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Midshaft clavicle fracture and acromioclavicular dislocation: A case report of a rare injury
J Shoulder Elbow Surg (2009) 18, e1-e4
www.elsevier.com/locate/ymse
Midshaft clavicle fracture and acromioclavicular dislocation: A case report of a rare injury Peter C. Yeh, MDa,*, Seth R. Miller, MDb, James G. Cunningham, MDb, Paul M. Sethi, MDb a b
Department of Orthopaedics and Rehabilitation, Yale University, New Haven, CT Orthopaedic & Neurosurgery Specialists, Greenwich, CT
Combined injury involving a distal clavicle fracture and acromioclavicular (AC) separation is not uncommon; however, fractures of the midshaft clavicle with an ipsilateral AC dislocation are rare. There have only been 3 reports in the American literature on this type of combination injury.1,2,7 We report a case of a horseback rider who fell on the affected shoulder and presented with this injury. She was treated surgically and has an excellent clinical result at 1 year postoperatively. This case illustrates the challenges of treating a displaced clavicle fracture and concurrent AC separation. It also shows that surgical intervention for this rare combination injury yields an excellent functional outcome. The patient consented to publication of this report.
Case report A 46-year-old, right-handedominant woman fell off a horse and landed on her right shoulder. Examination of the shoulder shortly after the accident showed ecchymosis and swelling in the region of the posterior aspect of the mid trapezius. She had marked tenderness at the mid clavicle, as well as posteriorly in the trapezius, and a nonpalpable clavicle at the level of the acromion. The neurologic and vascular status of the right upper extremity was normal. Her medical history was significant for a previous fall off a horse 3 years earlier when she sustained a grade I AC separation that resolved without sequelae. *Reprint requests: Peter C. Yeh, MD, 800 Howard Avenue, 133 YPB, New Haven, CT 06519. E-mail address: [email protected] (P.C. Yeh).
Radiographic examination of the right clavicle and AC joint showed a displaced midshaft fracture of the clavicle and widening of the AC joint with posterior displacement of the distal clavicular fragment (Figures 1 and 2). A computed tomography scan confirmed the posterior displacement of the distal clavicle and AC joint widening and also showed degenerative changes at the AC joint (Figure 3). The operative and nonoperative options were carefully reviewed, and surgery was elected. The patient was placed in the semiebeach chair position. Closed reduction of the AC joint was unsatisfactory; the joint was irreducible, and the manipulation increased the deformity at the fracture. At this point, isolated or percutaneous treatment, by use of a screw into the coracoid, was eliminated as a possible option. A transverse incision was then made across the clavicle toward the AC joint. The distal clavicle was clearly posteriorly displaced through a buttonhole defect in the trapezius muscle, the likely reason for the failed closed reduction (Figure 4). An attempt to reduce the AC joint was made, once the clavicle was extricated from the buttonhole, but this maneuver forced the fracture apex more superiorly. The AC and coracoclavicular (CC) ligaments were also found to be ruptured completely (Figure 5). The 2 fracture fragments were identified. The lateral clavicle was completely denuded of all soft-tissue attachments, suggestive of a degloving injury. After reduction of the fracture, fixation of the clavicle was performed with a precontoured plate. We altered the placement of the screws in order to reconstruct the CC ligaments anatomically. Despite open reductioneinternal fixation (ORIF) of the clavicle, the AC joint was still unstable, with superior and posterior displacement evident under stress. Given this finding, the AC and CC ligaments were reconstructed with a semitendinosus allograft placed through a single drill hole in the clavicle, looped around the coracoid, and sewn to itself (Figure 6). The patient’s extremity remained in a sling for 4 weeks, and she attended physical therapy sessions.
1058-2746/2009/$36.00 - see front matter Ó 2009 Journal of Shoulder and Elbow Surgery Board of Trustees. doi:10.1016/j.jse.2008.09.011
e2
Figure 1 AP radiograph showing midshaft clavicle fracture with widening of the AC joint.
P.C. Yeh et al.
