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The Treatment of Fractures of the Clavicle
The Treatment of Fractures of the Clavicle JULIUS S. NEVIASER, M.D., F.A.C.S.
FRACTURE of the clavicle is a common injury. It is a frequent athletic injury in a young adult but is more likely to occur in a youngster. Although any part of the bone may fracture, the break usually occurs at the middle, resulting in a displacement of the medial fragment upward and the lateral fragment downward and inward. The treatment of a fractured clavicle will depend to a great extent on the type and location of the fracture, the age and the sex of the patient, as well as the occupation or profession of the individual. FRACTURES IN CHILDREN
In children the fracture is frequently of the greenstick variety and may be corrected by direct pressure on either side of the fracture with upward and backward elevation of the shoulder. A figure-of-8 bandage applied about the shoulders will usually suffice to maintain the reduction. If some displacement is present the fragments will be held more securely by a figure-of-8 plaster bandage. Union takes place in about three or four weeks and the excessive callus formation at the fracture site tends to fade away rather quickly. The end results of fractures of the clavicle in children are generally quite good. FRACTURES IN ADULTS
Many methods have been recommended for the treatment of a fractured clavicle in an adult, some of which are rather complicated. The simplest and most frequently used is the figure-of-8 bandage wound over felt pads placed in front of the shoulders and extending into the axilla. This form of immobilization can be made more secure when the figure-of-8 turns are made of plaster bandage to form a yoke. Other closed methods of treatment are the use of a clavicular cross or splint, a plaster platform or plaster spica, and recumbency. Fortunately, whatever method of reduction and fixation is used, the fracture almost invariably unites in about four to six weeks. The bony thickening from
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Fig. 1. Patient R.D. A, Fracture of right clavicle with overriding of the fragments. Held by a clavicular splint. B, After 5 months union with overriding. Function excellent. C, Outline of clavicle seen better with the arm in abduction.
excess callus formation or from the slight overriding of the fragments due to imperfect reduction generally tends to decrease with the passage of time and seldom results in any impairment of function of the involved extremity (Fig. 1). Whatever treatment is used for fractures of the clavicle, it is important that the hand be kept free so that the finger joints do not become stiff. OPEN REDUCTION
Open reduction may be indicated in comminuted fractures of the clavicle, in an athlete who desires that his skeletal structure be restored to as near normal as is possible, or when there is clinical evidence of pressure of the fragments on the brachial plexus or subclavian vessels. The following case illustrates the method of open reduction by intramedually pinning which I prefer. M.S., a young man 29 years of age, sustained a fracture of the clavicle with an unusual displacement of the medial fragment downward and the lateral fragment upward (Fig. 2, A). A closed reduction was unsatisfactory. It resulted in a downward displacement of the distal fragment (Fig. 2, B). In addition, this patient complained of weakness and paresthesias in his hand and fingers suggestive of pressure on the brachial plexus and subclavian vessels. At operation the patient was placed in a sitting position. The fragments were aligned by a small incision made at the lower level of the fracture site with the skin pulled upward to approach the fractured fragments. The pin was inserted from behind through the posterior border of the outer third of the bone about 1 inch medial to its acromial end. Usually the pin passes easily through the lateral
The Treatment of Fractures of the Clavicle
1557
Fig. 2. Patient M.S. A, Fracture of left clavicle which presented evidence of numbness and weakness in the hand. B, Closed reduction unsatisfactory with separation of the fragments.
fragment and becomes firmly fixed in the medial fragment (Fig. 3). I prefer the small type of Knowles pin, as the small hub at the end of the pin prevents migration of the pin inward while the posterior insertion of the pin medial to the acromial end of the clavicle obviates the necessity for its subsequent removal (Fig. 4).
In an adult male, open reduction has some advantages such as early
Fig. 4 Fig. 3 Fig. 3. Fracture of clavicle held in position by insertion of an intramedullary pin. Fig. 4. M.S. Four months after open reduction of clavicle.
