Summary Midshaft clavicle fractures are common traumatic injuries seen in young adults that occur in the middle third of the clavicle. Diagnosis can be made radiographically with shoulder radiographs. Treatment is controversial but may be nonoperative or operative based on patient activity demands and the degree of radiographic displacement and shortening. Epidemiology Incidence common clavicle fractures account for 2.6-4% of all adult fractures Demographics often seen in young, active patients most common in males < 30 years old Location 75-80% of all clavicle fractures will occur in the middle third segment Etiology Pathophysiology mechanism of injury fall on an outstretched arm or direct trauma to the shoulder pathoanatomy 75-80% of all clavicle fractures will occur in the middle third segment the junction of the outer and middle thirds is the thinnest part of the bone and is the only area not protected by or reinforced with muscle and ligamentous attachments it is therefore prone to fracture, particularly with axial loading displaced fractures medial fragment: sternocleidomastoid muscle pulls the medial fragment posterosuperiorly lateral fragment: pectoralis and weight of arm pull the lateral fragment inferomedially open fractures usually the result of the medial fragment as it "buttonholes" through the platysma Associated conditions associated injuries are rare but may include ipsilateral scapular fracture scapulothoracic dissociation should be considered with significantly distracted/widened fracture fragments rib fracture pneumothorax neurovascular injury closed head injury Classification Neer Classification Nondisplaced < 100% displacement Nonoperative Displaced > 100% displacement Operative AO classification Type A = Simple A1 = spiral A2 = oblique A3 = transverse Nonoperative vs. operative Type B = Wedge B1 = spiral wedge B2 = bending wedge B3 = fragmented wedge Nonoperative vs. operative Type C = Complex C1 = complex spiral C2 = segmental C3 = irregular Operative Presentation Symptoms anterior shoulder pain Physical exam may have deformity may have skin tenting (impending open fracture) important to perform careful neurovascular exam Imaging Radiographs recommended views upright AP of bilateral shoulders 15° cephalic tilt (zanca view) helps to determine superior/inferior displacement may consider having the patient hold 5-10 lbs of weight in the affected hand CT views coronal, saggital, axial 3D reconstruction views findings may help evaluate displacement, shortening, comminution, articular extension, vascular injury, and nonunion Differential Adult distal third clavicle fx Pediatric medial clavicle physeal injury Pediatric distal clavicle physeal injury Acromioclavicular Joint Injury Treatment Nonoperative sling immobilization with gentle ROM exercises at 2-4 weeks and strengthening at 6-10 weeks indications < 2cm shortening and displacement < 1cm displacement of the superior shoulder suspensory complex no neurovascular injury Operative closed reduction and intramedullary fixation vs. open reduction internal fixation indications absolute open fractures displaced fracture with skin tenting subclavian artery or vein injury floating shoulder (clavicle and scapular neck fracture) symptomatic nonunion symptomatic malunion relative and controversial indications displaced with > 2cm shortening bilateral displaced clavicle fractures brachial plexus injury (questionable because 66% have spontaneous return) closed head injury seizure disorder polytrauma patient Techniques Sling Immobilization technique immobilize using sling or figure-of-eight brace prospective studies have not shown a difference in functional or cosmetic outcomes between sling and figure-of-eight braces no attempt at reduction should be made after 2-4 weeks begin gentle range of motion exercises strengthening exercises begin at 6-10 weeks outcomes nonunion (10-15%) risk factors comminution > 100% displacement > 2cm shortening advanced age female gender poorer cosmesis decreased shoulder strength and endurance seen with displaced midshaft clavicle fractures healed with > 2cm of shortening Closed Reduction and Intramedullary Fixation contraindications substantial comminution segmental fractures approach beach chair or supine posterolateral incision instrumentation cannulated screw specialized screw systems (e.g, Dual Trak) titanium elastic nail Hagle pin advantages smaller incision less soft-tissue disruption less prominent hardware avoids the supraclavicular cutaneous nerves commonly injured with plating disadvantages higher complication rate including hardware migration, hardware breakage, temporary brachial plexus palsy, and skin breakdown over the entry portal biomechanically inferior to plating Open Reduction Internal Fixation approach beach chair vs. supine direct superior vs. anterior incision instrumentation most common limited contact, pre-controured, dynamic compression plate k-wires for preliminary fixation other options 3.5mm reconstruction plate locking plates technique superior plating (compared to anteroinferior plating) higher