Figure 3 CT scan showing widened and posteriorly displaced AC joint, with degenerative changes at the joint.
Figure 2 Axillary radiograph showing a reduced shoulder with posterior displacement of the distal clavicular fracture.
The 1-year follow-up showed painless full active and passive range of motion with good strength of the right shoulder. The patient has no pain on axial loading of the AC joint and has resumed her normal preinjury activities, including riding horses (Figure 7).
Discussion
Figure 4 Intraoperative photograph showing buttonhole defect where the clavicle was embedded.
Midshaft fractures of the clavicle or AC joint separations as isolated injuries are quite common. However, the combined injury to the ipsilateral shoulder is quite rare. Fractures of the distal end of the clavicle with involvement of the AC joint are well recognized and were classified by Neer5 to include nondisplaced fractures (type I), displaced fractures with tearing of the CC ligaments (type II), and fractures involving the articular surface (type III). Reviewing the American literature, we found only 3 reports that included
fractures at the midshaft clavicle. In 1990, Lancourt et al2 reported the case of a 19-year-old horseback rider who was thrown from the animal and landed on her shoulder, sustaining the combination injury to her midshaft clavicle and AC joint. Closed reduction was unsuccessful, and surgical exploration, reduction, and fixation of the AC joint were performed with 2 crossed Steinmann pins. The clavicle fracture was not opened, and the CC ligaments
Midshaft clavicle fracture
e3
Figure 7 One year follow-up radiograph of healed clavicle fracture and reconstructed AC joint.
Figure 5 Intraoperative photograph showing reduced clavicle fracture (note the denuded bone fragments) and disrupted AC and CC ligaments.
Figure 6 Intraoperative photograph showing plate fixation of clavicle as well as reconstructed AC and CC ligaments with allograft.
were not explored. The pins were removed in the office 8 weeks later, and at 3-year follow-up, the authors reported a healed clavicle fracture, as well as full, painless range of shoulder motion with no AC separation on weight-bearing films.
Figure 8 Axillary radiograph with outline of clavicular fragments and acromion clearly demonstrating posterior displacement of distal clavicle fragment.
In 1992, Wurtz et al7 reported this combination injury in 4 patients. Two had fallen off a horse, one had fallen from a bicycle, and another was involved in a motor vehicle accident. Three of the patients (all with grade IV AC separation) underwent successful ORIF and went on to have asymptomatic range of motion. Two of the three were treated operatively by internal fixation with a CC cancellous bone screw. In the third, AC transfixation Steinmann pins were used. In each of these patients, the fixation device was removed approximately 6 to 8 weeks postoperatively. The fourth patient was diagnosed with a grade II injury and was treated nonoperatively with early range-of-motion exercises, which resulted in a good outcome of painless, full range of motion. In 1995, Heinz et al1 reported on the case of a competitive cyclist who sustained the injury during a race. This patient was treated conservatively with a figure-of-8 clavicle brace for 5 weeks. Although the authors report that the patient returned to cycling without problems with equal strength and motion compared with the unaffected side, follow-up radiographs showed a wide AC separation with superior displacement of the healed clavicle that was greater than the width of the clavicle. It is unclear what significance this will
e4 have on future function for the cyclist. It should be mentioned, however, that there is increasing evidence that sequelae from nonoperative treatment of clavicle fractures are more common than once thought6 and that shortening from a clavicle fracture yields decreased abduction endurance strength and overall patient satisfaction.4 It is important to complete a full clinical and radiologic workup after an axial trauma to the shoulder. As shown in Figure 1, an anteroposterior radiograph, which is commonly obtained in the emergency department, can underestimate the displacement of the distal clavicle. An axillary radiograph is critical in determining the nature of the AC separation if one sees AC joint widening on the anteroposterior radiograph. The history of previous AC separation could erroneously lead the surgeon to believe that the patient has osteolysis and to ignore the posterior displacement. An axillary radiograph was important in our case because it showed the posterior displacement of the distal end of the clavicle (Figure 8). It should be recognized that this injury is not only a bony injury but also a soft-tissue one. As such, examination of both the AC and CC ligaments is important to the success of the repair. This is not only achieved with direct visualization of the ligaments; it is also important to stress the clavicle after reduction and fixation of the fracture. In this case, when stressed, the clavicle tended to subluxate posteriorly and superiorly at the AC joint. Therefore, to achieve stability of the clavicle to the acromion and coracoid, repair of the AC and CC ligaments was undertaken with a semitendinosus allograft.
