Presentation of Clavicle Fractures and treatment for the Nottingham Fracture Forum 2015

1. ORTHOPAEDIC DEPARTMENT
SÖDERSJUKHUSET, STOCKHOLM, SWEDEN
HENRIK ILLERSTRÖM, M.D.
CLAVICLE FRACTURES

2. Clavicle Fractures

3. Clavicle Fractures Classification
• Allman: Medial – Midshaft – Lateral/distal
• Nordqvist & Petersson
• Craig
• Edingburgh
• Neer

4. Clavicle Fractures
• 3% of all fractures
• Midshaft fractures 80%
• Distal (or lateral) fractures 15%
• Medial fractures <5%

5. Medial Clavicle Fractures
• Risk for neurovascular damage
• Often epiphyseal separation (open until 30 y)
• Stability of fracture by the costo-clavicular lig.
• Preferably no surgery if undisplaced and no risk
for underlying structures

6. Lateral Clavicle Fractures
• Undisplaced fractures – have an intact
periosteal sleeve and are stable due to intact
conoid and trapezoid ligaments.
• If there is a intra-articular component that can
lead to AC-joint arthritis. Best treated with lateral
clavicle resection.

7. Lateral Clavicle Fractures
• Displaced fractures usually needs surgery
• Conservative treatment => 33% non-union
• Operative treatment => 6% non-union (Review -
Oh et al 2011)
• Increased incidence among elderly – tolerate
non-union reasonably well

8. Lateral Clavicle Fractures
• Hook-plate – removal after union >3months

9. Lateral Clavicle Fractures
• Contured locking plates, >2-3 screws in lateral
fragment

10. Lateral Clavicle Fractures
• Coraco-clavicular screw
• Sutures and or ligament grafts
• Needles and pins…

11. And now to the controversial part…

12. Mid Shaft Clavicular Fractures

13. Mid Shaft Clavicular Fractures
2 weeks

14. Mid Shaft Clavicular Fractures
• Undisplaced – non-operatively
• Conservative treatment – sling or figure of 8
bandage. No evidence for either. (Andersen et al
1987, Cochrane-Lenza et al 2009)
• Displaced – surgery or not…

15. Displaced Mid Shaft Clavicular
Fractures surgery or not?
• Cochrane review (Lenza et al 2013) of 8 RCTs
show low evidence. No difference between
surgery or conseravtive treatment. No QoL
• McKee 2012, meta-analysis of 6 RCTs show
lower rate of non-union and symtomatic
malunion and earlier functional return compared
to conseravtive treatment. Little evidence for
significantly improved long-term functional
outcome for surgery vs conservative treatment

16. More
• RCT Virtanen ET al 2012 no difference at one
year follow-up Constant and DASH scores. Poor
scores associated with non-union
• RCT Robinson et al 2013 showed significantly
less reported dissatisfaction after surgery but no
difference in Constant/DASH scores. High NNT,
>6 to prevent 1 non-union

17. Displaced Mid Shaft Clavicular
Fractures – surgical methods
• Plates
– Stable,Comminution
– Prominence
– Wound complications
• Pins
– Less invasive
– Less prominence
– Less control/stability

18. Displaced Mid Shaft Clavicular
Fractures – Conclusion
• Individualize for each patient
• Early return – Surgery
• Large displacement >2cm, Z-fragment – Surgery
• Communition – Plate
• No surgery – high risk for non-union (up to 23%)
• Surgery – high risk of complications (up to 48%)
– mostly hardware related (McKee 2012)

19. Thank you!