Current Concepts: Treatment of Clavicle Fractures - CMX Travel

Current Concepts:
Treatment of Clavicle Fractures
Carl J. Basamania, MD, FACS
The PolyClinic and
Swedish Orthopaedic Institute
Seattle, Washington

Disclosure:
• Potential Conflict of Interest
– DePuy/Johnson & Johnson
• Consultant & royalties
– Sonoma Orthopaedic Products
• Consultant & stockholder
• No honorariums, compensation paid by
outside sources for this lecture
• No “off label” discussion of any products

Background
• Nonoperative treatment has been
the standard of care
• Articles by Neer (1963) and Rowe
(1968) both found a high incidence
of complications with operative
treatment
• Both also reported a healing rate of
99% with non-operative treatment

Complications of non-operative treatment
15% nonunion, 31% dissatisfaction regardless of
healing
Hill, et al, JBJS(B), 1997

“All clavicles heal well”
• One of the greatest fallacies in all of
orthopaedics
• NO ONE has been able to reproduce
the results of Neer and Rowe
(nonunion

“All clavicles heal well” ?????
• Meta-analysis of 2144 clavicle fractures:
– Nonunion rate of 15.1%
– Associated with displacement,
comminution, female gender and age
– Relative risk reduction of 86% for nonunion
Zlowodski M, Zelle BA, Cole PA, Jeray K, McKee MD.
Treatment of acute midshaft clavicle fractures: systematic
review of 2144 fractures. J Orthop Trauma
2005;19(7):504-508.

“All clavicles heal well” ?????
• Union does not equate with good result
• Long term follow-up of conservatively
treated mid-shaft clavicle fx:
– Average f/u: 54 months
– Strength of injured side 66 – 86% of
uninjured side
– Constant score 69
– DASH score 25.1
• McKee, M.D., et al, ASES, 2003

“All clavicles heal well”????
• 46% of patients with clavicle
fractures did not consider
themselves fully recovered by 10
years post-injury
• 9% had pain at rest
• 29% had pain with activity
• Nowak, Clavicle Fractures, 2002

J. Bone Joint Surg. Am. 89:1-10, 2007
Plate Fixation

Advantages of Plate Fixation
• Easily available
• Commonly used
• Standard technique
• Tension band
• Direct osteon healing

• 3.5mm LCDC plate
strongest
• 3.5mm recon – easily
contoured
• 2.7mm DC plate
weakest
• Superior position
strongest
• However, fx pattern
tested was transverse
– Iannotti, Crosby,
JSES,11,5,2002
Plate Choice

Plate Position

Plate Position
• Superior plate better if transverse fx
• Anterior stronger if comminuted
• Load to failure:
– Non-comminuted:
• Superior 301N
• Anterior 217N
– Comminuted:
• Superior 198N
• Anterior 265N
– Harnroongroi, et al, Clin Biomech, 11,5,1996

Complications of Plate Fixation
• Painful, prominent
hardware
• Soft tissue
stripping
• Non-cosmetic scar
• Multiple stress
risers
– ? Permanent if >
33% of clavicle
diameter
• Nerve damage

103 plated clavicle fractures –
43% complication rate
15% major complication rate
14% reoperation rate
Complications of
plate fixation
Bostman, et al, J Trauma, 1997

Precontoured Plates
• Precontoured plates are
adequately shaped for
the fixation of fractures
in the medial threefifths
of the clavicular
shaft
• Precountoured plates
may not fit most white
females
• Clavicles from female
donors were narrower
than the plates
J Bone Joint Surg Am. 2007;89:2260-2265

Infection after Plate Fixation
• Reports range from 0.4% - 7.8%
• Bostman:
• – 5 deep, 3 superficial
– 7.8%
• Liu, et al (2008):
– 7 or 142
– Average time to presentation: 28 days
– 4.9%
• Kaohsiung J Med Sci. 2008 Jan;24(1):45-9

Lateralization of cantilever effect in
comminuted fractures – loss of tension
band effect
Would predict failure of lateral fixation

Failed Locking Plates

Failed Pre-Contoured Plates

Failed Plates

Ultimate Plate Failure

Intramedullary Fixation
• IM fixation is not
a new concept
Intramedullary fixation with beef
bone
(Brockway, JBJS, 1930)

IM Fixation of Clavicle Fractures
• Gerhard Kuntscher 1900-1972
• “Technik der Marknagelung”,
1942
• Described IM fixation of
clavicles
• Died at his desk in December
1972 while revising his book
“Praxis der Marknagelung”

Why Intramedullary Fixation?
• Minimizes soft tissue dissection
• Preservation of periosteal blood supply
• Callus healing
• Better resistance to repetitive bending
• Ease of reduction
– “If it’s IM – It’s anatomic!”
• Allows clavicle to shorten
• Minimal stress shielding
• Ease of hardware removal
• Cosmetic incisions

Problems with pin and IM fixation
• Limited sizes
• Migration
• Static distraction
(fully treaded pins)
• Pin irritation

Elastic nailing
Unfallchirurg 2006 · 109:200–211

Acta Orthopaedica 2007; 78
(3): 424–429
• Elastic nailing of 95
midshaft clavicle fractures
• Open fracture reduction
required in 53 patients
(56%)
• Nonunion 2%
• Malunion 8%
• Pin migration 4%
• Revision surgery 5%
Elastic Nailing
Average op time: closed 53 minutes
open 63 minutes

Elastic Nail
Acta Orthopaedica 2007; 78 (3): 421–423
• 32 cases
• 100% union
• Open reduction necessary in 50%
• Shortening > 5mm in 38%
• Nail migration 25%
– secondary shortening of the nail 16%
• Nail breakage 6%

Supraclavicular nerve
Supraclavicular nerve
Medial fragment
Platysma

Intramedullary Fixation

Intramedullary Technique

Lateral Placement

Securing Butterfly Fragments

Cutting the Pin

Acute Fracture Example

Postop Care
• No immobilization utilized
• Return to full ADL’s as soon as
tolerated
• Limit forward flexion ~ 3-4 weeks
• Pin removed under local anesthesia 8 -
12 weeks post-op

Acute Example

1 week postop

10 day followup

Plate versus Pin
• Thyagarajan, 2005
• 51 acute, midshaft fractures
–17 pinned
–17 plated
–17 nonoperative treatment

Plate versus Pin
• 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 versus Pin
• 62 elderly patients with midshaft fxs
• Mean shoulder score: pinning 85 points,
plating 84 points (P=.7)
• Pinning required significantly shorter
operative time (P

Conclusion
• 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