2. Prof. M. Shantharam Shetty
M.S(orth), FRCS, FACS
Pro Chancellor, Nitte University
Chairman, Tejasvini Hospital & SSIOT
Mangalore
3. The traditional belief and teaching was
that Midshaft clavicle fractures
uniformly heal without functional
deficit.
SO NOW WHY IS THE FUSS
ABOUT OSTEOSYNTHESIS ???
AND WHY THIS DEBATE?
4. Codman (1934)
We are proud that our brains are more developed than
the animals. We might also boast of our clavicles. It
seems to me that the clavicle is one of Man’s greatest
skeletal inheritances, for he depends to a greater
extent than most animals, except the apes and the
monkeys on the use of his hands and arms.
And today ………….
Why Osteosynthesis ?
The Perfect Shape and function of the clavicle is a
must and it adds beauty to the strapless shoulder and
perfect painless function is demanded by the patients
5. Since the dawn of time…
If thou examinest a man having a break in his collar-
bone (and) thou shouldst find his collar-bone short
and separated from its fellow
6. FRACTURES OF CLAVICLE
2 – 5 % OF ALL FRACTURES
MID THIRD - 69-82%
MEDIAL THIRD – 2-3%
LATERAL THIRD – 21-28%
MAJORITY OF MEDIAL AND LATERAL THIRD FRACTURES
ARE UNSTABLE AND REQUIRE FIXATION IN MAJORITY OF
THE CASES
Our debate is whether we should fix the mid shaft
fractures
7. MIDSHAFT CLAVICULAR FRACTURES
Non-operative treatment
“Most clavicular fractures heal well without any treatment”
“Why have clavicular fractures been the target of so much surgical
virtuosity when treatment with a sling gives consistently good
results”....
Nicholl EA et al. J Bone Joint Surg (1954) 36 B: 171-2
8. MIDSHAFT CLAVICULAR FRACTURES
Non-operative treatment
“Most clavicular fractures heal well without any treatment”
“Why have clavicular fractures been the target of so much surgical virtuosity
when treatment with a sling gives consistently good results”....
Nicholl EA et al. J Bone Joint Surg (1954) 36 B: 171-2
“The results of non-operative treatment have generally been good”…
Ledger M et al. J Shoulder Elbow Surg (2005) 14: 349-54
“Non-operative management remains the standard of care”
Preston CF, Egol K. Bull NYU Hosp Jt Dis. (2009) 67: 52-7
9. • Treatment : Figure of 8 bandage for 3 weeks
• Complications : Transient neuritis 2
Surgical treatment for progressive neuropathy 2
• At follow-up : Asymptomatic shoulder 185
Moderate pain rated as fair 39
poor 1
• Radiologically : Fractures healed normally 125
Malunions 53
Nonunions 7
MIDSHAFT CLAVICULAR FRACTURES
Non-operative treatment
HOWEVER…..
Nordqvist A et al. J Orthop Trauma (1998) 12 : 572-6
225 fractures (average age 33 yrs) evaluated after 17 years.
10. Prospective study in 208 patients with clavicle fractures (1989-1991)
Follow up 9-10 years
“Complete” recovery 112 (54%)
Significant sequelae 96 (46%) e.g. pain at rest or with activities,
cosmetic stigmata
Nowak J, Holgersson M & Larsson S J Shoulder Elbow Surg (2004) 13: 479-86
MIDSHAFT CLAVICULAR FRACTURES
Non-operative treatment
To continue....
• Poor outcome predictors:
1. no bone contact
2. comminuted fractures
3. women
4. elderly patients
11. Not all Midshaft clavicle fractures are the
same…
What we should understand is ….
