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Treatment options for clavicle fractures: When is ORIF and IM fixation indicated?
Top shoulder surgeons give treatment opinions from clinical diagnosis to rehabilitation.
The management of clavicle fractures has dramatically changed over the last decade. Classic teaching suggested that even if both ends of the clavicle were widely separated it would go on to heal. However, longitudinal studies in Sweden and recent experience throughout North America and Europe have suggested that this old teaching may not be accurate.
We present a round table discussion, therefore, with recognized leaders in the field to explore the current management of clavicle fractures and specifically to address when operative management may indeed be indicated.
William N. Levine, MD
Moderator
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William N. Levine, MD,
Christopher S. Ahmad, MD, assistant professor of orthopedic surgery, Columbia University College of Physicians and Surgeons, New York
Jesse B. Jupiter, MD, director, Orthopaedic Hand Service, Massachusetts General Hospital, Boston
Michael D. McKee, MD, FRCS(C) Upper Extremity Reconstructive Service, St. Michael’s Hospital, University of Toronto, Toronto William N. Levine, MD: How do you evaluate a patient with an acute clavicle fracture? (ie, history, physical examination, specific radiographic studies, etc.)
Jesse B. Jupiter, MD: As with all fractures, basic historical questions include the mechanism of injury, limb dominance, any associated injuries or medical conditions, occupation and avocations, and the patient’s perspectives of the injury. Examination should include regional issues such as joint mobility, distal neurovascular status and local conditions such as ecchymosis etc.
X-rays should include a frontal plane and one at 45° in a cephalad direction, and should include the whole clavicle. When there is deformity, especially shortening, a chest X-ray, which will include both clavicles, should be ordered as well. In injuries with segmental fragments, a CT with 3-D reconstruction is my choice.
Michael D. McKee, MD: Typically a mid-shaft clavicle fracture occurs from a fall directly on the point of the shoulder. A focused trauma history is taken. It is important to obtain an accurate assessment of the patient’s overall medical condition, recreational activities and occupation. It is important to get a feel for the patient’s expectations with regards to return to higher levels of physical functioning especially repetitive overhead activity, or repetitive flexion-extension of the shoulder (both occupationally and recreationally).
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Images: McKee MD |
When examining a patient with an acute clavicle fracture I typically look for the usual deformity of the “ptotic” shoulder, representing the inferior and medial displacement of the distal fragment with some anterior rotation. I measure the length of the clavicle clinically from the sternal notch to the acromioclavicular joint on both sides and record the difference. Careful neurological examination of the involved arm is performed, as well as a search for any other associated injuries including sternoclavicular joint, AC joint, proximal humerus and more distally in the arm.
I make a point of examining the patient from behind and superiorly. It is from these vantage points that certain aspects of the deformity, such as anterior rotation and translation of the shoulder girdle, can best be appreciated. Also, the posterior view is where the (static and dynamic) scapular winging can be noticed, which is typical with more severely displaced fractures as the scapula and shoulder girdle rotate anteriorly with the distal fragment.
Radiographic examination includes a standard anterior view of the clavicle, as well as an upshot, or cephalad, view with the beam angled 20° superiorly to eliminate overshadowing from the ribs (Figure 1).
If thoracic injuries are suspected from the history and physical examination then a chest x-ray are done to rule out pneumothorax, identify rib fractures, and other intra-thoracic injuries. The chest x-ray is also useful in measuring the opposite intact clavicle and comparing it to the injured side.
Christopher S. Ahmad, MD: Important aspects of the patient’s history are to understand his or her activity level, functional demands, and expectations.
For example, a 70-year old sedentary male who injures his clavicle on his non-dominant arm is managed differently than a 20-year old college wrestler with the same injury, on his dominant extremity. It is also important to appreciate the energy of the injury with higher-energy injures having more bone and soft tissue damage and being more likely to be indicated for surgery.
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Routine physical exam is necessary with evaluation of skin integrity and neurovascular status. It is also helpful to evaluate the scapular position and posture of the upper extremity, which may be shortened and protracted.
Radiographs should not only include a standard AP but also a 45° cephalic tilt view which can demonstrate lack of apposition of the 2 major fragments. Radiographs should also be analyzed for magnitude of shortening, cortical contact between the two fracture fragments on each view, and presence of comminution. Finally, relatively high-energy fractures with a segmental fragment pointing in the north-south direction should be appreciated as a fracture that may require surgical management.
Levine: How do you determine which mid-shaft clavicle fractures require surgery compared to those managed non-operatively?
Jupiter: Indications for surgery of mid-clavicle fractures, depending of course on the individual patient specifics, include fractures with a segmental fragment which is rotated and vertical, shortening of 2 cm or more when compared to other side, fractures with displacement of over the width of clavicle, open fractures, those associated with plexus injury, those associated with additional shoulder girdle fractures such as displaced glenoid or proximal humerus fractures, and finally, certain high-performance athletes or those whose job requires full mobility of the shoulder girdle in order to perform.
