Treatment of these fractures requires direct visualization and reduction of the fracture fragments through a. For nonoperative management, gentle range of movement can start from around 2 weeks with active range of movement generally from 6 weeks, followed by strengthening. Several studies have questioned the clinical relevance of distal clavicle nonunion, however. Clavicle fracture the clavicle serves as an important connection from the upper arm appendicular skeleton to the trunk axial skeleton. Work with your doctor and physical therapist to design a custom rehab program that is appropriate for your condition. An overview article pdf available in the open orthopaedics journal 71. Clavicle fractures are common skeletal injuries that are typi cally managed nonoperatively, which results in a high rate of fracture union with few or no. These methods can be roughly divided into operative and nonoperative methods. Predictors of persistent pain after fixation of distal. Conservative vs operative management of displaced midshaft.
Unstable distal clavicle fractures, classified as neer types ii and v. Clavicle fractures are very common injuries in adults 25% and children 1015% and represent the 4466% of all shoulder fractures. Definitive management is similar to that for type i and iii distal clavicle fractures. The aim of clavicle fracture treatment is to reconstitute the clavicle as a rigid strut for the shoulder girdle to allow painless motion and strength around the shoulder while avoiding symptomatic nonunion.
The local osseoligamentous anatomy and deforming forces result in increased risk of delayed union and nonunion than fractures in other parts of the clavicle. Management of type ii distal clavicle fractures has always been a challenge. Nonoperative management the goal of clavicle fracture treatment is to achieve bony union while minimizing dysfunction, morbidity, and cosmetic deformity. Clavicle fractures account for 5% to 15% of childhood fractures, and are the most common type of fracture in children. The evaluation and management of failed distal clavicle excision eric j. Disclosures the author and planners have disclosed no. Clavicle fractures matthew pecci, md, and jeffrey b. In these cases, the medial fragment often exhibits vertical instability after. Patients with clavicle fractures complain of marked pain, partic ularly with. Fractures tend to be stable, without necessitating operative management, if the trapezoid. Management of distal clavicle fractures abstract most clavicle fractures heal without difficulty. The decision whether to operate may be influenced by the amount of fracture displacement and the individual demands of the patient. Nonoperative treatment has a high risk of complications and should.
According to our units experience the first choice could be hook plate fixation. Successful management relies on the surgeons ability to accurately classify these injuries. The stainless steel plates are low profile and precontoured with locking and nonlocking screw options in each plate. Minimally invasive treatment for neer iib distal clavicle fractures with titaniumcable. Zanca view of the right shoulder, showing posterior displacement of the.
Most clavicle fractures occur when a fall onto the shoulder or an outstretched arm puts enough pressure on. These factors also contribute to challenges in fracture repair. Pain should serve as the guide for the rom obtained. Many techniques of surgical fixation of distal clavicle fractures have been described in the literature. However, radiographic nonunion after distal clavicle fracture has been reported in 10% to 44% of patients.
Mar 24, 2017 diagnosis and management of distal clavicle osteolysis. Neer 24 originally classified these fractures based on the position of the fracture line relative to the coracoclavicular cc ligament. Ellipse denotes a minimally distal clavicle fracture. Clavicle fractures are very common injuries in adults 25% and children 1015% 1 and represent the 4466% of all shoulder fractures 2. In general, surgical fixation is recommended for type ii distal clavicle fractures. Watson, and raffy mirzayan injuries to the distal clavicle and acromioclavicular joint frequently fare well with minimal intervention and conservative management. No evidence to support figure of 8 bandage or brace.
If age 12 years and shortened 2 cm refer to orthopaedics for opinion. Diagnosis and management of distal clavicle osteolysis. A ct angiogram or standard angiogram can be valuable in the setting of a distal vascular deficit following a clavicle fracture. The evaluation and management of failed distal clavicle. Classic teaching suggested that even if both ends of the clavicle were widely separated it would go on to heal. A clavicle fracture is a break in the collarbone, one of the main bones in the shoulder. Give parent fracture of the clavicle collarbone fact sheet. However, radiographic nonunion after distal clavicle fracture has been reported. Clavicle fractures non operative treatment sling for comfort initially up to 2 weeks start mobilisation as soon as pain bearable prevents shoulder stiffness warn about formation of a lump at fracture site fracture callous xray after 6 weeks look for callous fracture line will still be present. Recognize the signs and symptoms, assessment, diagnosis, and management of a patient with a clavicle fracture. Distal clavicular fracture as a special form of injury have been esti mated to account for only 12% to 15% of all clavicle fractures1.
