Distal clavicle fracture radiography and treatment: a pictorial essay

Evidence on treatment of clavicle fractures

Depending on the severity of the injury and the involvement of the soft tissue envelope, clavicle fractures can be treated operatively or non-operatively. In the past, displaced fractures of the clavicle shaft in adults have been treated non-operatively. However, the rate of nonunion following non-operative treatment seems to be higher than previously reported. In addition, publications reporting better functional outcomes following operative treatment are increasing. In recent years this has led to a paradigm shift towards an increase of operative fracture treatment. The aim of this review article was to summarize the currently available evidence on the treatment of clavicle fractures. Classifications, indications, and treatment options for different fracture patterns of the medial, midshaft, and lateral clavicles are presented and discussed.

Getting Athletes Back on the Field: Management of Clavicle Fractures and Return to Play

This chapter provides an overview of the prevalence of clavicle fractures in athletes. The evaluation and management of clavicle fractures in athletes is summarized, including surgical considerations, rehabilitation protocols, and return to sport guidelines. In this population, high rates of union are observed, but careful timing of return to sport is paramount to optimize performance and prevent reinjury.

Biological Reconstruction of the Coracoclavicular Ligament with Semitendinosus Autograft and Repair of Distal Clavicle Fractures

Most of the options available to treat distal clavicle fractures involve hardware-related complications and high failure rates. This study aims to determine the outcome of distal clavicle fractures treated by a technique that combines biological reconstruction of the coracoclavicular ligament with semitendinosus autograft with reinforced fibrous tissue tapes. In this retrospective study, 8 patients with displaced distal third clavicle fracture cho's IIB or II C were operated on with the described surgical technique between 2018 and 2021. The results were assessed by comparing the preoperative Constant Murley score and the postoperative DASH score. In addition to these variables, several other variables were also assessed, such as the coracoclavicular distance, the time until union, and all intraoperative and postoperative complications. The study included eight patients with an average age of 36.5 years, and the average time from surgery to recovery was five days. According to Cho's classification, all eight patients achieved radiographic union within 89 days. Of the eight cases, six were classified as II C and two as II B. The follow-up period was an average of 13 months. During the postoperative period, the Constant Murley score score increased from 22.2 preoperatively to 92.2 postoperatively. The mean DASH score was 89.6, and the mean postoperative DASH score was 7.75. In terms of the coracoclavicular distance, the mean preoperative was 20.2 mm, and the mean postoperative was 10.3 mm. One patient experienced a minor wound complication after surgery, treated with secondary suturing after the operation. No intraoperative complications occurred. There was no donor site morbidity observed in the patients. It has been demonstrated that the use of this technique in displaced unstable distal clavicle fractures using a fiber tape and a semitendinosus autograft results in a satisfactory union and excellent clinical outcomes with very few complications.

The emergency medicine management of clavicle fractures

BACKGROUND

Clavicle fractures are common. An emergency physician needs to understand the diagnostic classifications of clavicle fractures, have a plan for immobilization, identify associated injuries, understand the difference between treating pediatric and adult patients, and have an approach to multimodal pain control. It is also important to understand when expert orthopedic consultation or referral is indicated.

OBJECTIVE OF THE REVIEW

To provide an evidence-based review of clavicle fracture management in the emergency department.

DISCUSSION

Clavicle fractures account for up to 4% of all fractures evaluated in the emergency department. They can be separated into midshaft, distal, and proximal fractures. They are also classified in terms of their degree of displacement, comminution and shortening. Emergent referral is indicated for open fractures, posteriorly displaced proximal fractures, and those with emergent associated injuries. Urgent referral is warranted for fractures with greater than 100% displacement, fractures with >2 cm of shortening, comminuted fractures, unstable distal fractures, and floating shoulder. Nondisplaced or minimally displaced fractures with no instability or associated neurovascular injury are managed non-operatively with a sling. Pediatric fractures are generally managed conservatively, with adolescents older than 9 years-old for girls and 12 years-old for boys being treated using algorithms that are similar to adults.

CONCLUSIONS

When encountering a patient with a clavicle fracture in the emergency department the fracture pattern will help determine whether emergent consultation or urgent referral is indicated. Most patients can be discharged safely with sling immobilization and appropriate outpatient follow-up.