McKee: The majority of mid-shaft clavicle fractures can be treated non-operatively with a sling for comfort followed by the gradual institution of motion as the pain subsides and fracture site stability improves. I don’t believe that a figure-of-8 bandage is routinely indicated. A randomized clinical trial by Andersen, Jensen and Lauritzen showed no functional or radiographic difference between the sling and a figure-of-8 bandage and that the patients preferred the sling. Also, I have seen a number of patients with lower trunk brachial plexus palsy from having a figure-of-8 bandage tightened excessively.
The classic indications for operative fixation of a clavicular shaft fracture include open fractures, fractures with objective neurological injury, “floating shoulder” type injuries and those associated with vascular injuries. These are extremely rare, however, I believe the pendulum is swinging more towards primary operative fixation for some of these more displaced fractures. Recent evidence has suggested the incidence of nonunion and symptomatic malunion for more displaced fractures is much higher than previously thought. I reserve primary operative repair for young, healthy, active patients, especially those who plan to return to high-level athletic activities or occupations involving repetitive lifting or overhead activity. We show in a soon-to-be-published investigation that fractures which are clinically shortened by more than 2 cm to 3 cm with the typical “ptotic” appearance of the shoulder probably benefit from primary operative repair. Also, it is becoming apparent that the presence of scapular winging (dynamic or static), in association with anterior rotation of the distal clavicle fragment, is a prognostic indicator for poor outcome following non-operative care of these displaced mid-shaft fractures.
Ahmad: We consider surgery on active, healthy patients when the fracture pattern results in 1.5-cm or greater shortening, when there is no cortical contact between the medial and lateral clavicle fragments on both AP and 45° cephalic tilt views, and in high-energy fracture patterns that have comminution with a vertically displaced fragment.
Levine: Dr. Basamania and others have popularized intramedullary fixation of clavicle fractures over the last few years – what are your indications for intramedullary (IM) fixation? As a corollary to this question, if you do not recommend IM fixation, give us your current approach and surgical pearls for open reduction and internal fixation of mid-shaft clavicle fractures.
Jupiter: IM fixation is appropriate for non-displaced or displaced fractures without comminution, especially those that can be reduced by closed manipulation. Fractures that are comminuted or have a segmental fragment are not indications for IM fixation in my practice.
My approach is with a horizontal incision in Langer’s lines, identification and protection of the three main branches of the supraclavicular nerves, and preservation of much of the attached muscles to the bone. I will often use a small distractor applied dorsally for those fractures with a segmental piece, and apply a 3.5-mm low contact, dynamic compression (LCDC) plate on the anterior surface. I always use an oscillating drill.
McKee: Although it is popular in some areas, I do not routinely perform IM fixation of these injuries, as it is difficult to maintain length and accurate rotational alignment especially in comminuted fractures. Currently, I use a standard superiorly plating technique that involves a small incision, extensive undermining of skin medially and laterally, reflection of the deltotrapezial fascia in a single layer, and reduction of the fracture. A pre-contoured, anatomic clavicular plate is applied to the superior surface and fixed with a minimum of three solid bicortical screws proximally and distally (Figure 2). A lag screw across the fracture is used whenever possible. Small butterfly fragments are “teased” into placed whenever possible maintaining soft tissue attachments: They can be fixed with small lag screws or sutured into place. A careful two-layer closure (first layer the deltotrapezial fascia, second layer subcutaneous tissue) is then performed. It is important to use a plate appropriately sized for the patient. I believe that a 3.5-mm pelvic reconstruction plate is too small for any patient larger than 150 lbs. or so and in this situation the stronger precontoured plate or a compression plate is preferred.
Ahmad: I have not had experience with IM fixation for clavicle fractures but do appreciate the potential benefits of less surgical dissection and less supraclavicular nerve injury with the potential disadvantages of less rigid fixation and need for hardware removal when compared to ORIF.
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Preoperative counseling is important for patients electing operative intervention. Besides conveying routine surgical risk information, patients must be made aware of the incision location and related cosmesis, potential visualization of the plate contours because of its subcutaneous location, and potential numbness below the incision from division of supraclavicular nerve branches. When patients are aware preoperatively, they are more accepting of these issues postoperatively.
Surgical pearls begin with positioning to allow the scapula to retract, allowing the clavicle to come out to length. We use a hydraulically controlled shoulder positioner (Spyder/Tenet; Smith and Nephew) with the patient in the modified beach chair position.
Control of the upper extremity with the arm positioner allows the scapula to be placed posterior and superior which assists in reduction.
We use precontoured plates (Acumed) that facilitate compression of the fracture. We find them to be low profile and save time since intraoperative contouring is not necessary. Furthermore, since the advent of these lower profile pre-contoured plates, we have found a significant decrease in the need to remove the hardware due to patient discomfort.
An additional pearl that we have discovered with these plates is that while they are marked “right” and “left,” often the best “match” to the patient’s contour requires an opposite side plate – ie, using a right clavicle plate in the left shoulder.
Levine: Discuss your decision-making process in the evaluation and management of lateral clavicle fractures. When do you operate and when do you treat nonoperatively?