The problem clavicle fractures are common injuries, accounting for 815% of all fractures in children and adults. A poor result was more common in patients with distal clavicle. Kreher, md, boston university, boston, massachusetts c lavicle fractures constitute 5 patient information. Pdf management of type ii distal clavicle fractures has always been a challenge. Delayed surgical treatment of unstable distal clavicle fractures is associated with a higher complication rate.
Treatment of an open infected type iib distal clavicle fracture. However, depending on the degree of failure of the key components involved in supporting the full weight of the upper extremity during. Management of common upper limb fractures in adults. Weeks 04 the patient is instructed in active and prom exercises to the shoulder. Following a clavicle fracture, a figureofeight clavicle strap, along with a. Management of distal clavicle fractures semantic scholar. Treatment of these fractures requires direct visualization and reduction of the fracture fragments through a vertical incision. Therefore, combining with clinical considerations, the operative methods for treating distal clavicle fracture through rapid fixation between the clavicle and acromion or coracoid, that is, the fixations such as kwire, clavicular hook plate, and coracoclavicular screw will limit the postoperative movement of the acromioclavicular joint to some. Results of surgical treatment for unstable distal clavicular fractures. A fall onto the lateral shoulder most frequently causes a clavicle fracture. Jan 01, 2008 the usual mechanism of a clavicle fracture is a fall directly on the shoulder with the arm at the side. Distal third clavicle fractures represent only 25% of all clavicle fractures, 25,28,31 but they account for a high proportion of complications related to clavicle fracture treatment. Surgical management of distal clavicle fractures is indicated for open fractures, skin compromise, and associated vascular injury requiring surgery.
Threeweek followupanteroposterior and grashey views. This type of fracture is fairly commonaccounting for about 5 percent of all adult fractures. Most clavicle fractures occur when a fall onto the shoulder or an outstretched arm puts enough pressure on the bone that it snaps or breaks. Pdf management of distal clavicle fractures researchgate.
Fracture of the distal clavicle with detachment of the coracoclavicular ligamentsin adults. The management of clavicle fractures has dramatically changed over the last decade. Surgical treatment for unstable distal clavicle fracture. The treatment of distal clavicle fractures remains controversial. Electronic searches of the medline, embase and cochrane databases were performed. However, because radiographic nonunion does not correlate. Clavicle fracture standard rehab exercise program this program is designed to improve the functional mobility of your shoulder and arm. These revealed posterior displacement of the medial fragment of the clavicle figure 2a, figure 2b, figure 2c, figure 2d.
Rehabilitation protocol adopted from the massachusetts. A type i lateral clavicle fracture occurs distal to the cc ligaments, resulting in a minimally displaced fracture that is typically stable. The figureofeight clavicle strap is continued at all times. Radiographic examination included anteroposterior, axillary, and suprascapular y views of the shoulder. Stable fracture patterns generally heal uneventfully with nonsurgical management, but unstable fracture. This is a childrens fracture, also called a pseudodislocation of the acromioclavicular joint because there is a fracture of the distal clavicle but the acromioclavicular joint remains intact figure 122e. Excision of the distal clavicle dce is a commonly carried out surgical procedure used in the management of acromioclavicular joint pathology. The clavicle contributes to the freedom of motion seen at the shoulder by acting as a movable strut to which the scapula and upper arm are suspended at a distance from the. Type ii injuries are characterized by a medial fragment that is discontinuous with the cc ligaments.