12. unsatisfied patients: 10-30 %
- nonunion
- malunion: shortening, angulation and callus bump
- limited shoulder mobility, loss of strength
some discomfort or any kind of chronic pain: 20-30 %
poor cosmesis (contour, callus bump): 50 %
McKee MD et al. Deficits following nonoperative treatment of displaced midshaft clavicular fractures. J Bone Joint Surg (2006) 88 A:35–40
Lazarides S et al. Conservative treatment of fractures at the middle third of the clavicle. J Shoulder Elbow Surg (2006) 15:191-4
Nowak J et al. Sequelae from clavicular fractures are common: a prospective study of 222 patients. Acta Orthop (2005) 76:496-502
Robinson CM et al. Estimating the risk of nonunion following nonoperative treatment ... J Bone Joint Surg (2004) 86 A:1359-65
Nowak J et al. Can we predict long-term sequelae after fractures of the clavicle …? J Shoulder Elbow Surg (2004) 13:479-86
Matis N. Effects of clavicle shortening after clavicle fracture. Hefte Unfallchirurg (1999) 275:314-5
Hill JM. Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg (1997) 79 B:537-9
White RR. Adult clavicle fractures: Relationship between mechanism of injury and healing. Orthop Trans (1989) 13:514-5
Eskola A et al. Outcome of clavicular fracture in 89 patients. Arch Orthop Trauma Surg (1986) 105:337-8
MIDSHAFT CLAVICULAR FRACTURES
Non-operative treatment
CURRENT LITERATURE:
14. Hill JM et al. 52 patients 8 (15%)
J Bone Joint Surg (1997) 79 B: 537-9
Nordqvist A et al. 68 patients 22 (32%)
J Orthop Trauma (1998) 12: 572-9
MIDSHAFT CLAVICULAR FRACTURES
Non-operative treatment
NONUNION RATE IN DISPLACED FRACTURES
Level III evidence
Systematic Review
meta-analysis of 10 studies with 2144 acute clavicular shaft fractures
nonunion rate 15.1%
Zlowodzki M et al. J Orthop Trauma (2005) 19:504-7
usually reported nonunion rates ± 5%
15. MAL UNION
The problems seen following mal union are
Drooping of shoulder
Shortened Clavicle
Mal rotation
Resulting in Pain, shoulder function and cosmetically
2.5 Cms
17. MALUNION
A. Following Mal union Muscle
mechanical disadvantage is
seen
B. R.O.M - is altered at scapular,
SCJ and ACJ.
C. There is a decrease in the sub-
clavicular space following
malunion
C
And So What ???
19. NON UNION
Most Clavicle fracture Non
Unions are symptomatic
Therefore Non union
should be considered a
PROBLEM
HiII – JBJS – A 1997
Jan Nowak Acta orthopaedica 2005:76(4) : 496-502
2013 – We cannot afford to have 1/5 patients
having this problem
20. why is there a dramatic difference between the outcome of
non-operatively treated clavicular fractures in previous reports
and those in contemporary studies?
MIDSHAFT CLAVICULAR FRACTURES
Non-operative treatment ?
• in the past almost all reports were retrospective case
series
• many historical series included children and adolescents
• more high energy injuries nowadays
• better registration / closer follow-up
• focussed interest by doctors / shoulder surgeons
• more active / demanding patients
• current use of patient oriented outcome measures (QoL)
• higher patient expectations (media!)
21. MIDSHAFT CLAVICULAR FRACTURES
Non-operative treatment
Indications for surgery
Absolute indications for surgery include open
fractures and neurovascular injury requiring repair or
exploration,”
Strongest relative indication for surgery is a
displaced clavicle with 2 cm or more of shortening,
tenting of skin with likely soft tissue interposition
Other relative indications include multiple
extremity involvement, floating shoulder, seizure
disorders, and cosmesis.
All these require surgery
22. MIDSHAFT CLAVICULAR FRACTURES
Non-operative treatment
I.M. Nails
• Titatium Elastic Nail (TEN)
currently used implants for clavicular fracture osteosynthesis
Plates
• RECON PLATE
•LCDCP
•LCP
• Reconstruction LCP
•Anatomical plate
Which is the best implant?
23. Study of shape of clavicle
In a cadaveric bone study of 50 males
and females 25 each of left and right, it
was found that it is better to put the
plates superiorly and put an anatomical
plate which almost matches the shape of
the clavicle, specially in middle 3rd
fractures.
26. MIDSHAFT CLAVICULAR FRACTURES
choice of plate position on clavicle
ANTERIOR vs SUPERIOR
The superior group had significantly
higher number of hardware failures and
hardware removal compared to the
anterior group. Placement of the plate
anteriorly rather than superiorly on the
clavicle yielded better results with
regards to these two factors. Hence
anterior plating as a better method of
fixation of midshaft clavicular fractures.