P.C. Yeh et al. It was only after both bony and soft-tissue repair was performed that successful management of the fracturedislocation was achieved. There are many techniques to repair these ligaments, not limited to the technique used here. Choosing the right technique for a specific patient population is important to the successful management of the injury.3 To our knowledge, this is the only report that addresses ORIF of a clavicle fracture with ipsilateral AC and CC ligament reconstruction.
References 1. Heinz WM, Misamore GW. Mid-shaft fracture of the clavicle with grade III acromioclavicular separation. J Shoulder Elbow Surg 1995;4:141-2. 2. Lancourt JE. Acromioclavicular dislocation with adjacent clavicular fracture in a horseback rider. Am J Sports Med 1990;3:321-2. 3. Mazzocca AD, Arciero RA, Bicos J. Evaluation and treatment of acromioclavicular joint injuries. Am J Sports Med 2007;35:316-29. 4. McKee MD, Pedersen EM, Jones C, Stephen DJG, Kreder HJ, Schemitsch EH, et al. Deficits following nonoperative treatment of displaced midshaft clavicular fractures. J Bone Joint Surg Am 2006;88:35-40. 5. Neer CS II. Fractures of the distal third of the clavicle. Clin Orthop Relat Res 1968;58:43-50. 6. Nowak J, Holgersson M, Larsson S. Sequelae from clavicular fractures are common. Acta Orthop 2005;76:496-502. 7. Wurtz LD, Lyons FA, Rockwood CA. Fracture of the middle third of the clavicle and dislocation of the acromioclavicular joint. A report of four cases. J Bone Joint Surg Am 1992;74:133-7.
www.elsevier.com/locate/ymse
Midshaft clavicle fracture and acromioclavicular dislocation: A case report of a rare injury Peter C. Yeh, MDa,*, Seth R. Miller, MDb, James G. Cunningham, MDb, Paul M. Sethi, MDb a b
Department of Orthopaedics and Rehabilitation, Yale University, New Haven, CT Orthopaedic & Neurosurgery Specialists, Greenwich, CT
Combined injury involving a distal clavicle fracture and acromioclavicular (AC) separation is not uncommon; however, fractures of the midshaft clavicle with an ipsilateral AC dislocation are rare. There have only been 3 reports in the American literature on this type of combination injury.1,2,7 We report a case of a horseback rider who fell on the affected shoulder and presented with this injury. She was treated surgically and has an excellent clinical result at 1 year postoperatively. This case illustrates the challenges of treating a displaced clavicle fracture and concurrent AC separation. It also shows that surgical intervention for this rare combination injury yields an excellent functional outcome. The patient consented to publication of this report.
Case report A 46-year-old, right-handedominant woman fell off a horse and landed on her right shoulder. Examination of the shoulder shortly after the accident showed ecchymosis and swelling in the region of the posterior aspect of the mid trapezius. She had marked tenderness at the mid clavicle, as well as posteriorly in the trapezius, and a nonpalpable clavicle at the level of the acromion. The neurologic and vascular status of the right upper extremity was normal. Her medical history was significant for a previous fall off a horse 3 years earlier when she sustained a grade I AC separation that resolved without sequelae. *Reprint requests: Peter C. Yeh, MD, 800 Howard Avenue, 133 YPB, New Haven, CT 06519. E-mail address: [email protected] (P.C. Yeh).
