Peggers’ Super Summary of Clavicle Fractures
Anatomy:
· 1st bone to ossify (5th week of gestation) and last ossification centre to fuse at 22-25 years of age sternal end
· Widest medially and thinnest laterally
· Medial 1/3 protects n/v structures
· Coracoclavicular ligaments; trapezoid and conoid
Associated injuries:
· 10% have rib fractures
· Medial 1/3 n/v injury
Types of fractures: (Allman classification)
· Middle 1/3 Group 1 (80%)
· Distal 1/3 Group 2 (15%)
o Type I undisplaced
o Type II displaced
· Medial 1/3 Group 3 (5%)
o Type I – minimally displaced
o Type II – displaced
o Type III – intra-articular
o Type IV – Epiphyseal separation
o Type V – comminuted
Paediatric fractures:
· Manage like adult – surgical intervention rarely indicated
Fracture classification:
· Medial 1/3rds – displacement best seen in 400 view aka serendipity view
· Middle 1/3rds
· Lateral 1/3rds
When to operate:
· >2cm of shortening of clavicle
· Displaced lateral 1/3 – unstable
· Displaced medial 1/3 threatening mediastinal structures
· n/v or skin damage
Simplified Mx options:
Non-surgical – 5-10% non-union rate at 24 weeks
· Sling supports elbow
Surgical
· Internal fixation
o Plate
o Intramedullary – Hagie or Rockwood pin
o Tape – Mersilene
o Sutures
o Screw
Evidence:
· >2cm of shortening causes pain and lack of shoulder power & increase non union. McKee et al. JBJS 2006
· RF for non union female, advancing age, comminution and displacement.
Robinson et al. JBJS 2004
· Shortening > 2cm in adolescents operation can help union time from 8 to 7 weeks and time to activities 16 to 12 weeks.
Vander Have et al. J Paediatric Orthop 2010
Conservative Management of #
· Sling supporting elbow for 1-6 weeks until pain subsides
· Mobilise limb once pain subsides
· Non-union after 4 months
Complications:
Early
· Subclavian, brachial plexus and pneumothorax injuries are rare
Late
· Non-union middle 1-15% lateral 1/3 10-40% rate
· Malunion
· Stiffness and pain