Posterior Displacement and Angulation of Displaced Lateral Clavicle Fractures: A 3-Dimensional Analysis

Background:

The management of lateral clavicle fractures is often challenging because of difficulties in identifying displacement patterns that indicate an unstable fracture.

Hypothesis:

The aim of this study was to evaluate displacement patterns through analysis using 3-dimensional (3D) rendering software for displaced lateral clavicle fractures. We hypothesized that most displaced lateral clavicle fractures would have posterior displacement and angulation as well as superior displacement of the medial fragment.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

Radiographs of 37 displaced lateral clavicle fractures were imported into the 3D rendering software to reconstruct the fracture model. For the computational simulation of fracture reduction, the medial fragment was manipulated and returned into place using the software’s moving tools. Two corresponding points were marked between the medial and lateral fragments to measure 3D spatial location in the x-axis (shortening), y-axis (horizontal displacement), and z-axis (vertical displacement). The displacement angle on the cranial view was also measured based on the medial end of the clavicle.

Results:

There were 32 cases (86.5%) of superior displacement of the medial fragment (mean, 5.8 mm; range, –6.5 to 19.0 mm), 35 cases (94.6%) of posterior displacement of the medial fracture fragment (mean, 8.8 mm; range, –3.2 to 18.3 mm), and 23 cases (62.2%) of distraction of the fracture site (mean, 2.1 mm; range, –9.2 to 12.2 mm). All 37 patients revealed posterior angulation of the fracture site (mean, 8.9°; range, 2.2°-39.4°).

Conclusion:

Most displaced lateral clavicle fractures have posterior displacement and angulation as well as superior displacement of the medial fragment. Our results revealed that 3D evaluation of lateral clavicle fracture displacement patterns is useful for assessing fracture stability and making treatment decisions.

New possibilities: the LockDown device for distal clavicle fractures

Background and hypothesis

The majority of distal clavicle fractures are displaced fractures and constitute a treatment challenge because they have a 30% chance of delayed union or nonunion. Although several options for surgical reconstruction have been described, in patients with a comminuted and/or small distal fragment, these reconstructive options have proved to be prone to failure. Moreover, secondary surgery for removal is necessary in most cases. We hypothesized that the LockDown device, a braided synthetic ligament device, combined with resection of the distal fracture fragment is a suitable alternative in specified patients with distal clavicle fractures.

Methods

Eleven patients with distal clavicle fractures were treated with distal fracture resection and the LockDown procedure. All patients underwent regular follow-up with data collection; additionally, 7 were assessed at 1-year follow-up according to the study protocol. On the basis of radiography, these patients had a clear coracoclavicular ligament disruption and subsequent cranial dislocation of the medial fragment. Regular follow-up was performed at 6 weeks, 3 months, and 6 months. Control radiographs were taken at 3 and 6 months. Furthermore, the 7 enrolled patients were assessed at 1 year, when the Disabilities of the Arm, Shoulder and Hand score, Constant shoulder score, Nottingham Clavicle Score, and range of motion were recorded. Residual pain was ascertained by a visual analog scale score.

Results

In total, 11 patients were treated with distal clavicle resection and the LockDown procedure. Eight patients underwent surgery within 3 weeks after presentation at the emergency department. The other 3 patients were operated on after a trial of conservative treatment (due to persisting pain and delayed union). None of the patients had postoperative complications. At 3 months, 9 of the 11 patients had made a full recovery.

Discussion

All 11 patients had good short-term clinical outcomes. None showed acromioclavicular instability. Furthermore, secondary surgery was avoided, and hardware complications did not occur. In low-demand patients or patients with a high risk of nonunion, this technique may be a favorable alternative to other known techniques.

Surgical techniques for management of acromioclavicular joint separations: review and update for radiologists

Imaging plays a central role in the postoperative management of acromioclavicular (AC) joint separations. There are more than 150 described techniques for the surgical management of AC joint injuries. These procedures can be categorized as varying combinations of the following basic techniques: a) soft-tissue repair, b) trans-articular AC joint fixation, c) coracoclavicular (CC) fixation, d) non-anatomic reconstruction of the CC ligaments, e) anatomic reconstruction of the CC ligaments, f) distal clavicle resection, and g) dynamic muscle transfer. The goals of this article are to describe the basic techniques for the surgical management of AC joint separations with an emphasis on technique-specific complications and postoperative imaging assessment.