load to failure increased plate strength with inferior bone comminunion increased risk of neurovascular injury decreased removal of deltoid attachment advantages improved results with ORIF for clavicle fractures with > 2cm shortening and > 100% displacement improved functional outcomes/less pain with overhead activity faster time to union decreased symptomatic malunion rate improved cosmetic satisfaction improved overall shoulder satisfaction increased shoulder strength and endurance disadvantages increased risk of need for future procedures implant removal debridement for infection outcomes time to union operative (16.4 weeks) vs. non-operative (28.4 weeks) postoperative Rehabilitation early sling for 7-10 days followed by active motion late strengthening at ~6 weeks when pain-free motion and radiographic evidence of union full activity including sports at ~3 months Complications Nonoperative treatment nonunion (10-15%) risk factors fracture comminution (Z deformity) fracture displacement female gender advanced age smoker treatment if asymptomatic, no treatment necessary if symptomatic, ORIF with plate and bone graft (particularly atrophic nonunion) malunion definition shortening > 3cm angulation > 30° translation > 1cm presentation increased fatigue with overhead activities thoracic outlet syndrome dissatisfaction with appearance difficulty with shoulder straps, backpacks and the like treatment clavicle osteotomy with bone grafting, if symptomatic Operative treatment hardware prominence ~30% of patient request plate removal superior plates associated with increased irritation neurovascular injury (3%) superior plates associated with increased risk of subclavian artery or vein penetration subclavian thrombosis supraclavicular nerve injury nonunion (1-5%) infection (~4.8%) risk factors illicit drug use diabetes previous shoulder surgery mechanical failure (~1.4%) pneumothorax adhesive capsulitis 4% in surgical group develop adhesive capsulitis requiring surgical intervention
Technique Guide CPT Codes: 23515 Open treatment of clavicular fracture, includes internal fixation, when performed Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Clavicle Shaft Fracture ORIF Orthobullets Team Trauma - Midshaft Clavicle Fractures
QUESTIONS 1 of 23 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Previous Next (SBQ18TR.1) A 28-year-old male sustains the injury seen in Figure A. After discussing the risks and benefits of surgery, he elects to pursue nonoperative treatment. Of the following possible complications from nonoperative treatment, which is the most likely? QID: 211111 FIGURES: A Type & Select Correct Answer 1 Skin necrosis 2% (25/1438) 2 Nonunion 90% (1296/1438) 3 Complex regional pain syndrome (CRPS) 1% (17/1438) 4 Sternoclavicular joint arthritis 1% (11/1438) 5 Acromioclavicular joint arthrosis 5% (76/1438) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ12TR.3.1) A 32-year-old female sustained a closed clavicle fracture after a fall as shown in Figures A and B. After a long discussion of the risks and benefits the patient elects to undergo nonoperative management. When discussing nonunion, which of the following is the best estimate for risk of nonunion with nonoperative treatment? QID: 214312 FIGURES: A B Type & Select Correct Answer 1 1% 1% (23/1547) 2 5% 18% (283/1547) 3 15% 48% (745/1547) 4 30% 20% (317/1547) 5 50% 11% (173/1547) L 4 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ12TR.23) A 25-year-old patient is involved in a motor vehicle accident. An isolated orthopaedic injury is sustained to the upper extremity with no compromise of skin integrity or neurovascular function. A radiograph of the injury is shown in Figure A. The patient is interested in pursuing surgical intervention. What is a reported outcome of surgery when compared to nonoperative management at 1 year postoperatively? QID: 3938 FIGURES: A Type & Select Correct Answer 1 Increased rates of symptomatic nonunion 3% (146/4823) 2 Similar rates of symptomatic nonunion 8% (382/4823) 3 No differences in cosmetic results 2% (107/4823) 4 Increased functional outcome scores 80% (3840/4823) 5 Improved range of motion of the shoulder 7% (324/4823) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (SBQ12TR.3) A 22-year-old left hand dominant laborer sustains the injury shown in Figures A and B as the result of a fall from a ladder. Which of the following has been shown to be true regarding operative versus nonoperative treatment of this injury? QID: 3918 FIGURES: A B Type & Select Correct Answer 1 Decreased chance of nonunion with nonoperative treatment 4% (251/6071) 2 Improved Constant and DASH scores with operative treatment at all time points 68% (4157/6071) 3 Increased symptomatic malunion rate with operative treatment 1% (87/6071) 4 No change in shoulder abduction strength 19% (1131/6071) 5 Increased time to union with operative treatment 7% (422/6071) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ11.118) A 35-year-old right hand dominant man falls from a ladder and sustains the injury seen in Figure A. When discussing the