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use of the arm, elimination of cumbersome forms of immobilization and rapid restoration of function. There are less indications for surgery in women. The patient has to decide which is worse from an esthetic point of view, the bony prominence or the operative scar. FRACTURE OF THE OUTER END OF THE CLAVICLE
This deformity resembles that of an acromioclavicular dislocation. It usually follows a direct fall on the shoulder. The lateral fragment is
small and remains in normal relationship to the acromioclavicular joint. The medial fragment will ride upward, particularly if the coracoclavicular ligaments are ruptured. Satisfactory reduction is seldom obtained by conservative measures unless the displacement is slight. Excision of the outer fragment is not necessary unless it is markedly comminuted. Although this type of injury invariably requires open reduction, I feel that very little will be gained by attempting a repair of the coracoclavicular ligaments. It is a known fact that, when the trapezoid and conoid ligaments are ruptured, they not infrequently heal with calcification of these ligaments (Fig. 5). If the calcification is extensive (Fig. 6), the rotary motion of the clavicle is restricted and the patient will lose some abduction of his shoulder. By attempting a surgical repair of these ligaments we add further trauma to them, thereby increasing the tendency toward further calcification and added loss of shoulder abduction.
Fig. 5. D.E. Healed fracture of outer end of clavicle. Note calcification of trapezoid and conoid ligaments.
The Treatment of Fractures of the Clavicle
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Fig. 6. Abduction of arm limited due to marked calcification of the trapezoid and conoid ligaments. Four months after injury.
Use of a stout Kirschner wire yields excellent results. The wire is passed through the acromion and into the lateral and medial fragments after the bone ends have been reduced (Fig. 7). Even if the wire should be passed through the upper part of the acromion or under it, yet into the lateral and medial fragments, a satisfactory reduction can be maintained (Fig. 8). Postoperatively the arm is kept in a sling and early pendulum exercises are encouraged. The wire is left in position for about
Fig. 7. Patient R.H. A, Comminuted fracture of outer end of clavicle. B, Open reduction of fracture of outer end of clavicle. Kirschner win;! inserted through acromion into the clavicular fragments.
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Fig. 8. Patient D.F. A, Fracture of outer end of right clavicle with marked upward displacement of medial fragment. B, Appearance of fragments after open reduction. Wire inserted through the upper portion of the acromion. C, Wire removed after 5 weeks. Position of fragments satisfactory.
a month. After its removal, active motion and use of the arm are encouraged. The end results are uniformly excellent (Fig. 9). COMPLICATIONS OF FRACTURES OF THE CLAVICLE
Early complications are neurovascular in origin. Although uncommon, they may occur if the force is severe enough. There may be injury to the brachial plexus, the subclavian vessels, and even the ribs and pleura so that pneumothorax or hemothorax may ensue. As a rule, the vascular damage responds to conservative treatment which consists of continued pressure over the site of injury, anti-shock therapy and rest. If there should be evidence of increased bleeding then operative intervention is indicated to repair the artery and ligate the vein. If the patient's condition permits, intramedullary fixation of the clavicle can be carried out. Late complications are much more frequent and are generally the result of malunion with overriding of the fragments, nonunion and excess callus formation. Clinically, these complications are manifested by neurological and/or vascular signs. Favorable results are obtained when treatment is directed at the underlying cause of the compression. Malunion, nonunion and excessive callus formation can all be eliminated
The Treatment of Fractures of the Clavicle
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by cleidectomy but I find that this procedure results in some weakness of the arm, while the shoulder tends to ride forward and in time there is a contracture of the pectorals. I prefer to resect that part of the clavicle between the costoclavicular ligament and the coracoclavicular ligaments. Since the site of mechanical compression is usually at this location, the patient invariably gets relief from this form of partial cleidectomy, and the cosmetic result, especially in a woman, is much better. S.M., a white woman aged 23 years, sustained a fracture of the left clavicle in an automobile accident. The fracture was reduced and a muslin figure-of-8 bandage was applied which the patient wore for 6 weeks. About 3 months .after her injury she complained of difficulty when she lifted her left arm. She stated the arm would get numb in the elevated position but in the dependent position she had neither pain nor any trouble using it. I first saw this patient 7 months after her injury. Upon physical examination the motions of the left shoulder were within normal range but the radial pulse at the left wrist would decrease in volume when the arm was abducted to 80 degrees and it would obliterate completely when the arm was fully elevated. There was some bony thickening at the middle of the clavicle. X-rays taken of the left
Fig. 9. Patient R.H. (Same case as in Figure 7). A, Good union as well as position of fracture after removal of Kirschner wire. B, Excellent view of the united fractured clavicle taken with the arm in abduction and external rotation.