[Fracture diagnosis: upper extremities : Shoulder and shoulder girdle]

BACKGROUND

The shoulder girdle is a chain of bones and joints which connect the upper extremity to the axial skeleton. The shoulder as a biomechanical unit has a remarkable range of motion and is therefore frequently prone to injuries of the three major joints (sternoclavicular joint, acromioclavicular joint, glenohumeral joint) and the bony elements (clavicle, scapula, humerus). Projection radiography is still the first imaging modality for injuries of the shoulder and usually sufficient for initial diagnosis and injury classification. Computed tomography (including 3D reconstructions) and magnetic resonance imaging provide additional useful information for the detection of accompanying soft-tissue injury, for surgical planning and in cases of complex anatomy (e.g., scapular fractures).

PURPOSE

We aim to describe the fundamentals of injuries of the shoulder girdle and the proximal humerus with special emphasis on radiological diagnostics.

MATERIALS AND METHODS

A selective PubMed literature search was performed using the following terms: "sternoclavicular joint dislocation", "clavicle fracture", "acromioclavicular joint injury", "scapular fracture", "shoulder dislocation", "proximal humerus fracture", and "shoulder girdle injuries".

RESULTS

The article describes the basics of the anatomy, the trauma mechanism and the epidemiology of the most common injuries of the shoulder girdle and the proximal humerus. Special emphasis is given to radiological diagnostics, including basic projection radiography and advanced cross-sectional imaging.

Comparative analysis of locking plates versus hook plates in the treatment of Neer type II distal clavicle fractures

Objective

This study was performed to compare the clinical effects of locking plates (LPs) with those of hook plates (HPs) in the treatment of Neer type II distal clavicle fractures.

Methods

From August 2014 to April 2018, 64 patients with Neer type II distal clavicle fractures were treated in our department. The clinical effects were assessed with respect to the operation time, intraoperative blood loss, incision length, fracture healing, postoperative pain, postoperative complications, and postoperative shoulder joint function.

Results

There were no significant differences in the healing time, operation time, or intraoperative blood loss between the LP and HP groups. The incision length was significantly shorter in the LP than HP group, and the postoperative complication rate was significantly lower in the LP than HP group. The visual analog scale score, Constant–Murley score, and University of California Los Angeles score were significantly better in the LP than HP group.

Conclusions

Compared with HPs, the use of LPs involves a smaller incision in the treatment of Neer type II distal clavicle fractures and significantly reduces postoperative pain and complications. Therefore, priority can be given to the use of LPs in the treatment of Neer type II distal clavicle fractures.

Coracoclavicular Double-Button Fixation of Displaced Lateral Clavicular Fracture in a Patient without Coracoid Process

Background

Displaced distal clavicular fractures are generally operated on because of the high nonunion rate after nonoperative treatment. Several surgical techniques have been developed to reduce the nonunion rate and improve functional outcomes. One of them is closed reduction and minimally invasive coracoclavicular double-button fixation, which requires the integrity of the coracoid process to be performed.

Case Summary

We present a 35-year-old male patient who had been successfully subjected to a modified Latarjet procedure for glenohumeral instability with bony defect treatment, and 7 months later suffered a distal clavicle fracture in his ipsilateral shoulder. With a CT scan, we analyzed the coracoid remnant size (7 mm), and we consider it enough to perform a minimally invasive double-button technique, using this remnant as a distal fixation.

Postoperative and Follow-Up

Radiographic and clinical fracture union occurred 10 weeks after the procedure. The patient returned to sports at the same level he had before surgery and achieved full strength and range of motion.

Conclusion

Closed reduction and minimally invasive double-button fixation of displaced distal clavicular fractures is a safe, reproducible, and versatile technique, which can even be performed without an intact coracoid process.