plate in superior position
Santosh V. et al J. Orthopaedics 2007; 4(4) e1
Anterior Versus Superior Plating of Fresh
Displaced Midshaft Clavicular Fractures
28. MIDSHAFT CLAVICULAR FRACTURES
choice of plate type is based on its position on clavicula
Plate under
Supraclavicular nerve
CLAVICLE FRACTRURE ASSOCIATED WITH SCAPULAR FRACTURE
40. Systematic Review
meta-analysis of 10 studies with 2144 acute clavicular shaft fracture
Zlowodzki M et al. J Orthop Trauma (2005)
PLATING OF CLAVICULAR SHAFT FRACTURES
infection
4.6 %
nonunion
2.2 %
complications
ugly scar
refracture after plate removal
41. Non-operative treatment compared with plate fixation
of displaced midshaft clavicular fractures
A multicenter, randomized clinical trial
PLATING OF CLAVICULAR SHAFT FRACTURES
Canadian Orthopaedic Trauma Society. J Bone Joint Surg-A (2007) 89: 1-10Level I evidence
DESIGN:
• 8 centers
• 132 patients ,16 - 60 years
• randomized: sling (65) vs. AO-plating (67)
• F-U 1 year
TECHNIQUE:
• oblique incision
• 3.5 recon plate (LC-DCP)
• superior plate position
• 3 screws proximal and distal
OUTCOME MEASURES:
• 6, 12, 24, 52 weeks
• clinical & radiological
• Constant-Murley score
• DASH
LOST TO FOLLOW UP:
• non-operative: 15
• plate: 5
42. plating group 4 x more satisfied than non-op group (p=0.002)
52 patients satisfied with appearance in plating group vs. 26 in non-op group (p=0.002)
droopy shoulder (non-op group) of greater cosmetic concern than scar (ORIF group)
PLATING OF CLAVICULAR SHAFT FRACTURES
patient satisfaction (1 year)
Level I evidence Canadian Orthopaedic Trauma Society. J Bone Joint Surg (2007) 89A: 1-10
outcome (1 year)
16.4
same
7
9
-
31 (63%)
-
28.4
same
2
0
1
23 (37%)
5
0.001
-
0.042
0.001
-
0.008
non-operative (62) plating (49) p
fracture union (radiol. in wks)
range of motion
nonunion
malunion (osteotomy)
mechanical failure
overall complication rate
implant removal
43. MIDSHAFT CLAVICULAR FRACTURES
nonoperative treatment
I.M. Nails
• Titatium Elastic Nail (TEN)
currently used implants for clavicular fracture osteosynthesis
Plates
• LCP
• Reconstruction LCP
44. MIDSHAFT CLAVICULAR FRACTURES
operative treatment: i.m. nailing
Jubel A. et al. Operat Orthop Traumatol (2004) 16:365-79
man, 38 yrs.
p.o.
1 yr. p.o.
open reduction 40 - 50 %
45. TENS NAILING OF CLAVICULAR SHAFTFRACTURES
Results
Elastic stable intramedullary nailing is best for midshaft clavicular
fractures without comminution: results in 60 patients.
PROSPECTIVE NON-RANDOMIZED STUDY (Level II evidence)
• 60 operative (TEN) vs. 52 non-operative (simple sling)
• surgery < 3 days, final F-U 2 years
• results: - faster healing
- better restoration of length in simple fractures
- less non- and delayed union
- telescoping in comminuted fractures
Smekal V. et al. Injury (2010) 41: 713-8
46. migration
TENS NAILING OF CLAVICULAR SHAFTFRACTURES
Mistakes / Complications
TEN too thin
telescoping of comminuted fracture
poor reduction
47. Type A simple, two part
Type B wedge fragment
Type C comminuted
Indications for TEN
MIDSHAFT CLAVICULAR FRACTURES
• good indication
• relative indication
• poor indication
48. The modified Rockwood Clavicle Pin
(DePuy).
PRE OP X RAY
12 WEEKS AFTER IMPLANT REMOVAL
MID SHAFT CLAVICULARFRACTURES
INTRAMEDULLARYCLAVICULARPIN
IMMEDIATE POST OP
Benjamin et al J Pediatr Orthop 2012;32:334–339
49. MIDSHAFT CLAVICULAR FRACTURES
Non-operative management remains the
standard of care
All conservatively treated displaced fractures
heal as malunions
Nonunion rate in conservatively treated
displaced fractures is ≥ 15 %
Shortening (> 15-20 mm) is associated with
more nonunions and unsatifactory results
Last word as on Today ....
50. MIDSHAFT CLAVICULAR FRACTURES
Conclusions
• There is Level I evidence that operative treatment is the best for
displaced shaft fractures especially when there is gross
displacement,Tenting of skin and likely soft tissue interposition.
• Associated scapular fractures which are unstable
• In young and active patients with a displaced clavicular shaft
fracture, surgical treament is to be considered seriously
• The indication forTEN nailing is restricted to simple fractures
(Type A, selected type B)
