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ASIF screw
Injury, Int. J. Care Injured (2005) 36, 1172—1175
www.elsevier.com/locate/injury
Intramedullary fixation of Neer type 2 fractures of the distal clavicle with an AO/ASIF screw J.E. Scadden *, R. Richards 17 St Johns Street, Winchester, Hampshire S023 0HF, UK Accepted 17 May 2005
Summary Background: Neer 2 fractures of the distal clavicle are notorious for their high rates of non-union and numerous methods of fixation are recommended. We review a simple method of fixation of these fractures with an intramedullary AO/ASIF malleolar screw. Method: Ten patients with Neer type 2 fractures of the distal clavicle were treated between 1996 and 2002. All had open reduction and internal fixation with an intramedullary 4.5 mm AO/ASIF malleolar screw. In all cases the coraco-clavicular ligaments were not repaired, and the screws were removed once the fractures had united. Results: All fractures united at between 6 and 12 weeks. All patients had a good functional result, with an excellent to good Oxford Shoulder score. Conclusion: This is a simple technique with a universally available implant and good fracture healing. We report no cases of screw breakage or migration and we question the necessity to repair the coraco-clavicular ligaments. # 2005 Elsevier Ltd. All rights reserved.
Introduction The Neer 2 fracture which involves the distal clavicle, accounts for nearly half of all clavicular nonunions.9 For this reason, most authors recommend primary fixation of this fracture type.5 In the literature there are many methods described for the fixation of these fractures, including hook plates,6 screw stabilisation from clavicle to corocoid process,1,13 Dacron slings3,7,12 and the use * Corresponding author. E-mail address: [email protected] (J.E. Scadden).
of intramedulary devices such as Hagie, Knowles or Steinman pins.2,11,14 Most of these procedures involve the use of implants not readily available. This paper reviews the results of intramedullary fixation of Neer 2 fractures with an AO/ASIF malleolar screw–—a simple procedure with a universally available device.
Materials and methods The notes and X-rays were reviewed of ten patients, who had had Neer 2 Fractures of the distal clavicle,
0020–1383/$ — see front matter # 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2005.05.022
Intramedullary fixation of Neer type 2 fractures
1173
between 1996 and 2002. The diagnosis was made by X-ray and an independent observer confirmed the classification. All patients reviewed had been treated with an intramedullary AO/ASIF 4.5 mm malleolar screw (Stratec Medical Ltd., Welwyn Garden City, UK); and all had been operated on by the senior author.
Operative technique Operations were performed under general anaesthetic; the patient was in a beach chair position, with a sand bag behind the shoulder. A sabre incision was made in the Langer line, over the distal clavicle (Fig. 1). With minimal periosteal stripping, the fracture ends were mobilised. The intramedullary cavities of both fragments were pre-drilled. The lateral in a retrograde direction and the proximal in an antegrade direction (Figs. 2 and 3). The exit point of the distal drill was in the posterior lateral corner of the clavicle. The fracture was reduced and a 4.5 mm AO/ASIF malleolar screw of appropriate length was inserted from the distal to proximal fragment (Fig. 4). The coracoclavicular ligaments were not repaired.
Figure 2
Antegrade drilling of the distal fragment.
Figure 3
Retrograde drilling of the distal fragment.
In all patients, the fractures were initially immobilised in a collar and cuff for 2—3 weeks, before mobilisation was started.
Follow-up All of the patients were initially seen at 6 weeks and at 3 months. All patients were scored using the Oxford Shoulder Score, which was obtained at review or telephonically at between 2 and 4 years post-op.
Results
Figure 1
Incision in Langer line over distal clavicle.
The mean age at fixation was 29.3 years, ranging from 18 to 84 years. Eight of the 10 cases were male and half were right sided. All were isolated injuries,
1174
J.E. Scadden, R. Richards
Figure 4
Final placement of screw.
Figure 7
Figure 5 male.
Callus at 6 weeks postoperatively.