Radiographic examination of the right clavicle and AC joint showed a displaced midshaft fracture of the clavicle and widening of the AC joint with posterior displacement of the distal clavicular fragment (Figures 1 and 2). A computed tomography scan confirmed the posterior displacement of the distal clavicle and AC joint widening and also showed degenerative changes at the AC joint (Figure 3). The operative and nonoperative options were carefully reviewed, and surgery was elected. The patient was placed in the semiebeach chair position. Closed reduction of the AC joint was unsatisfactory; the joint was irreducible, and the manipulation increased the deformity at the fracture. At this point, isolated or percutaneous treatment, by use of a screw into the coracoid, was eliminated as a possible option. A transverse incision was then made across the clavicle toward the AC joint. The distal clavicle was clearly posteriorly displaced through a buttonhole defect in the trapezius muscle, the likely reason for the failed closed reduction (Figure 4). An attempt to reduce the AC joint was made, once the clavicle was extricated from the buttonhole, but this maneuver forced the fracture apex more superiorly. The AC and coracoclavicular (CC) ligaments were also found to be ruptured completely (Figure 5). The 2 fracture fragments were identified. The lateral clavicle was completely denuded of all soft-tissue attachments, suggestive of a degloving injury. After reduction of the fracture, fixation of the clavicle was performed with a precontoured plate. We altered the placement of the screws in order to reconstruct the CC ligaments anatomically. Despite open reductioneinternal fixation (ORIF) of the clavicle, the AC joint was still unstable, with superior and posterior displacement evident under stress. Given this finding, the AC and CC ligaments were reconstructed with a semitendinosus allograft placed through a single drill hole in the clavicle, looped around the coracoid, and sewn to itself (Figure 6). The patient’s extremity remained in a sling for 4 weeks, and she attended physical therapy sessions.
1058-2746/2009/$36.00 - see front matter Ó 2009 Journal of Shoulder and Elbow Surgery Board of Trustees. doi:10.1016/j.jse.2008.09.011
e2
Figure 1 AP radiograph showing midshaft clavicle fracture with widening of the AC joint.
P.C. Yeh et al.
Figure 3 CT scan showing widened and posteriorly displaced AC joint, with degenerative changes at the joint.
Figure 2 Axillary radiograph showing a reduced shoulder with posterior displacement of the distal clavicular fracture.
The 1-year follow-up showed painless full active and passive range of motion with good strength of the right shoulder. The patient has no pain on axial loading of the AC joint and has resumed her normal preinjury activities, including riding horses (Figure 7).
Discussion
Figure 4 Intraoperative photograph showing buttonhole defect where the clavicle was embedded.
Midshaft fractures of the clavicle or AC joint separations as isolated injuries are quite common. However, the combined injury to the ipsilateral shoulder is quite rare. Fractures of the distal end of the clavicle with involvement of the AC joint are well recognized and were classified by Neer5 to include nondisplaced fractures (type I), displaced fractures with tearing of the CC ligaments (type II), and fractures involving the articular surface (type III). Reviewing the American literature, we found only 3 reports that included
fractures at the midshaft clavicle. In 1990, Lancourt et al2 reported the case of a 19-year-old horseback rider who was thrown from the animal and landed on her shoulder, sustaining the combination injury to her midshaft clavicle and AC joint. Closed reduction was unsuccessful, and surgical exploration, reduction, and fixation of the AC joint were performed with 2 crossed Steinmann pins. The clavicle fracture was not opened, and the CC ligaments
Midshaft clavicle fracture
e3
Figure 7 One year follow-up radiograph of healed clavicle fracture and reconstructed AC joint.
Figure 5 Intraoperative photograph showing reduced clavicle fracture (note the denuded bone fragments) and disrupted AC and CC ligaments.
Figure 6 Intraoperative photograph showing plate fixation of clavicle as well as reconstructed AC and CC ligaments with allograft.
were not explored. The pins were removed in the office 8 weeks later, and at 3-year follow-up, the authors reported a healed clavicle fracture, as well as full, painless range of shoulder motion with no AC separation on weight-bearing films.
Figure 8 Axillary radiograph with outline of clavicular fragments and acromion clearly demonstrating posterior displacement of distal clavicle fragment.
