middle-third clavicle fractures
A 32-year-old, right-hand-dominant male who works as a rancher fell off his horse onto an outstretched left upper extremity with immediate pain and deformity to his left clavicle. He presents later the same day. His injury radiograph is shown in Figure 6–1.
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Figure 6–1
How would this fracture be classified?
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Neer classification Type IIB
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Group I, complete displacement
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Group II, Type IIB
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Group III, anterior displacement
Discussion
The correct answer is (B). Clavicle fractures are first placed into a group by location of the fracture. Group I fractures occur in the middle third of the clavicle. These are the most commonly encountered (80–85%) and are further classified as completely displaced with >100% displacement versus minimally or incompletely displaced when there is still some bone overlap between the main medial and lateral fragments. Group II clavicle fractures occur in the lateral third and are further classified using the Neer classification for Types I through V. Medial third fractures
are Group III and are further defined by either anterior or posterior displacement.
Indications to perform open reduction with internal fixation for a middle-third clavicle fracture include all of the following EXCEPT:
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Skin compromise over the fracture site
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Displaced fracture with 2.5 cm of shortening
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Ipsilateral scapular neck fracture
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Asymptomatic nonunion
Discussion
The correct answer is (D). Nonunions are not uncommon with nonoperative treatment (4.5% of completely displaced middle-third fractures), but unless symptomatic, are not an indication for surgical intervention. Taut skin over a bony prominence which decreases blood blow to the skin can lead to a closed fracture becoming an open fracture and should be addressed in a timely fashion. Midshaft clavicle fractures with severe shortening (>2 cm) are likely to lead to a nonunion and may change shoulder kinematics if the fracture is untreated and left in this shortened position. A scapular neck fracture on the same side as a clavicle fracture is a floating shoulder, and stability of the suspensory shoulder complex should be restored for best chance of return to function. Other relative indications for operative treatment include inability to self-protect (closed head injury, seizure disorder), brachial plexus injury, and a polytrauma patient.
After discussion of management options, the patient chooses to proceed with operative treatment. The postoperative radiograph is shown in Figure 6–2.
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Figure 6–2
Which of the following statements is true in regard to operative options?
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Intramedullary screw fixation has a lower complication rate than plate and screw fixation.
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Superior plating has a higher rate of soft tissue irritation than anterior plating.
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Anterior plating is biomechanically stronger than superior plating.
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Anterior plating has a higher risk of neurovascular injury during placement than superior plating.
Discussion
The correct answer is (B). Studies demonstrate that approximately 30% of patients with plate and screw fixation request hardware removal due to soft tissue irritation, and this rate is higher for superior plates. Intramedullary screw or nail fixation is an alternative for length-stable fractures, but there is a higher overall complication rate due to hardware migration. Superior plating can sustain a higher load before failure and bending strength, and it is generally preferred for inferior bony comminution. However, there is an increased risk of penetrating the subclavian artery or vein during drilling intraoperatively for superior plates.
Objectives: Did you learn...?
Surgical indications for middle-third clavicle fractures?
Advantages and disadvantages of various operative techniques for fixation of clavicle fractures?