Radiograph of a Neer type 2 fracture in 37year
seven as the result of a fall on an outstretched hand and three due to sporting injuries. The patients presented at between 1 and 6 weeks. All fractures united which was confirmed both clinically and radiographically (Figs. 5—8). The mean time to union in the patients was 44.1 days (6—12 weeks). The screws were removed in all patients via a stab incision under local anaesthetic at between 8 and 14 weeks. The mean Oxford Shoulder Score from the
Figure 8
Fracture union and screw removal at 8 weeks.
patients was 21.4 (range 17—32). The Oxford shoulder score is from 12 to 60, excellent scores are between 12 and 23 and good between 23 and 33.4 There were no screw breakages, or incidents of screw migration. All of those patients who were initially in employment returned to work.
Discussion
Figure 6 screw.
Fracture reduced with 4.5 mm AO malleolar
Neer 2 fractures of the distal clavicle that require fixation are rare. Zenni et al. reported on 800 fractured clavicles of which only five were fractures of the distal third requiring fixation.14 It has previously been reported that fixation of these fractures with an intramedullary device has a high complication rate, this includes screw migration and breakage.8 In our series of 10 patients between 1996 and 2002, we report no complications and are able to demonstrate excellent clinical results with good
Intramedullary fixation of Neer type 2 fractures
bone healing. This was reflected by excellent to good Oxford Shoulder Scores. Our review demonstrates that the AO/ASIF malleolar screws are robust enough to withstand the forces generated across the fracture site during union. The position of the implant does not interfere with the acromio-clavicular or acromiohumoral joint, thus problems with impingement and stiffness are avoided. Neither the coronoid or trapeziod ligaments were repaired nor was there a need to augment the fixation with wires or slings around the coronoid process. As this did not adversely affect the outcome in our series we question whether these added procedures are necessary. The Synthes AO/ASIF screws are available in most orthopaedic units so this obviates need to purchase expensive equipment for these rare fractures. In our series none of the patients had comminution of the distal fragment, however if this occurs it may be a contra-indication to intramedullary fixation as would a narrow intermedullary canal.
Conclusion We feel that the use of the Synthes AO/ASIF malleolar screws to achieve intramedullary fixation of Neer 2 fractures of the distal clavicle is a simple technique, with a high union rate and good clinical outcome.
1175
References 1. Ballmer FT, Gerber Cl. Coracoclavicular screw fixation for unstable fractures of the distal clavicle. A report of 5 cases. J Bone Joint Surg B 1991;73:291—4. 2. Boehme D. Non-union of the clavicle. Treatment with a modified Hagie intramedullary pin and bone graft. J Bone Joint Surg B 1991;73A:1219—26. 3. Chen C-H, Chen W-J, Shih C-Hl. Surgical treatment for distal clavicle fracture with coraco-clavicular ligament disruption. J of Trauma- Injury infection & critical care 2002;52(1):72—8. 4. Dawson J, Fitzpatrick R, Carr A. The assessment of shoulder instability. The development and validation of a questionnaire. J Bone Joint Br 1999;81(3):420—6. 5. Edwards DJ, Kavanaugh TG, Flannery MC. Fractures of the distal clavicle: a case for fixation. Injury 1992;23:44—6. 6. Mizue F, Shirai Y, Ito H. Surgical treatment of comminuted fractures of the distal clavicle using Wolter clavicular plates. Journal of Nippon Medical School 2000;67(1):32—4. 7. Neviaser RJ, Neviaser JS, Neviaser TJ, Neviaser JS. A simple technique for internal fixation of the clavicle. Clin Orthop 1975;109:103—7. 8. Noreil H. Migration of a threaded Steinman pin. J Bone Joint Surg 1965;47A:1024. 9. Nordqvist A, Peterson C, Redland-Johnell I. The natural course of lateral clavicular fractures. Acta Orthop Scandinavia 1993;64:87—91. 11. Rockwood CA. Fracture of the outer clavicle in children and adults. J Bone Joint Surg Br 1982;64B:642. 12. Weber MCB, Haines JF. The treatment of lateral clavicle fractures. Injury 2000;31:175—9. 13. Yamaguchi H, Arakawa H, Kobayashi M. Results of the Bosworth method for unstable fractures of the distal clavicle. Int Orthop 1998;22:366—8. 14. Zenni EJ, Krieg JK, Rosen MJ. Open reduction and internal fixation of clavicular fractures. J Bone Joint Surg 1981;63A:147—52.
