WHEN AND HOW TO OPERATE

A DISPLACED LATERAL
CLAVICLE FRACTURE

Dr Pamudji Utomo SpOT (K)

Dr Pamudji Utomo SpOT (K)

Background
Epidemiology
Clavicle

fractures --> 2.6 % - 12 % of all fractures

Clavicle

fractures --> 44 % - 66 % of shoulder fractures

Middle

third fractures --> 80 % of all clavicle fractures

Proximal

third fractures 5 %

Lateral

/ distal third 15 %

(Koval K, Zuckerman JD. 2010)

Topographic Anatomy
The
clavicle
is
narrowest in its
midportion, high
incidence
of
fractures in this
area.

(Lazarus MD, Seon C. 2006)

Clavicle Functions

(https://online .epocrates.com)

The clavicle function as a strut, bracing the shoulder from the trunk
and allowing the shoulder to function at optimal strength. The
medial one third protect the brachial plexus, the subclavian and
axillary vessels, and the superior lung. (Koval K, Zuckerman JD. 2010)

Mechanism of Injury

A fall on the shoulder or

the outstretched hand
A fall directly on the
shoulder (87%)
Secondary to muscle
contraction seizure or
stress fracture (rare)

(Cole A, pavlou P, Warwick D.

2010)
(Jackson J. 2011)

Fracture Classification

Neer Classification

AO Classification

15-C: Location: Lateral End

15-C1: Clavicle, Lateral End, Extra Articular

15-C2 : Clavicle, Lateral End, Intra-articular

Groups

15-C2.1: With slight displacement

(C-C Ligament Intact)

15-C1.1: Impacted (C-C Ligament Intact)

Subgroups

15-C1.2 : Noncomminuted (C-C Ligament disrupted)

15-C2.2: Noncomminuted (C-C Ligament disrupted)

15-C1.3 : Comminuted (C-C Ligament disrupted)

15-C2.3: Comminuted (C-C Ligament disrupted)

(Ruedi TP, Murphy WM. 2000)

Treatment

of

lateral

clavicle

fractures
Conservative or Operative
Problem:
Traditionally, nonsurgical management has been favored as
the initial treatment.
Recent evidence suggests that specific subsets of patients
may be at high risk for nonunion, shoulder dysfunction, or
residual pain after nonsurgical management.
(Tiren D, Vroemen JPAM. 2013)

Treatment of type I and type III Neer Classification

fractures does not appear to be debated
Mostly conservative + physiotherapy
Neer type II:
Wide variety of treatment
Particular deformity + lack of stability
High risk of complications
ORIF

(Dugdale D et al. 1990)

Treatment Options

Nonoperative
Sling
Brace

Surgical
Plate Fixation
Screw or Pin Fixation
K-Wire
Suture and sling techniques
(Van der Meijden OA, Gaskill TR, Millett PJ. 2011)

Surgical treatment indication of lateral-third clavicle

fracture:

CC ligament disruption displacement of the

medial clavicle lead to high risk of nonunion
(28%)
Open Fractures or with Soft-tissue compromise
Multiple trauma
floating shoulder injuries are present.

(Van der Meijden OA, Gaskill TR, Millett PJ. 2011)

Surgical Treatment Options

Plate and Screw
Several plates have been described in the literature
including the Balser plate, the Wolter plate, the AO
clavicular hook plate

Wolter Plate

Balser Plate

(http://eorif.com)

(Bansal M, et al. 2010)

Hook Plate

stability of the fracture is preserved without disturbing the

biomechanics of the AC joint
Complications: fracture of the plates hook, cut-out,
enlargement of the hooks hole in the acromion.
(Charity RM, Haidar SG, Ghosh S, Tillu AB. 2007)

Locking Plate

Madsen et al. Addition of a suture anchor for

coracoclavicular fixation to a superior locking plate
improves stability of type IIB distal clavicle fractures.

(Madsen,
2013)

Screw or Pin Fixation

Coracoclavicular Screw
Belmer and Gelber (1991) Coracoclavicular fixation
provided and maintained reduction of the fracture.
According to their study, healing occurred uneventfully
within nine weeks in all cases.

(Fazal MA, Saksena J, Haddad FS.2007)

Coracoclavicular
Screw and Loop
suture

(Lazarus MD, Seon C. 2006)

Lin HH et al (2013) evaluated effects of a single cortical

screw (4.5-mm diameter, 60-mm length) All patients
had good to excellent final Constant-Murley functional
results.

IM Pin Fixation

(Wheeles CR. 2013)

Loop Suture
Soliman et al: Under-coracoid-around-clavicle (UCAC)
loop rigid fixation and lead to bony union, provides
adequate stability with excellent results.

(Soliman O, et al. 2013)

Keith M. Baumgarten (2008) presented an arthroscopic

fixation of type II-variant, unstable distal clavicle fracture.

Figure 2: Arthroscopic view through the anterolateral portal showing the base of
the coracoid with the inferior button of the TightRope device deployed. Figure
3: AP radiograph 6 months postoperatively, revealing osseous union of the distal
clavicle. Figure 4: Symmetric anatomic appearance of the right acromioclavicular
joint and distal clavicle 6 months postoperatively

(Baumgarten KM. 2008)

K-wire and Tension Band Wiring

(Wu K et al. 2013)

K-wire by closed technique

Comparison Study
Bishop JY et al No significant difference in ultimate load to
failure was found in a biomechanic comparison study among
4 groups : suture fixation with a cerclage suture and
coracoclavicular suture, distal clavicle locking plate, distal
clavicle locking plates with suture augmentation, and distal
clavicle hook plate.

(Bishop JY. et al, 2013)

Comparison Study
Karl Wu et al hook plate fixation of unstable lateral
clavicle fractures was associated with statistically better
shoulder function and earlier implant removal than K-wire
tension band fixation.

(Wu K et al. 2013)

Comparison Study

Sylvia et al. reported a meta analysis of Surgical

treatment of Neer type-II fractures of the distal clavicle
(21 studies, 350 patients). Functional outcome was
similar between the treatment modalities (plate,
suture, and pin).

(Stegeman SA et al. 2013)

Conclusion

Lateral clavicle fracture can be treated conservatively or

operatively.

Many surgical techniques has been proposed for lateral

clavicle fracture.

Specific treatment should be individualized based on

fracture characteristics and patient expectations

THANK YOU