Management of Clavicular Fracture

A Review on Clavicular Fracture: Conservative vs. Surgical Management

Muhamad Na’im B. Ab Razak

University Science Malaysia

Two friends, both age 18 years old alleged MVA (car vs. motorbike) this morning. Victims are riding a motorcycle on speed of approximately 60 km/hr when a car suddenly appears from the right side. This causing them shock and could not control the motorcycle and crashed. During the fall, both of them fall on the left side of the body and hit the road divider.

After the accident, both of them sustain injury to the left shoulder region associated with tenderness, bruises and swelling. X-ray reveals fracture of the left clavicle on both victims. Apart from that, there is no other injury found. Both of the patients are discharged with conservative management.

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Group II fracture based on Allman classification that is simple displaced fracture which is complete, transverse and shortening. There is also callus formation around the fractured clavicle which indicates that this patient is actually having previous history of clavicular fracture. Therefore, this is a new fracture on the old fractured site.

This is also a group II fracture based on Allman classification that is complete, transverse and presence of angulations of approximately 90⁰ with shortening.

Discussion

Clavicular fracture accounts for about 5% of all fracture and 80% of it are due to the mid shaft fracture. 15% of it occurs at the lateral end while less than 5% occurs at the medial end. [Amir Estephan]. 70% of the clavicular fractures are due to motor vehicle accidents.

The main mechanism responsible for clavicular fracture is a direct fall onto the shoulder. Minority of the cases are due to a fall onto an outstretched hand.

Traditionally, all types of clavicular fracture is managed conservatively either using shoulder sling or figure of eight brace and majority of it healed but with variable amounts of deformity.

However, current study shows only medial end fracture of clavicle can be managed conservatively because this type of fracture seldom causing displacement due to extensive ligamentous attachments. Debates continue on which management is the best for mid shaft fracture and lateral end fracture.

As a general rule in managing mid shaft fracture, conservative management is the best option provided that the fracture did not cause severe displacement or shortening of the bone. Operating all type of mid shaft fracture with minimal displacement may lead to over treatment. Therefore, simple mid shaft fracture can either be managed by 1) simple support of extremity with sling or sling and swath and 2) reduction and immobilization with figure of eight brace.

Besides the presence of displacement, age is also a determinant factor in treating the mid shaft fracture. In a conclusion draw by Prinz KS et al, they stated that the method of choice in children under the age of ten with a displaced clavicular fracture is the non-surgical treatment supported by sufficient pain medication. Older children reach good results but suffer from more pain and are dissatisfied by the cosmetic results and immobilization. Because of this, active older children and adolescents with a displaced clavicular fracture benefit from elastic stable intramedullary nailing.

Management for fracture of lateral end clavicle can be a great challenge due to the complexity of the anatomy and biomechanical property of that region. It is being recommended that, operative fixation should be done if there is significant dislocation of AC joint because of ruptured AC and coraco-clavicular ligaments.

Furthermore, non-operative management of lateral end clavicular fracture has high incidence of non-union, delayed union and resulting shoulder girdle instability. [S. P. Badhe]

In treating fractures of distal third clavicle; percutaneous fixation using a malleolar screw, a cannulated screw or a simple K-wire is more preferred as compared to Open Reduction Internal Fixator (ORIF) like hook plate osteosynthesis as it is easy to apply, simple, cheap and have higher rate of union.

Since ORIF is invasive procedures; it is associated with complication like infection, loss of fracture hematoma, non-union and specific complications like acromial fracture at the hook and hook-cut out, rotator cuff tear, and subacromial impingement. Furthermore, it needs to be removed as soon as the union occurs to avoid osteolysis. Plate removal will further induce stress to the patient. [Oguz Cebesoy]

A retrospective study made by Yih-Shiunn Lee et al in 2009 shows different result. According to them, K-wire fixation gives unacceptable result based on study made by Kona et al whereby 47% complication has been reported and 32% associated with non union. Therefore, they compare the efficacy of internal fixation with a hook plate and tension band wire. Based on their findings, they made a conclusion that both hook plating and tension band wiring for treatment of unstable fractures of the distal clavicle could achieve good results. However, internal fixation with a hook plate had more advantages and fewer complications than the tension band wire.

In a study done by S. P. Badhe et al, they found out that a modified tension band suturing technique using a number 5 Ethibond suture is the best technique and can avoid problems related to extensive soft tissue dissection, implant removal or implant failure. The suture is passed through the holes in a figure of eight fashion and the fracture is fixed with the knot on the superior aspect. This is then reinforced by drilling two further holes and passing a second similar suture of Ethibond.

If there is involvement of coracoclavicular ligaments, apart than techniques explains by S.P. Badhe et al, another two sutures may be used to anchor the ligaments and these will provides a reliable technique for restoring stability in patients with acute distal clavicle fracture [Shin SJ]

Reference

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2) Djahangiri A & Farron A, "When to operate an isolated midshaft clavicle fracture?", Rev Med Suisse] 2009 Aug 5; Vol. 5 (212), pp. 1542-5, Medline.

3) Jeevan Chandrasenan, Sachin Badhe, Timothy Cresswell & Joe De Beer, "The Clavicular Hook Plate: Consequences in Three Cases", Eur J Trauma Emerg Surg 2007, No. 5, URBAN & VOGEL, 2007.

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7) Oguz Cebesoy, "Percutaneous fixation in fractures of the distal third of the clavicle: simpler, cheaper, better", International Orthopaedics, 31:129, Springer-Verlag, 2006.

8) Prinz KS, Rapp M, Kraus R et al, "Dislocated midclavicular fractures in children and adolescents: who benefits from operative treatment?", Z Orthop Unfall 2010 Jan, Vol. 148 (1), Medline.

9) Shin SJ, Roh KJ, Kim JO & Sohn HS, "Treatment of unstable distal clavicle fractures using two suture anchors and suture tension bands.", Injury, Dec; Vol. 40 (12), pp. 1308-12, Medline, 2009.

10) S. P. Badhe, T. M. Lawrence, & D. I. Clark, "Tension band suturing for the treatment of displaced type 2 lateral end clavicle fractures", Arch Orthop Trauma Surg, 127:25–28, Springer-Verlag, 2006.

11) Vinzenz Smekal, Juergen Oberladstaetter, Peter Struve & Dietmar Krappinger, "Shaft fractures of the clavicle: current concepts", Arch Orthop Trauma Surg (2009) 129:807–815, Springer-Verlag, 2008.

12) Yih-Shiunn Lee, Ming-Jye Lau & Ya-Chun Tseng, "Comparison of the efficacy of hook plate versus tension band wire in the treatment of unstable fractures of the distal clavicle", International Orthopaedics, 33:1401–1405, Springer-Verlag, 2008.