Clavicle Fractures
Anatomy
- S shaped tubular bone
- connecting shoulder girdle with chest
Incidence
- common
- underlying structures
- vessels
- brachial plexus
- lung, mediastinum
Shaft Fractures
Newborns & Infants
- common as birth injuries
- unites by D7 to D10
- ensure comfort
- avoid P° on clavicle
- handle gently - avoid movement of affected limb with feeding, changing clothes
- with pseudoparalysis - cotton wool under in axilla, flex elbow to 90° & strap arm to chest
Ages 2 to 12 years
- treated symptomatically
- no reduction if < 6 years old - will remodel - figure of 8 bandage
- see the child weekly to assess skin, NV status & look for any other problems
- unites in 3 - 4 weeks
- undisplaced, incomplete & plastic deformation
- simple sling for comfort
- avoid vigorous activities for 3 months
Ages 12 to 16 years
- limited remodelling & closed reduction if necessary
- # heals in about 6 weeks
- multiple trauma - clavicular # treated by recumbancy with a pillow between scapulae
Medial & Distal Fractures
- mostly physeal injuries
- sling is treatment of choice
- medial #’s - rarely a problem, rarely significant displacement
- lateral #’s - stable because the C-C & A-C ligs attached to the periosteal tube
- remodelling will occur
Adults
- more difficult to treat - bone & periosteum is different from children
- associated ST & bone injury may be greater
- potential for healing is less
Shaft Fractures
- reduce if necessary
- figure of 8 &⁄or sling
- immobilize for 6 - 8 weeks
Indications for primary ORIF
- NV injury
- threatened skin
- open fracture
- multiple trauma
- floating shoulder - displaced clavicle # + unstable scapula #
- some type 2 distal clavicle #’s
- medical reasons - seizures, Parkinson’s
- ???? cosmesis
- very few clavicle #’s need 10 ORIF
Options
- plate
- intramedullary pins (Steinman’s or Knowles pins)
- with or without primary bone grafting
Distal Clavicle Fractures
- Type 1
- ligs are intact - displacement is minimal
- sling + early mobilization (isometric exercises)
- Type 2
- difficult to treat non operatively - immobilization is difficult
- fragments are distracted by muscle forces & the weight of the arm
- proximal fragment is unstable - non-union occurs often
- sling does not reduce the deformity & a figure of 8 can increase the deformity
- if there is bony contact - conservative treatment is an option
- probably best treated by ORIF if displaced & unstable
Options
- cerclage wires, intramedullary pins, sutures binding the proximal fragment to the coracoid process, ligament repair if necessary
- may or may not choose to primarily bone graft
- Type 3
- if unstable & seen acutely - treat as for type 2
Medial clavicle injuries
- symptomatic support only unless there is NV injury
- then ORIF - avoid intramedullary fixation because of complications
- technique of Roussow & de Beer
- mediolateral intramedullary fixation
- figure of 8 & /or sling