www.elsevier.com/locate/injury
Intramedullary fixation of Neer type 2 fractures of the distal clavicle with an AO/ASIF screw J.E. Scadden *, R. Richards 17 St Johns Street, Winchester, Hampshire S023 0HF, UK Accepted 17 May 2005
Summary Background: Neer 2 fractures of the distal clavicle are notorious for their high rates of non-union and numerous methods of fixation are recommended. We review a simple method of fixation of these fractures with an intramedullary AO/ASIF malleolar screw. Method: Ten patients with Neer type 2 fractures of the distal clavicle were treated between 1996 and 2002. All had open reduction and internal fixation with an intramedullary 4.5 mm AO/ASIF malleolar screw. In all cases the coraco-clavicular ligaments were not repaired, and the screws were removed once the fractures had united. Results: All fractures united at between 6 and 12 weeks. All patients had a good functional result, with an excellent to good Oxford Shoulder score. Conclusion: This is a simple technique with a universally available implant and good fracture healing. We report no cases of screw breakage or migration and we question the necessity to repair the coraco-clavicular ligaments. # 2005 Elsevier Ltd. All rights reserved.
Introduction The Neer 2 fracture which involves the distal clavicle, accounts for nearly half of all clavicular nonunions.9 For this reason, most authors recommend primary fixation of this fracture type.5 In the literature there are many methods described for the fixation of these fractures, including hook plates,6 screw stabilisation from clavicle to corocoid process,1,13 Dacron slings3,7,12 and the use * Corresponding author. E-mail address: [email protected] (J.E. Scadden).
of intramedulary devices such as Hagie, Knowles or Steinman pins.2,11,14 Most of these procedures involve the use of implants not readily available. This paper reviews the results of intramedullary fixation of Neer 2 fractures with an AO/ASIF malleolar screw–—a simple procedure with a universally available device.
Materials and methods The notes and X-rays were reviewed of ten patients, who had had Neer 2 Fractures of the distal clavicle,
0020–1383/$ — see front matter # 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2005.05.022
Intramedullary fixation of Neer type 2 fractures
1173
between 1996 and 2002. The diagnosis was made by X-ray and an independent observer confirmed the classification. All patients reviewed had been treated with an intramedullary AO/ASIF 4.5 mm malleolar screw (Stratec Medical Ltd., Welwyn Garden City, UK); and all had been operated on by the senior author.
Operative technique Operations were performed under general anaesthetic; the patient was in a beach chair position, with a sand bag behind the shoulder. A sabre incision was made in the Langer line, over the distal clavicle (Fig. 1). With minimal periosteal stripping, the fracture ends were mobilised. The intramedullary cavities of both fragments were pre-drilled. The lateral in a retrograde direction and the proximal in an antegrade direction (Figs. 2 and 3). The exit point of the distal drill was in the posterior lateral corner of the clavicle. The fracture was reduced and a 4.5 mm AO/ASIF malleolar screw of appropriate length was inserted from the distal to proximal fragment (Fig. 4). The coracoclavicular ligaments were not repaired.
Figure 2
Antegrade drilling of the distal fragment.
Figure 3
Retrograde drilling of the distal fragment.
In all patients, the fractures were initially immobilised in a collar and cuff for 2—3 weeks, before mobilisation was started.
Follow-up All of the patients were initially seen at 6 weeks and at 3 months. All patients were scored using the Oxford Shoulder Score, which was obtained at review or telephonically at between 2 and 4 years post-op.
Results
Figure 1
Incision in Langer line over distal clavicle.
The mean age at fixation was 29.3 years, ranging from 18 to 84 years. Eight of the 10 cases were male and half were right sided. All were isolated injuries,
1174
J.E. Scadden, R. Richards
Figure 4
Final placement of screw.
Figure 7
Figure 5 male.
Callus at 6 weeks postoperatively.