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Fig. 10. Patient S.M. A, Ununited fracture of left clavicle. Seven months after injury. Had paresthesias in hand with arm elevated. B, Another view in which nonunion is easily seen. C, Two months after resection of middle portion of the clavicle. Patient had no paresthesias in the hand. D, Two months after operation Pulse good with the arm abducted.
shoulder region revealed a pseudarthrosis of the middle third of the clavicle with overriding of the fragments. The lateral fragment was slightly inferior to the medial fragment. There was some excess callus formation about the fracture site (Figs. 10, A, B). At operation the pulse could be obliterated when the left arm was abducted but when the middle portion of the clavicle was resected between the two ligaments the pulse remained palpable even with the arm in full abduction. Roentgenograms taken 2 months later showed no change in the appearance of the resected clavicle. The patient was comfortable. She had no paresthesias and the pulse was strong with the arm elevated (Fig. 10, C, D).
Dr. Michael DeBakey, in his talk on recent developments in vascular surgery before the American Academy of Orthopedic Surgeons meeting held in Miami in January 1963, mentioned that he has had cases of aneurysm of the subclavian artery following fractures of the clavicle with possible excess callus formation as the etiological factor in the production of the aneurysm. He recommended excising the aneurysm, replacing it with a graft and resecting the inner end of the clavicle.
+ The Treatment of Fractures of the Clavicle
1563
SUMMARY
The conservative and operative treatment of fractures of the clavicle has been presented. The indications for open reduction have been outlined. Intramedullary fixation is regarded as the best procedure to secure alignment and firm fixation of the fragments. Fractures of the outer end of the clavicle are best treated by Kirschner wire fixation. Partial cleidecto my involving the middle portion of the clavicle is recommended for relieving the symptoms which result from neurovascular compression following malunion or nonunion of the clavicle. REFERENCES 1. Bateman, J. E.: The Shoulder and Environs. St. Louis, C. V. Mosby Co., 19.55. 2. Bateman, J. E.: Trauma to Nerves in Limbs. Philadelphia, W. B. Saunders Co., 1962. 3. Conwell, H. E. and Reynold~, F. C.: Key and Conwell's Management of Fractures, Dislocations and Sprains. St. Louis, C. V. Mosby Co., 1961. 4. Neviaser, J. S.: Injuries in and about the shoulder joint. In The American Academy of Orthopedic Surgeons Instructional Course Lectures, 1956, Vol. 13, pp. 187-216. 5. O'Donoghue, D. H.: Treatment of Injuries to Athletes. Philadelphia, W. B. Saunders Co., 1962. 6. Watson-Jones, R.: Fractures and Joint Injuries. 4th Ed., Baltimore, Williams & Wilkins Co., 1955. 1918 K Street, N.W. Washington 6, D.C.
FRACTURE of the clavicle is a common injury. It is a frequent athletic injury in a young adult but is more likely to occur in a youngster. Although any part of the bone may fracture, the break usually occurs at the middle, resulting in a displacement of the medial fragment upward and the lateral fragment downward and inward. The treatment of a fractured clavicle will depend to a great extent on the type and location of the fracture, the age and the sex of the patient, as well as the occupation or profession of the individual. FRACTURES IN CHILDREN
In children the fracture is frequently of the greenstick variety and may be corrected by direct pressure on either side of the fracture with upward and backward elevation of the shoulder. A figure-of-8 bandage applied about the shoulders will usually suffice to maintain the reduction. If some displacement is present the fragments will be held more securely by a figure-of-8 plaster bandage. Union takes place in about three or four weeks and the excessive callus formation at the fracture site tends to fade away rather quickly. The end results of fractures of the clavicle in children are generally quite good. FRACTURES IN ADULTS
Many methods have been recommended for the treatment of a fractured clavicle in an adult, some of which are rather complicated. The simplest and most frequently used is the figure-of-8 bandage wound over felt pads placed in front of the shoulders and extending into the axilla. This form of immobilization can be made more secure when the figure-of-8 turns are made of plaster bandage to form a yoke. Other closed methods of treatment are the use of a clavicular cross or splint, a plaster platform or plaster spica, and recumbency. Fortunately, whatever method of reduction and fixation is used, the fracture almost invariably unites in about four to six weeks. The bony thickening from
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Fig. 1. Patient R.D. A, Fracture of right clavicle with overriding of the fragments. Held by a clavicular splint. B, After 5 months union with overriding. Function excellent. C, Outline of clavicle seen better with the arm in abduction.