Middle third most common broad arm sling to support limb for 2 weeks or until comfortable. Distal clavicle fracture radiography and treatment. Rarely, clavicle fractures can occur from a direct blow or from a fall on an outstretched. The majority of clavicle fractures are treated conservatively. Understanding these injuries and their imaging features enhances care and ensures patients are. For younger and active patients there is a wide variety of operative options, each with advantages and disadvantages. A fractured clavicle, or fractured collarbone, is a common sports injury that generally occurs from an impact to the shoulder of a fall on an outstretched arm. They are caused by direct trauma, falls on the shoulder, or falls onto an. Distal clavicle fractures and acromioclavicular joint injuries. Because of the high rate of nonunion, neer 4 and others 2,3,6,2345 have advocated primary surgical management of distal clavicle fracture. Nonoperative treatment has a high risk of complications and should be considered only for elderly and frail patients. A clavicle fracture is also known as a broken collarbone.
Abstractmost clavicle fractures heal without difficulty. The emphasis of this article is on the management of these injuries. Radiographs confirm the diagnosis and aid in further. The course of treatment typically depends on the type of fracture, because. Management of acute clavicle fractures sciencedirect. Conservative management of clavicle fracture clavicle fractures typically result from a direct blow to the shoulder, occurring most frequently to the middle third of the clavicle. The most common initial approach to conservative management is.
Jan 14, 2019 many techniques of surgical fixation of distal clavicle fractures have been described in the literature. These fractures may be partial or complete and often require surgical repair and immobilization while they heal. Medial third clavicle fractures are rare injuries, with limited information available on their characteristics or treatment results. More than 200 methods of operative and nonoperative methods for management of clavicle fractures have been described 6. Type ii distal clavicle fractures, which involve displacement, are. The coracoclavicular ligaments remain attached to the thick periosteal sleeve, whereas the proximal fragment ruptures through the thin. Review article management of distal clavicle fractures. The clavicle plate and screw system is a comprehensive set of plates, screws, and instruments designed to treat midshaft and distal clavicle fractures.
Jun 19, 2014 management of distal clavicle had taken various turns ever since neers observation of the highly unstable nature of the fracture and the high rate of non union associated with it. Rehabilitation protocol adopted from the massachusetts general hospital sports physical therapy program and the american academy of orthopedic surgeons for nonsurgical rehabilitation of clavicle fractures 7,15. However, recent wellconducted studies demonstrate that plate fixation of displaced midshaft clavicle fractures may result in improved functional outcome and a lower rate of malunion and nonunion, compared. Nonsurgical and surgical management provide similar results. The range of management may include only one initial visit with radiograph confirmation of fracture at time of diagnosis and no follow up or up to three visits with possible subspecialty referral and radiographs at week 1 and 4. Fractures of the distal clavicle represent 1530% of all clavicle fractures. Surgical options to achieve bony union include transacromial wire fixation, a modified weaverdunn procedure, use of a. Clinicians describe the successful treatment of medial clavicle stress fractures with cessation of the inciting activity for several weeks followed by physical therapy to improve posture, scapulothoracic mechanics, and rotator cuff strength 43,44. Clavicle fracture rehabilitation protocol range of motion immobilizer exercises phase i 06 weeks 04 weeks. Immobilized at all times day and night off for hygiene and gentle exercise only 04 weeks. Historically, only unstable distal clavicle fractures were treated operatively. Type ii distal clavicle fractures, which involve displacement, are associated with the highest incidence of nonunion.
Evaluation and treatment of distal clavicle fractures clinics in. Group 2 fracture management varies according to the subtype, and factors influencing management include ligamentous integrity and comminution or displacement degree. Non operative management splint then functional bracing management of type ii distal clavicle fractures has always been a challenge. Fractures of the distal clavicle account for approximately 10% to 30% of all clavicle fractures. Surgical treatment for unstable distal clavicle fracture with. Traditionally, distal clavicle fractures have been classified based on the fracture location relative to the coracoclavicular ligaments and acromioclavicular articulation, as described by neer. Initially clavicle fractures are managed with a sling supporting the elbow to reduce the effect of gravity pulling down the shoulder and the attached half of the clavicle. Historically, the vast majority of clavicle fractures have been treated nonoperatively in the acute setting. Clavicle fracture broken collarbone orthoinfo aaos.
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