risks and benefits of operative versus nonoperative treatment for his fracture, which of the following is true? QID: 3541 FIGURES: A Type & Select Correct Answer 1 No difference in shoulder function 8% (402/4996) 2 Higher risk of nonunion with operative management 2% (82/4996) 3 Higher risk of symptomatic malunion or nonunion with nonoperative management 82% (4099/4996) 4 Earlier return to sport with nonoperative management 1% (25/4996) 5 No difference in union rates 7% (370/4996) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ10.101) A 32-year-old female sustains an isolated midshaft clavicle fracture, as shown in Figure A. Her clinical exam does not reveal skin tenting or neurovascular injury, but shortening is measured at 2.6 cm. Which of the following treatment methods has been shown to have the lowest rate of nonunion and symptomatic malunion? QID: 3195 FIGURES: A Type & Select Correct Answer 1 Open reduction and internal fixation with plating 91% (1760/1931) 2 Open reduction and percutaneous pinning 1% (18/1931) 3 Closed reduction and percutaneous pinning 1% (17/1931) 4 Closed reduction and external fixation 0% (1/1931) 5 Nonoperative treatment with a sling and early range of motion 6% (125/1931) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ08UE.37.1) A 62-year-old woman falls off a bike and sustains the injury shown in Figure A. She presents to clinic for her 6-month follow-up appointment and reports persistent pain. Current imaging is shown in Figure B. Which of the following factors is not a risk factor to the development of this patient’s diagnosis? QID: 212889 FIGURES: A B Type & Select Correct Answer 1 Shortening of 3cm 2% (44/1885) 2 Comminution 3% (64/1885) 3 Sling immobilization as opposed to figure-of-eight brace 84% (1590/1885) 4 Female gender 7% (141/1885) 5 Advanced age 2% (39/1885) L 5 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ08.219) A 22-year-old male sustains a right shoulder injury after being thrown from his motorcycle. After nine months of conservative treatment, he continues to complain of pain. A current radiograph is shown in Figure A. What is the most appropriate treatment? QID: 605 FIGURES: A Type & Select Correct Answer 1 Addition of a bone stimulator 0% (4/1192) 2 Figure of eight brace 1% (6/1192) 3 Closed reduction and percutaneous pinning 0% (2/1192) 4 Open reduction and intramedullary nailing 6% (69/1192) 5 Open reduction and compression plating 93% (1105/1192) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ08.168) A 20-year-old woman is involved in a high-speed motor vehicle collision and sustains bilateral tibial plateau fractures as well as the clavicle fracture shown in Figure A. What is the most appropriate management of the clavicular injury? QID: 554 FIGURES: A Type & Select Correct Answer 1 Closed reduction and figure of 8 splinting 1% (23/2611) 2 Open reduction and plate fixation 96% (2502/2611) 3 Open reduction and percutaneous pinning 0% (4/2611) 4 Simple sling to involved side 2% (62/2611) 5 Sling with abduction pillow to involved side 0% (6/2611) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ08.54) Which of the following factors increase the risk of nonunion in midshaft clavicle fractures when treated nonoperatively? QID: 440 Type & Select Correct Answer 1 Sling immobilization 0% (11/2435) 2 Displacement and comminution 93% (2254/2435) 3 Age less than 40 years old 0% (11/2435) 4 Immediate motion exercises 5% (126/2435) 5 Male 1% (20/2435) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ07.1) A 45-year-old male falls onto his left shoulder while biking and an injury radiograph is shown in Figure A. He elects for nonoperative treatment. What is the most likely clinical outcome at one year after injury? QID: 662 FIGURES: A Type & Select Correct Answer 1 Symmetric cosmesis of shoulders 6% (85/1497) 2 Decreased shoulder motion 5% (80/1497) 3 Symptomatic nonunion 15% (229/1497) 4 Shoulder instability 0% (1/1497) 5 Decreased shoulder strength and endurance 73% (1095/1497) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ07.275) Which of the following factors is associated with the highest rate of nonunion of a midshaft clavicle fracture? QID: 936 Type & Select Correct Answer 1 younger patients 7% (80/1200) 2 female gender 55% (656/1200) 3 simple fracture pattern 9% (108/1200) 4 sling immobilization 6% (70/1200) 5 early range-of-motion 23% (279/1200) L 4 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ07.25) A 31-year-old male sustains the injury shown in Figure A. As compared to treatment with a simple sling, what is the primary advantage of treatment with a figure-of-eight brace? QID: 686 FIGURES: A Type & Select Correct Answer 1 Decreased sleep disturbance 2% (22/1223) 2 Decreased personal care and hygiene impairment 3% (34/1223) 3 Decreased rates of malunion 3% (34/1223) 4 Improved long-term clinical outcomes 1% (7/1223) 5 No advantage, equivalent result between a simple sling and figure-of-eight brace 92% (1120/1223) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic
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