CLAVICLE FRACTURE

PRESENTATOR:DR MOHD HAIDI SYUHAIRI BIN HANAFI SUPERVISOR:MISS (DR) ISNONI ISMAIL

Department of Orthopaedic Surgery and Rehabilitation

OVERVIEW
Anatomy Ossification Functions Classification Signs and Symptoms Physical Examination Treatment Rehabilitation

ANATOMY

OSSIFICATION
1st bone to ossify and last bone to finish ossification. from 3 centers :

- 2 primary centers, medial and lateral5th or 6th week intrauterine life - secondary center(sternal end)18th or 20th year, unites25th year

VARIATIONS

- thicker and more curved in manual workers, sites of muscular attachments more marked. - right clavicle stronger and shorter. - In femalesshorter, lighter, thinner, smoother and less curved. -femaleslateral end little below medial end; -malessame level or slightly higher than the medial end

FUNCTIONS
Acts as a strut to keep the scapula in positionarm can hang freely Cover cervicoaxillary canalprotects neurovascular bundle Transmits physical impacts from upper limb to axial skeleton.

may be congenitally absent or imperfectly developedcleidocranial dysostosis +shoulders droop +can be approximated anteriorly in front chest.

Clavicle Fractures

Mechanism
Fall onto shoulder (87%) Direct blow (7%) Fall onto outstretched hand (6%)

The clavicle is the last ossification center to complete (sternal end) at about 22-25yo.

Trimodal distribution
80 70 60 50 40 30 20 10 0 Group I (13yrs) Group 2 (47yrs) Group 3 (59yrs) Percent

Classification
A.Group 1 Middle Third (80%)

B.Group 2 Distal Third (15%) Type 1:lateral to cc ligament Type 2a:medial to cc ligament Type 2b:between cc ligament(conoid torn,trapezoid intact) Type 3:# into ACJ C.Group 3 ProximalThird (5%)

Complaints
Pain Swelling Possible nausea, dizziness, spotty visiondue to extreme pain

Physical examination

Attitude-arm held close to body,supported by hand Tenderness Deformity Swelling Crepitus

Ecchymosis Bleedingopen fracture (rare) Decreased breath soundsindicating possible pneumothorax Decreased pulsessuggesting vascular compromise Diminished sensation or weaknesssuggesting neurologic compromise Nonuse of the arm on the affected side

Diagnostic
XrayAP view CT scan maybe required

Middle

rd 3

Distal

rd 3

Proximal

rd 3

Other test
Chest radiographyif pneumothorax suspected Angiographyif vascular injury suspected

Treatment

Medial and Middle fractureusually nonoperative

1.Ice 2.Analgesic 3.Sling immobilizationfor3-4 weeks with early ROM


1.
2. 3.

Distal fracture
Much controversy exists regarding the appropriate management. Current recommendationsfix surgically Neer found that although distal third clavicle fractures are rare, they account for approximately half of all clavicular nonunions.

Surgical indications
1. 2. 3. 4. 5. 6. Fractures with neurovascular injury Fractures with severe associated chest injuries Open fractures Group II, type II fractures Cosmetic reasons, uncontrolled deformity Nonunion

Surgical choice
OR+plate fixation OR+pin insertion

Advantages of plate fixation

1.

2.
3. 4.

Easily available Commonly used Standard technique Direct osteon healing

Complication of plate fixation

Painful, prominent hardware Soft tissue stripping Non-cosmetic scar Multiple stress risers Permanent if 33% of clavicle diameter Nerve damage Infection

Infection after plate fixation

Reports range from 0.4% - 7.8% Bostman: 7.8% Liu, et al (2008): Average time to presentation: 28 days 4.9%

Kaohsiung J Med Sci. 2008 Jan;24(1):45-9Lateralization of cantilever eff

Post op care
No immobilization utilized Return to full ADLs as soon as tolerated Limit forward flexion ~ 3-4 weeks Pin removed under local anesthesia 8 12 weeks post-op

Problems with pin

Limited sizes Migration Static distraction (fully treaded pins) Pin irritation

Plate vs Pin vs Non-op

Pinning: 100% union within 2-4 months Shorter hospital stay Plate: 23.5% scar related pain 17.5% prominent hardware & discomfort Nonop 23.5% nonunion 29.4% cosmetic complaints 6% malunion

AAOS 2005

Plate or Pin?
Plate or intramedullary fixation can be considered for both However, both have their limitations Plate fixation is probably ideal with: transverse, simple fractures nonunions with bone loss For all the rest, consider IM fixation

Lee et al, Orthopedics. 2007, Nov;30(11):959-6

Associated injury
1. 2. 3. 4. 5. Brachial Plexus Injuries Vascular Injury Rib Fractures Scapula Fractures Pneumothorax

Rehabilitation
Most fracture heal in about 3 months. Rehabilitation exercises will begin as soon as patient can tolerate motion with very gentle exercises (pendulum exercises) designed to regain motion.

Prognosis
Generally excellentshoulder has the largest range of motion of any joint in the body. Even if the fracture fragments do not heal exactly in their normal position,the shoulder joint can easily compensate and provide with a well functioning shoulder joint.

Thank you for your attention