Inter- and intraobserver agreement of three classification systems for lateral clavicle fractures - reliability comparison between two specialist groups

BACKGROUND

Although of great value in the management of lateral clavicle fractures, substantial variation in their classification exists. We performed a retrospective study to address the inter- and intraobserver reliability of three different classification systems for lateral clavicle fractures.

METHODS

Radiographs of 20 lateral clavicle fractures that represented a full spectrum of adult fracture patterns were graded by five experienced radiologists and five experienced trauma surgeons according to the Orthopaedic Trauma Association (OTA), the Neer, and the Jäger/Breitner classification systems. This evaluation was performed at two different time points separated by 3 months. To measure the observer agreement, the Fleiss kappa coefficient (κ) was applied and assessed according to the grading of Landis and Koch.

RESULTS

The overall interobserver reliability showed a fair agreement in all three classification systems. For the OTA classification system, the interobserver agreement showed a mean kappa value of 0.338 ranging from 0.350 (radiologists) to 0.374 (trauma surgeons). Kappa values of the interobserver agreement for the Neer classification system ranged from 0.238 (trauma surgeons) to 0.276 (radiologists) with a mean κ of 0.278. The Jäger/Breitner classification system demonstrated a mean kappa value of 0.330 ranging from 0.306 (trauma surgeons) to 0.382 (radiologists).The overall intraobserver reliability was moderate for the OTA and the Jäger/Breitner classification systems, while the overall intraobserver reliability for the Neer classification system was fair.The kappa values of the intraobserver agreements showed, in all classification systems, a wide range with the OTA classification system ranging from 0.086 to 0.634, the Neer classification system ranging from 0.137 to 0.448, and a range from 0.154 to 0.625 of the Jäger/Breitner classification system.

CONCLUSIONS

The low inter- and intraobserver agreement levels exhibited in all three classification systems by both specialist groups suggest that the tested lateral clavicle fracture classification systems are unreliable and, therefore, of limited value. We should recognize there is considerable inconsistency in how physicians classify lateral clavicle fractures and therefore any conclusions based on these classifications should be recognized as being somewhat subjective.

[Effectiveness of anatomical locking plate internal fixation combined with coracoclavicular ligament reconstruction for Neer type b distal clavicle fractures]

Objective

To investigate the effectiveness of anatomical locking plate internal fixation combined with coracoclavicular ligament reconstruction in treatment of the Neer type Ⅱb distal clavicle fractures by comparing with the simple anatomical locking plate internal fixation.

Methods

The clinical data of 40 patients with Neer type Ⅱb distal clavicle fractures who met the criteria between February 2013 and January 2017 were analyzed. Eighteen cases were treated with anatomical locking plate internal fixation and coracoclavicular ligament reconstruction by using a suture anchor (reconstruction group), and 22 cases were treated only with anatomical locking plate internal fixation (non-reconstruction group). There was no significant difference in gender, age, injured side, causes of injury, associated injuries, time from injury to operation between 2 groups ( P>0.05). The operation time, medical expense, postoperative coracoclavicular distance, Constant-Murley scores of injured side, and complications were recorded and compared between 2 groups.

Results

All patients were followed up 12-27 months (mean, 16.3 months). One patient in reconstruction group had superficial wound infection. One patient in non-reconstruction group had pullout of screws from the distal fragment and reduction loss at 1 month postoperatively. The operation time and medical expense in reconstruction group significantly increased when compared with those in non-reconstruction group ( P<0.05). All fractures in 2 groups achieved bony union at last follow-up. The rate of coracoclavicular distance increase of injured side in non-reconstruction group was significantly higher than that in reconstruction group ( t=2.371, P=0.023). The Constant-Murley scores at 1 month, 3 months after operation, and last follow-up were significantly improved when compared with preoperative values in 2 groups ( P<0.05), but no significant difference was observed between 2 groups ( P>0.05).

Conclusion

Both anatomical locking plate internal fixation with and without coracoclavicular ligament reconstruction can achieve good effectiveness for the Neer type Ⅱb distal clavicle fractures. Therefore, the coracoclavicular ligament reconstruction does not need, except for comminuted fractures with the length of lateral fragment less than 1 cm or the patients with poor compliance.