Jupiter: Lateral clavicle fractures that are widely displaced in active patients are an operative indication for me. Minimally displaced fractures (less than the width of the clavicle) or those in less active or patients over 65 are not recommended for surgery.
McKee: Lateral clavicle fractures that are non-displaced can be treated non-operatively. Displaced lateral clavicle fractures (with the typical superior translation of the proximal fragment and inferior translation of the distal fragment) have a relatively poor natural history with a delayed nonunion rate approaching 40%. If the fracture is significantly displaced, I typically recommend operative fixation for a young, active patient.
The usual technical problem is mechanical purchase in the smaller distal fragment. This can be overcome in a number of ways. One is by using a special distal clavicular plate with a distal flare that allows more screws to be inserted in the distal fragment. The second, for very distal fractures, I use the so-called “hook plate,” which gains mechanical purchase by having a bar or a hook that goes underneath the acromion thus maintaining reduction. Either of these techniques can be augmented by putting a screw from the proximal fragment into the coracoid to help hold the proximal fragment down as an adjunctive way of obtaining stability. I have been disappointed with intramedullary or tension-band wire techniques for distal clavicle fractures in general for my patient population (especially in larger individuals).
Ahmad: Because lateral clavicle fractures have a high incidence of nonunion we recommend ORIF for our younger patients. Recently however, Robinson et al observed that nonoperative management in middle-aged and older patients provides good outcome even if nonunion occurs. Therefore, our older patients are typically treated nonoperatively. Patients with intact coracoclavicular ligaments attached to the medial fragment also typically do well without surgery (Figures 3 and 4)
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Levine: Finally, briefly review your routine aftercare plan for patients following ORIF for mid-shaft clavicle fracture. Does it change for lateral clavicle fractures?
Jupiter: My routine aftercare following ORIF of clavicle fractures is a sling for comfort, which can be removed as needed, but no overhead motion for the first 10 days.
Following that, full motion is allowed but no resistive activities above the shoulder until union seems evident (usually by 6-8 weeks). This would also go with lateral fractures, unless I am not as secure with the fixation.
McKee: Most surgery in young, healthy individuals for displaced clavicular fractures is done on an outpatient basis. The patient is discharged home with a dressing and sling and then seen back in the clinic at 10 to 14 days postoperatively when sutures or clips are removed.
The patient is seen by the physiotherapist and given instructions in gentle range-of-motion activities (both active and passive) and allowed to gradually discontinue the use of the sling. There are no resisted activities or strengthening allowed at this point. Also, the patient is cautioned against playing any sports and against anything that might result in a fall on the shoulder.
The patient is then seen at 6 weeks postoperative and radiographs are taken that usually show bony union of the fracture.
If this is confirmed on a clinical examination the patient is allowed strengthening and resistive exercises. I typically ask the patients not to participate in contact sports for another 4 to 6 weeks, depending on the activity desired, although compliance with this is quite variable especially in the young male population that typically suffers these injuries.
I do not routinely recommend plate removal and I have found with the pre-contoured plates the incidence of soft tissue irritation now is much less than it was previously with the straighter plates. My postoperative regimen for lateral clavicle fractures is quite similar although the institution of motion and strengthening may be delayed if distal purchase is tenuous.
Ahmad: We use a Tegaderm occlusive dressing (3M Healthcare) so patients may shower immediately post-operatively. Patients are maintained in a sling and may come out of the sling to exercise their elbow, hand, and wrist.
Shoulder exercises are limited to pendulums. Patients obtain X-rays at 2-, 6-, and 12-weeks postoperatively. Sling use is discontinued at 6 weeks and active motion is allowed. Strengthening is initiated at 12 weeks. Shoulder stiffness has not been a problem and patients often do not require formal physical therapy.
For more information
- Andersen K, Jensen PO, Lauritzen J. Treatment of clavicular fractures. Figure-of-eight bandage versus a simple sling. Acta Orthop Scand. 1987;58:71-74.
- McKee MD and the Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. J Bone Joint Surg Am. 2007;89:1-10.
- Robinson CM, Cairns DA. Primary nonoperative treatment of displaced lateral fractures of the clavicle. J Bone and Joint Surg. 2004;86-A(4):778-782.
- Christopher S. Ahmad, MD, assistant professor, orthopedic surgery, Columbia University, Center for Shoulder, Elbow and Sports Medicine, 622 W. 168th St., New York, NY; 212-305-5561; csa4@columbia.edu.
- Jesse B. Jupiter, MD, director Orthopedic Hand Service, Massachusetts General Hospital, 15 Nonesuch Way, Weston, MA 02493; 617-726-5100.
- Michael D. McKee, MD, FRCS(C), 55 Queen St. E #800, Toronto, Ontario, Canada, M5C 1R6; 416-864-5880; mckeem@smh.toronto.on.ca. He has indicated he has no financial relationship with any company or product mentioned.
- William N. Levine, MD, vice chairman and associate professor, Department of Orthopaedic Surgery and director of sports medicine at Columbia University Medical Center, 622 W 168th St PH-11, New York, NY 10032; 212-305-0762; wnl1@columbia.edu.