Скачать или смотреть Clavicle Fracture: Symptoms, Types, Treatment, and Recovery

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The ligaments that support the clavicle. are known as the coracoclavicular (CC) ligaments, the conoid ligament, which is medial and located approximately 4.5 cm from the lateral end of the clavicle, and the trapezoid ligament, which is lateral and approximately 3 cm from the end. These ligaments are the primary stabilizers that prevent superior vertical translation of the distal clavicle. .
Clavicle fractures most commonly occur at the mid-shaft, accounting for about 80–85% of cases. Fractures of the medial clavicle are rare (approximately 5%), usually stable, and typically treated non-operatively. Lateral clavicle fractures represent about 10–15% of clavicle fractures.
Neer classified lateral clavicle fractures into three types based on the integrity of the CC ligament complex and involvement of the acromioclavicular (AC) joint.
Type I: Both the conoid and trapezoid ligaments remain intact and attached to the medial fragment. The fracture is lateral to the ligaments, and the medial fragment remains stable due to ligament support.
Type II: The medial fragment is not supported by ligaments, either because they are torn or the fracture occurs medial to the ligaments. The lateral fragment may retain the ligaments partially, completely, or not at all. The key issue is that the medial fragment lacks ligamentous support and displaces superiorly. This type is the least stable and has the highest risk of non-union. Even though non-union is common, it may not always be symptomatic. Surgery is often considered for displaced Type II fractures of the lateral third of the clavicle.
Type III: The fracture extends into the AC joint.
The typical deformity seen in clavicle fractures involves the sternocleidomastoid muscle pulling the medial fragment superiorly, while the weight of the arm and pectoralis major muscle pull the lateral fragment inferiorly.
Clinical examination includes checking for deformity and skin tenting, which may indicate an impending open fracture. A distracted clavicle could signify scapulothoracic dissociation. Always assess for neurovascular deficits, especially brachial plexus injury, as the neurovascular bundle, including the subclavian artery, lies close to the clavicle, within approximately 1 cm.
Radiographic evaluation involves obtaining bilateral shoulder X-rays to compare clavicle lengths and assess for shortening. Recommended views include an AP and a 20-degree cephalad upshot, especially in the operating room. Look for shortening, displacement, comminution, and Z-type fractures.
Risk factors for non-union include:
Significant displacement
Comminution
Older age, particularly in females
Smoking
Lateral third fractures with medial fragment displacement (up to 50% non-union rate)
Absolute indications for surgery:
Open fractures
Vascular injury
Skin tenting
Note: Brachial plexus injury alone is not an absolute indication.
Most clavicle fractures can be treated non-operatively, especially minimally displaced or undisplaced fractures. These typically heal well with conservative management, even with some displacement. Non-operative treatment includes a sling or figure-eight strap, followed by range of motion exercises in a few weeks. A small bony bump (healing callus) is common. Studies show no significant difference between sling and figure-eight strap. Early shoulder movement does not increase the risk of non-union.
Relative indications for surgery:
Comminuted fractures
Segmental fractures
Z-type fractures
Shortening more than 2 cm
Displacement more than 100%
In such cases, non-operative management may lead to reduced endurance and functional distress, although the range of motion may remain similar to those treated operatively.
Surgical fixation options include plate fixation, with two main techniques:
Superior plate fixation: Offers mechanical advantage due to placement on the tension side. It avoids deltoid dissection but poses a risk of neurovascular injury during drilling and hardware may be prominent.
Antero-inferior plate fixation: Allows for longer screws with safer trajectories and less hardware prominence, but requires deltoid dissection. It may be better tolerated by patients who carry loads or wear backpacks.
Contoured plates with locking screw capabilities are preferred. Dr. Ebraheim personally uses superior plate fixation with locking plates. Approximately 30% of clavicle plates are eventually removed.
Plate removal is typically performed around one year postoperatively.
Complications of clavicle fracture or its surgical treatment include:
Non-union
Malunion
Complications related to fixation:
Symptomatic hardware: The most common reason for reoperation.
nfraclavicular numbness: Due to injury of the supraclavicular nerve.