excess callus formation or from the slight overriding of the fragments due to imperfect reduction generally tends to decrease with the passage of time and seldom results in any impairment of function of the involved extremity (Fig. 1). Whatever treatment is used for fractures of the clavicle, it is important that the hand be kept free so that the finger joints do not become stiff. OPEN REDUCTION
Open reduction may be indicated in comminuted fractures of the clavicle, in an athlete who desires that his skeletal structure be restored to as near normal as is possible, or when there is clinical evidence of pressure of the fragments on the brachial plexus or subclavian vessels. The following case illustrates the method of open reduction by intramedually pinning which I prefer. M.S., a young man 29 years of age, sustained a fracture of the clavicle with an unusual displacement of the medial fragment downward and the lateral fragment upward (Fig. 2, A). A closed reduction was unsatisfactory. It resulted in a downward displacement of the distal fragment (Fig. 2, B). In addition, this patient complained of weakness and paresthesias in his hand and fingers suggestive of pressure on the brachial plexus and subclavian vessels. At operation the patient was placed in a sitting position. The fragments were aligned by a small incision made at the lower level of the fracture site with the skin pulled upward to approach the fractured fragments. The pin was inserted from behind through the posterior border of the outer third of the bone about 1 inch medial to its acromial end. Usually the pin passes easily through the lateral
The Treatment of Fractures of the Clavicle
1557
Fig. 2. Patient M.S. A, Fracture of left clavicle which presented evidence of numbness and weakness in the hand. B, Closed reduction unsatisfactory with separation of the fragments.
fragment and becomes firmly fixed in the medial fragment (Fig. 3). I prefer the small type of Knowles pin, as the small hub at the end of the pin prevents migration of the pin inward while the posterior insertion of the pin medial to the acromial end of the clavicle obviates the necessity for its subsequent removal (Fig. 4).
In an adult male, open reduction has some advantages such as early
Fig. 4 Fig. 3 Fig. 3. Fracture of clavicle held in position by insertion of an intramedullary pin. Fig. 4. M.S. Four months after open reduction of clavicle.
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use of the arm, elimination of cumbersome forms of immobilization and rapid restoration of function. There are less indications for surgery in women. The patient has to decide which is worse from an esthetic point of view, the bony prominence or the operative scar. FRACTURE OF THE OUTER END OF THE CLAVICLE
This deformity resembles that of an acromioclavicular dislocation. It usually follows a direct fall on the shoulder. The lateral fragment is
small and remains in normal relationship to the acromioclavicular joint. The medial fragment will ride upward, particularly if the coracoclavicular ligaments are ruptured. Satisfactory reduction is seldom obtained by conservative measures unless the displacement is slight. Excision of the outer fragment is not necessary unless it is markedly comminuted. Although this type of injury invariably requires open reduction, I feel that very little will be gained by attempting a repair of the coracoclavicular ligaments. It is a known fact that, when the trapezoid and conoid ligaments are ruptured, they not infrequently heal with calcification of these ligaments (Fig. 5). If the calcification is extensive (Fig. 6), the rotary motion of the clavicle is restricted and the patient will lose some abduction of his shoulder. By attempting a surgical repair of these ligaments we add further trauma to them, thereby increasing the tendency toward further calcification and added loss of shoulder abduction.
Fig. 5. D.E. Healed fracture of outer end of clavicle. Note calcification of trapezoid and conoid ligaments.
The Treatment of Fractures of the Clavicle
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Fig. 6. Abduction of arm limited due to marked calcification of the trapezoid and conoid ligaments. Four months after injury.
Use of a stout Kirschner wire yields excellent results. The wire is passed through the acromion and into the lateral and medial fragments after the bone ends have been reduced (Fig. 7). Even if the wire should be passed through the upper part of the acromion or under it, yet into the lateral and medial fragments, a satisfactory reduction can be maintained (Fig. 8). Postoperatively the arm is kept in a sling and early pendulum exercises are encouraged. The wire is left in position for about
Fig. 7. Patient R.H. A, Comminuted fracture of outer end of clavicle. B, Open reduction of fracture of outer end of clavicle. Kirschner win;! inserted through acromion into the clavicular fragments.
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Fig. 8. Patient D.F. A, Fracture of outer end of right clavicle with marked upward displacement of medial fragment. B, Appearance of fragments after open reduction. Wire inserted through the upper portion of the acromion. C, Wire removed after 5 weeks. Position of fragments satisfactory.
