acromioclavicular joint and may in turn require surgical treatment.
Surgery is highly recommended if the fracture is open (skin perforation), if the skin is damaged, or if it is at risk due to bone tension. Related indications include a patient with multiple traumas, seizures or severe shoulder injuries (floating shoulder).
According to the most recent literature, indications for surgical treatment are: total dislocation (at 100%) of the fractured parts, 2 cm of clavicle shortening (fracture overlap), or comminuted fracture.
TREATMENT OF MEDIAL CLAVICLE FRACTURES – HOW DOES THE MEDIAL CLAVICLE FRACTURES ARE TREATED WHEN SURGICAL INTERVENTION IS REQUIRED?
Fractures of the medial third of the clavicle can be treated conservatively or surgically. In the case of open fracture (perforation of the skin by the bone) surgical treatment is preferred.
In the case of closed fractures, the method of treatment is co-decided with the patient. When the fractures of the clavicle are slightly displaced, they are closely monitored with repeated radiographs and in this case non-surgical treatment is recommended. However, if the fracture is comminuted or there is a high degree of displacement, then the decision to perform surgery is co-decided with the patient, as the treatment is still controversial with recent studies showing better results after surgery.
A recent study examined the patient outcomes and complication rates after conservative or surgical treatment of osteosynthesis of dislocated clavicle fractures. The findings of the study showed that surgical treatment leads to improved upper extremity function and lower rates of misalignment and malfunction after the first postoperative period. However, post-operative complications including skin irritation due to osteosynthesis, trauma infection, and osteosynthesis failure have been reported.
In the case of surgical treatment of a fracture of the middle third of the clavicle an anatomical plate with screws or an intramedullary nail may be used, although there is still no clear indication as to which material is best.
In a recent study of 40 patients undergoing medial clavicle fracture surgery, the results of using intramedullary nail and plate/screws were studied with no difference between the two methods.
REMOVAL OF OSTEOSYNTHESIS MATERIALS – DO THE MATERIALS REMAIN IN THE BODY OR SHOULD THEY BE REMOVED?
In the case of intramedullary nail use, the material should always be removed after the fracture is healed. The nail (essentially a rod) is used temporarily to maintain the correct alignment of the fracture until healing. In the case of a special plate, the material may sometimes need to be removed, especially if the plate protrusions irritate the patient locally and is no longer tolerated.
COMPLICATIONS OF CONSERVATIVE TREATMENT OF FRACTURES IN THE MEDIAL THIRD OF THE CLAVICLE
Some of the most common complications of conservative treatment are pain (usually treated with anti-inflammatory drugs) difficulty in lifting weights over 5 pounds, pain during sleep on the affected side, apparent deformity and local tenderness. Hill et al. reported the complications associated with non-surgical treatment.
COMPLICATIONS AFTER SURGICAL TREATMENT
Complications usually include postoperative infection, osteosynthesis failure, material rejection and new fracture after removal of osteosynthesis.
Zlowodzki et al. reported that the rate of non-healed fractures of conservatively treated fractures was 15% while those treated surgically with plate/screw osteosynthesis were 2.2%. Finally, in those where an intramedullary nail was used, the pseudo-articulation rates reached 2%.
Bostman et al. reported the complications of the anatomical plate in displaced fractures of the clavicle. This study included 103 patients with dislocated fractures of the medial third of the clavicle treated with plate/screws. 23% experienced one or more of the following complications: deep infection, plate fracture, pseudo-articulation or fracture after plate removal. The infection rate was 7.8%.
POST-OPERATIVE COURSE – WHAT HAPPENS AFTER SURGERY?
The purpose of the surgery is to rearrange the fragments of the fracture and to hold them in place so that the osteoblasts create a new bone that will promote fracture healing. Thus, retention with anatomic plate and screws or with intramedullary nail acts as a temporary internal stabilization, while the bone is healed. Generally, it takes about 4 weeks to be healed and active arm movements to be allowed. The surgeon in collaboration with a physiotherapist will recommend appropriate exercises to restore shoulder and upper extremity functionality in general.
After 4 weeks (or longer if the surgeon deems it necessary) the suspension folder will be removed and the upper extremity will be used for daily activities such as showering, dressing and riding.
Radiological examinations should be performed regularly during these weeks after surgery to allow the surgeon to assess the fracture healing process and decide when limb strengthening exercises may begin (usually about 3 months post-operatively).
OUTCOMES OF THE OUTER THIRD OR THE DISTAL END OF THE CLAVICLE
Fractures of the outer third of the clavicle represent 15% of all fractures of the clavicle. Neer classified these fractures according to the relationship of the fracture to the acromioclavicular joint and the coracoclavicular ligaments. Type I fractures are characterized by minimal displacement. Type II fractures are displaced as they are located more centrally than the coracoclavicular ligaments, whereas Type III fractures involve the acromioclavicular joint and are considered intra-articular fractures.
The treatment options for fractures of the outer third of the clavicle depend on the type of fracture.
Type I fractures are considered stable because the coracoclavicular ligament remains intact and prevents dislocation of bone fragments. That’s why a suspension folder is usually used to support the upper limb during the first few days. After the first few days the suspension envelope can be removed, depending on the degree of pain and the activity gradually increases, while strengthening exercises begins as soon as the pain subsides.
Type II fractures are more complex and can be further subdivided into those located more centrally than the coracoclavicular ligaments and those located more peripherally than the coracoclavicular ligaments. These are unstable fractures that present a high rate of pseudoarticulation (30%).
Given this high rate of pseudoarticulation, most surgeons recommend surgical treatment of these fractures. Today, several different osteosynthesis techniques and materials are used such as wires, intramedullary nails, plates / screws, special sutures as well as special coracoclavicular screws.
POST-OPERATIVE RECOVERY: In the first few days the patient uses the suspension folder to relieve pain. After 10-14 days the wound is evaluated and a passive motion program is commenced. At 6 weeks post-operatively and after a radiologic examination, gradual strengthening exercises begin. At 3 months, after a new radiologic examination, the patient regains complete mobility.
CONSERVATIVE TREATMENT COMPLICATIONS: The highest risk of conservative treatment is the high rate of pseudoarticulation (30%). If the pseudo-arthrosis is asymptomatic, patients only have a slight loss of function. If it is symptomatic, then surgery should be recommended. Conservatively treated Type III fractures have a higher risk of developing post-traumatic arthritis of the acromioclavicular joint. Conservative treatment for this type of fracture involves a suspension folder that is used to support the upper extremity and after the first few days, the limb begins to be gradually mobilized with pendulum exercises. The suspension folder can be removed as the pain decreases, while activity gradually increases.