Treatment of Clavicula fractures in sports

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Treatment of Clavicula fractures in sports?

• Christian Fink

10th EFORT Congress, Vienna 3-6 June 2009
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Introduction

• Extremely common injury in sports
• 5-10 of all fractures
• 44 of all shoulder girdle injuries

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Anatomy

• S-shaped in axial plane
• Straight in frontal plane
• Cross section
• Prismatic medial
• Tubular - middle
• Flat - lateral

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Anatomy

• Blood Supply
• Only bone in body that does not have a nutrient
  artery
• blood supply is entirely from periosteum

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Clavicle Function

• Bony strut
• Power and stability of arm
• Motion of shoulder girdle
• Muscle attachments
• Protection of neurovascular structures
• Respiratory function

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Classification

• Group 1 - Middle 1/3
• 80 of clavicle fractures
• Group 2 - Lateral 1/3
• 15
• Neer subdivided in 5 types
• Group 3 - Medial 1/3
• 5

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Mechanism of Injury

• Trauma
• Indirect blow to point of shoulder
• Direct blow to clavicle

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Radiographic Evaluation

• Shaft fractures
• AP
• 45 degree cephalic tilt
• Distal fractures
• Standard views inadequate alone
• Use 1/3 exposure of shoulder series
• AP cephalic tilt of 15 degrees
• Y- scapular

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AP and 45 degree Cephalic Tilt
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15o Cephalic Tilt
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Treatment - Group 1 Fractures

• Nonoperative treatment is standard of care
• Closed/open reduction/internal fixation with
  plates or intramedullary fixation

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Treatment of Shaft Fractures

• Non operative
• Sling
• Figure of Eight bandage

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Sling vs. Figure of Eight

• Anderson et al Acta Ortho Scan 1987
• McCandless and Mowbray Practitioner 1979
• Stanley and Norris Injury 1987
• SUVA 2000
• --- better results with sling (fewer non-union,
  higher patient satisfaction)

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Complications

• Nonunion
• Malunion
• Neurovascular problems
• Post-traumatic arthrosis

Delayed return to sports
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Predisposing factors for Non-union

• High energy trauma
• Refracture
• Distal 1/3 fractures
• Marked displacement (gt15mm)
• Significant shortening (gt15mm)
• Vertical intervening fragments

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Nonunion

• Incidence
• Overall 4.2
• Conservative 5.9 / displaced 15.1
• Operative Plates 2.5 / displaced 2.2
  Intramedullary 1.6 / displaced 2

Treatment of Acute Midshaft Clavicle
fractures Systematic Review of 2144
Fractures Zlowodzki et al. 2005, J Orthop Trauma
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Nonunion

• Hill et al. JBJS-B 1997, Closed treatment of
  displaced middle-third fractures gives poor
  results.
• 52 patients with displaced mid 1/3 fractures
• Figure of 8 or sling
• F/u 38 months post injury

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Nonunion

• Hill et al. Closed treatment of displaced
  middle-third fractures gives poor results.
• Nonunion 15
• Unsatisfied 31
• Cosmetically displeasing 54
• Initial shortening ? 2 cm associated with
  nonunion (p ? 0.0001)
• Final shortening ? 2cm assoc. with unsatisfactory
  result

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Malunion

• Shortening or angulation
• Cosmetic problem
• ?Functional problem?
• Pain
• Decreased strength

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Functional Problem?

• Eskola 1986
• gt15mm shortening leads to more pain
• Hill 1997
• gt2cm predictive of nonunion and unsatisfactory
  result
• Basamania 1997
• Medialized shoulder syndrome
• Strength deficit with significant shortening

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Surgical Indications

• Skin compromise
• Delayed/Non union
• Dislocation gt 15mm
• Shortening gt 15mm
• Athletes ?

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Surgical Options

• Plate fixation
• 3.5mm DCP
• 3.5mm Pelvic reconstruction plate
• Contured plates
• Intramedullary fixation
• Knowles pins
• Modified Hagie Pin (Basamania Pin)
• K-wires
• TEN

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Plate fixation

• Advantages
• Simple
• Familiar technique
• Disadvantages
• Soft tissue stripping
• Incision less cosmetic
• Screw holes - stress riser
• (Timing of implant removal in
  Athletes!!!!????)