a month. After its removal, active motion and use of the arm are encouraged. The end results are uniformly excellent (Fig. 9). COMPLICATIONS OF FRACTURES OF THE CLAVICLE
Early complications are neurovascular in origin. Although uncommon, they may occur if the force is severe enough. There may be injury to the brachial plexus, the subclavian vessels, and even the ribs and pleura so that pneumothorax or hemothorax may ensue. As a rule, the vascular damage responds to conservative treatment which consists of continued pressure over the site of injury, anti-shock therapy and rest. If there should be evidence of increased bleeding then operative intervention is indicated to repair the artery and ligate the vein. If the patient's condition permits, intramedullary fixation of the clavicle can be carried out. Late complications are much more frequent and are generally the result of malunion with overriding of the fragments, nonunion and excess callus formation. Clinically, these complications are manifested by neurological and/or vascular signs. Favorable results are obtained when treatment is directed at the underlying cause of the compression. Malunion, nonunion and excessive callus formation can all be eliminated
The Treatment of Fractures of the Clavicle
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by cleidectomy but I find that this procedure results in some weakness of the arm, while the shoulder tends to ride forward and in time there is a contracture of the pectorals. I prefer to resect that part of the clavicle between the costoclavicular ligament and the coracoclavicular ligaments. Since the site of mechanical compression is usually at this location, the patient invariably gets relief from this form of partial cleidectomy, and the cosmetic result, especially in a woman, is much better. S.M., a white woman aged 23 years, sustained a fracture of the left clavicle in an automobile accident. The fracture was reduced and a muslin figure-of-8 bandage was applied which the patient wore for 6 weeks. About 3 months .after her injury she complained of difficulty when she lifted her left arm. She stated the arm would get numb in the elevated position but in the dependent position she had neither pain nor any trouble using it. I first saw this patient 7 months after her injury. Upon physical examination the motions of the left shoulder were within normal range but the radial pulse at the left wrist would decrease in volume when the arm was abducted to 80 degrees and it would obliterate completely when the arm was fully elevated. There was some bony thickening at the middle of the clavicle. X-rays taken of the left
Fig. 9. Patient R.H. (Same case as in Figure 7). A, Good union as well as position of fracture after removal of Kirschner wire. B, Excellent view of the united fractured clavicle taken with the arm in abduction and external rotation.
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Fig. 10. Patient S.M. A, Ununited fracture of left clavicle. Seven months after injury. Had paresthesias in hand with arm elevated. B, Another view in which nonunion is easily seen. C, Two months after resection of middle portion of the clavicle. Patient had no paresthesias in the hand. D, Two months after operation Pulse good with the arm abducted.
shoulder region revealed a pseudarthrosis of the middle third of the clavicle with overriding of the fragments. The lateral fragment was slightly inferior to the medial fragment. There was some excess callus formation about the fracture site (Figs. 10, A, B). At operation the pulse could be obliterated when the left arm was abducted but when the middle portion of the clavicle was resected between the two ligaments the pulse remained palpable even with the arm in full abduction. Roentgenograms taken 2 months later showed no change in the appearance of the resected clavicle. The patient was comfortable. She had no paresthesias and the pulse was strong with the arm elevated (Fig. 10, C, D).
Dr. Michael DeBakey, in his talk on recent developments in vascular surgery before the American Academy of Orthopedic Surgeons meeting held in Miami in January 1963, mentioned that he has had cases of aneurysm of the subclavian artery following fractures of the clavicle with possible excess callus formation as the etiological factor in the production of the aneurysm. He recommended excising the aneurysm, replacing it with a graft and resecting the inner end of the clavicle.
+ The Treatment of Fractures of the Clavicle
1563
SUMMARY
The conservative and operative treatment of fractures of the clavicle has been presented. The indications for open reduction have been outlined. Intramedullary fixation is regarded as the best procedure to secure alignment and firm fixation of the fragments. Fractures of the outer end of the clavicle are best treated by Kirschner wire fixation. Partial cleidecto my involving the middle portion of the clavicle is recommended for relieving the symptoms which result from neurovascular compression following malunion or nonunion of the clavicle. REFERENCES 1. Bateman, J. E.: The Shoulder and Environs. St. Louis, C. V. Mosby Co., 19.55. 2. Bateman, J. E.: Trauma to Nerves in Limbs. Philadelphia, W. B. Saunders Co., 1962. 3. Conwell, H. E. and Reynold~, F. C.: Key and Conwell's Management of Fractures, Dislocations and Sprains. St. Louis, C. V. Mosby Co., 1961. 4. Neviaser, J. S.: Injuries in and about the shoulder joint. In The American Academy of Orthopedic Surgeons Instructional Course Lectures, 1956, Vol. 13, pp. 187-216. 5. O'Donoghue, D. H.: Treatment of Injuries to Athletes. Philadelphia, W. B. Saunders Co., 1962. 6. Watson-Jones, R.: Fractures and Joint Injuries. 4th Ed., Baltimore, Williams & Wilkins Co., 1955. 1918 K Street, N.W. Washington 6, D.C.