In 1992, Wurtz et al7 reported this combination injury in 4 patients. Two had fallen off a horse, one had fallen from a bicycle, and another was involved in a motor vehicle accident. Three of the patients (all with grade IV AC separation) underwent successful ORIF and went on to have asymptomatic range of motion. Two of the three were treated operatively by internal fixation with a CC cancellous bone screw. In the third, AC transfixation Steinmann pins were used. In each of these patients, the fixation device was removed approximately 6 to 8 weeks postoperatively. The fourth patient was diagnosed with a grade II injury and was treated nonoperatively with early range-of-motion exercises, which resulted in a good outcome of painless, full range of motion. In 1995, Heinz et al1 reported on the case of a competitive cyclist who sustained the injury during a race. This patient was treated conservatively with a figure-of-8 clavicle brace for 5 weeks. Although the authors report that the patient returned to cycling without problems with equal strength and motion compared with the unaffected side, follow-up radiographs showed a wide AC separation with superior displacement of the healed clavicle that was greater than the width of the clavicle. It is unclear what significance this will
e4 have on future function for the cyclist. It should be mentioned, however, that there is increasing evidence that sequelae from nonoperative treatment of clavicle fractures are more common than once thought6 and that shortening from a clavicle fracture yields decreased abduction endurance strength and overall patient satisfaction.4 It is important to complete a full clinical and radiologic workup after an axial trauma to the shoulder. As shown in Figure 1, an anteroposterior radiograph, which is commonly obtained in the emergency department, can underestimate the displacement of the distal clavicle. An axillary radiograph is critical in determining the nature of the AC separation if one sees AC joint widening on the anteroposterior radiograph. The history of previous AC separation could erroneously lead the surgeon to believe that the patient has osteolysis and to ignore the posterior displacement. An axillary radiograph was important in our case because it showed the posterior displacement of the distal end of the clavicle (Figure 8). It should be recognized that this injury is not only a bony injury but also a soft-tissue one. As such, examination of both the AC and CC ligaments is important to the success of the repair. This is not only achieved with direct visualization of the ligaments; it is also important to stress the clavicle after reduction and fixation of the fracture. In this case, when stressed, the clavicle tended to subluxate posteriorly and superiorly at the AC joint. Therefore, to achieve stability of the clavicle to the acromion and coracoid, repair of the AC and CC ligaments was undertaken with a semitendinosus allograft.
P.C. Yeh et al. It was only after both bony and soft-tissue repair was performed that successful management of the fracturedislocation was achieved. There are many techniques to repair these ligaments, not limited to the technique used here. Choosing the right technique for a specific patient population is important to the successful management of the injury.3 To our knowledge, this is the only report that addresses ORIF of a clavicle fracture with ipsilateral AC and CC ligament reconstruction.
References 1. Heinz WM, Misamore GW. Mid-shaft fracture of the clavicle with grade III acromioclavicular separation. J Shoulder Elbow Surg 1995;4:141-2. 2. Lancourt JE. Acromioclavicular dislocation with adjacent clavicular fracture in a horseback rider. Am J Sports Med 1990;3:321-2. 3. Mazzocca AD, Arciero RA, Bicos J. Evaluation and treatment of acromioclavicular joint injuries. Am J Sports Med 2007;35:316-29. 4. McKee MD, Pedersen EM, Jones C, Stephen DJG, Kreder HJ, Schemitsch EH, et al. Deficits following nonoperative treatment of displaced midshaft clavicular fractures. J Bone Joint Surg Am 2006;88:35-40. 5. Neer CS II. Fractures of the distal third of the clavicle. Clin Orthop Relat Res 1968;58:43-50. 6. Nowak J, Holgersson M, Larsson S. Sequelae from clavicular fractures are common. Acta Orthop 2005;76:496-502. 7. Wurtz LD, Lyons FA, Rockwood CA. Fracture of the middle third of the clavicle and dislocation of the acromioclavicular joint. A report of four cases. J Bone Joint Surg Am 1992;74:133-7.