Radiograph of a Neer type 2 fracture in 37year
seven as the result of a fall on an outstretched hand and three due to sporting injuries. The patients presented at between 1 and 6 weeks. All fractures united which was confirmed both clinically and radiographically (Figs. 5—8). The mean time to union in the patients was 44.1 days (6—12 weeks). The screws were removed in all patients via a stab incision under local anaesthetic at between 8 and 14 weeks. The mean Oxford Shoulder Score from the
Figure 8
Fracture union and screw removal at 8 weeks.
patients was 21.4 (range 17—32). The Oxford shoulder score is from 12 to 60, excellent scores are between 12 and 23 and good between 23 and 33.4 There were no screw breakages, or incidents of screw migration. All of those patients who were initially in employment returned to work.
Discussion
Figure 6 screw.
Fracture reduced with 4.5 mm AO malleolar
Neer 2 fractures of the distal clavicle that require fixation are rare. Zenni et al. reported on 800 fractured clavicles of which only five were fractures of the distal third requiring fixation.14 It has previously been reported that fixation of these fractures with an intramedullary device has a high complication rate, this includes screw migration and breakage.8 In our series of 10 patients between 1996 and 2002, we report no complications and are able to demonstrate excellent clinical results with good
Intramedullary fixation of Neer type 2 fractures
bone healing. This was reflected by excellent to good Oxford Shoulder Scores. Our review demonstrates that the AO/ASIF malleolar screws are robust enough to withstand the forces generated across the fracture site during union. The position of the implant does not interfere with the acromio-clavicular or acromiohumoral joint, thus problems with impingement and stiffness are avoided. Neither the coronoid or trapeziod ligaments were repaired nor was there a need to augment the fixation with wires or slings around the coronoid process. As this did not adversely affect the outcome in our series we question whether these added procedures are necessary. The Synthes AO/ASIF screws are available in most orthopaedic units so this obviates need to purchase expensive equipment for these rare fractures. In our series none of the patients had comminution of the distal fragment, however if this occurs it may be a contra-indication to intramedullary fixation as would a narrow intermedullary canal.
Conclusion We feel that the use of the Synthes AO/ASIF malleolar screws to achieve intramedullary fixation of Neer 2 fractures of the distal clavicle is a simple technique, with a high union rate and good clinical outcome.
1175
References 1. Ballmer FT, Gerber Cl. Coracoclavicular screw fixation for unstable fractures of the distal clavicle. A report of 5 cases. J Bone Joint Surg B 1991;73:291—4. 2. Boehme D. Non-union of the clavicle. Treatment with a modified Hagie intramedullary pin and bone graft. J Bone Joint Surg B 1991;73A:1219—26. 3. Chen C-H, Chen W-J, Shih C-Hl. Surgical treatment for distal clavicle fracture with coraco-clavicular ligament disruption. J of Trauma- Injury infection & critical care 2002;52(1):72—8. 4. Dawson J, Fitzpatrick R, Carr A. The assessment of shoulder instability. The development and validation of a questionnaire. J Bone Joint Br 1999;81(3):420—6. 5. Edwards DJ, Kavanaugh TG, Flannery MC. Fractures of the distal clavicle: a case for fixation. Injury 1992;23:44—6. 6. Mizue F, Shirai Y, Ito H. Surgical treatment of comminuted fractures of the distal clavicle using Wolter clavicular plates. Journal of Nippon Medical School 2000;67(1):32—4. 7. Neviaser RJ, Neviaser JS, Neviaser TJ, Neviaser JS. A simple technique for internal fixation of the clavicle. Clin Orthop 1975;109:103—7. 8. Noreil H. Migration of a threaded Steinman pin. J Bone Joint Surg 1965;47A:1024. 9. Nordqvist A, Peterson C, Redland-Johnell I. The natural course of lateral clavicular fractures. Acta Orthop Scandinavia 1993;64:87—91. 11. Rockwood CA. Fracture of the outer clavicle in children and adults. J Bone Joint Surg Br 1982;64B:642. 12. Weber MCB, Haines JF. The treatment of lateral clavicle fractures. Injury 2000;31:175—9. 13. Yamaguchi H, Arakawa H, Kobayashi M. Results of the Bosworth method for unstable fractures of the distal clavicle. Int Orthop 1998;22:366—8. 14. Zenni EJ, Krieg JK, Rosen MJ. Open reduction and internal fixation of clavicular fractures. J Bone Joint Surg 1981;63A:147—52.