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Poigenfurst Injury 199223(4),237-241.

• 122 fractures in 121 patients
• ORIF acutely with 3.5mm DCP for most
• 4 nonunion
• 25 complication rate
• Considered all complications technical failures

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Poigenfurst Injury 199223(4),237-241.

• Inadequate plate construct with 3.5mm pelvic
  reconstruction plate

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Poigenfurst Injury 199223(4),237-241.

• Inadequate plate construct with 1/3 tubular plate

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Bostman et al. J. of Trauma 43(5), 778-83,1997

• 103 consecutive patients
• 9.5 of 1,081 clavicle fractures
• Indications
• gross displacement and angulation
• gt2.5cm shortening
• 50 used 3.5 DCP, 50 3.5mm reconstruction
• 77 patients had uneventful recovery
• 23 patients had major complications
• 4 nonunion

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Bostman et al. J. of Trauma 43(5), 778-83,1997
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Bostman et al. J. of Trauma 43(5), 778-83,1997

• Predictors of failure
• EtOH intoxication on presentation
• Severely comminuted fractures
• No difference in complication rate for DCP vs.
  pelvic reconstruction plate

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Plates
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132 patients randomized
Sign. better results operative group
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Lim et al. 2003, Proceedings 20th Annual meeting
of the Orthopaedic Trauma Association - sign.
better results subjectively compared to
conventional plates
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Intramedullary Fixation

• Advantages
• Less exposure
• Cosmetic incision
• Hardware removal easy
• NO SCREW HOLES
• Less complications in reported series

• Disadvantages
• No rotational control
• Technically difficult

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Neviaser et al. CORR 1975

• 11 pts. (7 fresh fractures, 4 non-unions)
• Pinned with IM Knowles pin
• Immobilized for 6 weeks in sling
• 100 healed
• No complications
• Pins not removed

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Ngarmukos et al. JBJS-B, 1998

• 110 midshaft clavicle fractures
• lt4 of total of clavicle fractures
• Indications for ORIF not stated
• 7 fractures open
• 99 fractures acute
• 11 established nonunion

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Ngarmukos et al. JBJS-B, 1998

• Technique
• Results
• 100 union rate
• No broken wires
• 3 pins migrated and necessitated removal prior to
  bony union

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Basamania AAOS 2000

• 35 patients (all males)
• All fractures gt100 displaced
• Average age 25.6 years (range 20 - 54 years)
• Mechanism of injury sports - 28, MVA - 5,
  military airborne operations - 2

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Results

• All patients reported less pain evening of
  surgery than day before
• All patients resumed full ADLs had full ROM
  within two weeks
• All patients resumed unrestricted physical
  activities, including pushups parachuting
  within 12 weeks
• No significant deformity at fracture site

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Post-Operative Care

• No immobilization utilized
• Return to full ADLs as soon as tolerated
• Pin removed under local anesthesia 8 - 10 weeks
  post-op

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Healed Fracture
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TEN (Titanium elastic nail, Synthes)
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12 patients, professional athletesVAS pre op
71.7 3d post op19.2 Hospital stay 2.9
daysResumption of training 5.9 d
competition 16.8 d
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J Trauma 2008, 64
31 patients No non union Medial migration of
TEN 7
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Type II Distal Fractures

• Surgical treatment necessary
• Fragments are displaced by muscle forces and
  weight of the arm
• Nonunion rates 30-50
• Fixation options
• K-wires
• Cerclage wiring
• Plating

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Or distal radius plates
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Summary

• Very common injury
• Most do well with conservative management
• Liberalize the operative indications
  (especially in athletes)
• Improved function
• Improved union rates
• Decrease malunion rates
• Reduced pain during the first weeks

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Summary

• Intramedullary fixation (TEN)
• preferable in athletes for mid shaft
  fractures (Implant removal!!)

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Thank you