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MediClinic Cape Town


Netcare Blaauwberg Hospital


British Medical Books Health Issues Computerized Tomography

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