FIGURE 22-1 A: Radiograph of a left midshaft clavicular fracture in an infant sustained during the birthing process. (Courtesy of Joshua M. Abzug, MD.) B: Neonatal pseudarthrosis of the clavicle. (From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)

The anterior shoulder, typically the right side, is the most likely location where the clavicle fracture occurs, as babies are typically in the left occiput anterior (LOA) position.⁶⁰ In addition, this is the most common side of injury in neonatal brachial plexus palsy. Therefore, when an infant sustains a clavicle fracture during the birthing process and limited motion is present about the affected extremity, it is unknown if the child has a concomitant brachial plexus injury or is not moving their arm secondary to the pain associated with the fracture, a so-called pseudopalsy. Once the fracture heals, typically in 1 to 3 weeks in a newborn, repeat assessment of the brachial plexus should be performed to distinguish pseudopalsy from a nerve injury.

The exact mechanism for sustaining the clavicle fracture during the birthing process remains unknown. It is likely related to lateral compression of the shoulder girdle against the pelvis. However, neonatal clavicle fractures have also been shown to occur during cesarean sections.⁶⁰

Toddlers who sustain clavicle fractures may sustain the injury due to a fall from a height or injuries sustained during child abuse.^22,70,114 In a series of children aged 4 years or younger, children abused had an incidence of clavicle fractures of approximately 4% compared to only about 1% in the control group.¹¹⁴

School age clavicle fractures occurring in children are typically the result of a fall where the child sustains a lateral compressive force to the shoulder.¹³¹ Typical activities include falls off of playground equipment, falls from bicycles, and sporting activities. Alternatively, a direct blow to the clavicle can lead to fracture in a child; however, this mechanism is less common. The common fall onto an outstretched hand does not typically transmit enough force to the clavicle to sustain a fracture.⁶⁴

Adolescents sustain clavicle fractures due to similar mechanisms as school age children as well as due to high-energy mechanisms or competitive athletics. Motor vehicle and all-terrain vehicle (ATV) accidents are common high-energy mechanisms in adolescents that can result in either isolated clavicular fractures or clavicular fractures associated with polytrauma similar to adults.^73,116 High-level competitive athletes also commonly sustain clavicle fractures due to collision sports, such as football, or much less commonly, due to repetitive, high-intensity training leading to a stress fracture.¹ Specific sporting activities that can lead to stress fractures include rowing, diving, baseball, and gymnastics, among others.^1,140,147

The proposed mechanism leading to a clavicular stress fracture is excessive cyclic scapular protraction and retraction leading to clavicular fatigue.¹ Excessive motion at the sternoclavicular and acromioclavicular (AC) joints transfers the forces to the clavicle itself, with the end result being these forces exceeding the ultimate tensile strength of the clavicle.¹ This most commonly occurs in athletes who rapidly increase their training program.

Associated Injuries with Midshaft Clavicle Fractures

Injuries that are associated with clavicle fractures depend on the age of the child with the fracture. Neonates can have a concomitant neonatal brachial plexus palsy. The most common type of neonatal brachial plexus palsy is an injury affecting C5 and C6 with resultant limited shoulder movement, elbow flexion, forearm supination, and wrist extension.⁴⁶ Differentiation between a pseudopalsy, the child not moving their arm secondary to the clavicle fracture itself, and a concomitant neonatal brachial plexus palsy can be made by 3 to 4 weeks of age, as the pain from the fracture will be markedly decreased. Toddlers who sustain clavicle fractures as a result of nonaccidental trauma are likely to sustain concomitant fractures, such as fractures of the rib, tibia/fibula, humerus, or femur, intracranial bleeding, eye contusions, retinal hemorrhage, and burns.^28,114 Lastly, adolescents involved in high-energy mechanisms of injury can have associated polytrauma including injury to surrounding structures or vital organs. Concomitant rib fractures, scapula fractures, pneumothorax, brachial plexus injury, or subclavian vessel injury may be present.⁶⁴ Abdominal, head, spine, and/or lower extremity trauma can also occur.

Signs and Symptoms of Midshaft Clavicle Fractures

Clavicle fractures in neonates commonly present after difficult deliveries with decreased active movement about the shoulder region, crying upon passive movement of the shoulder and entire upper extremity, swelling, crepitation, and an asymmetrical bony contour. The Moro (startle) reflex, (a newborn reflex in which a noise or sudden movement causes the baby to extend their neck, arms, and legs followed by pulling the arms and legs back in), may be decreased as well.⁶⁰ Presence of limited digit motion or Horner syndrome (ptosis, miosis, and anhydrosis) indicates the presence of a more serious concomitant brachial plexus birth palsy with injury affecting the lower portions of the brachial plexus.

Toddlers who sustain clavicle fractures associated with suspected abuse should undergo a complete head-to-toe survey, as if they were a trauma patient, looking for concomitant injuries and/or signs of abuse. This includes a thorough neurologic evaluation, an ophthalmologic examination, and a skeletal survey to look for corner fractures or additional fractures in various stages of healing.

Examination of a child or adolescent with a clavicle fracture includes looking for deformity, swelling, and ecchymosis about the affected clavicle. Any tenting of the skin (Fig. 22-2) or open wounds should be noted. In addition, one should look at the lateral aspect of the shoulder for an abrasion or erythema, as this is most commonly the site of impact. Inspection may also demonstrate some drooping of the involved side as the scapula appears internally rotated and the shoulder appears shortened compared to the contralateral side. If significant swelling is present, this may be difficult to recognize.⁶⁴

Pain about the entire shoulder girdle is typically present, however significant tenderness to palpation is present overlying the fracture itself. Crepitus, with any attempt of active or passive range of motion, may be present. As noted above, concomitant injury to the brachial plexus may occur, especially the ulnar nerve because of its location adjacent to the middle third of the clavicle. Therefore, a thorough neurologic examination is required for all patients who sustain clavicular fractures. This includes assessing motor and sensory function throughout the entire upper extremity. It may be difficult to have a child in pain perform certain functions necessary to complete the neurologic evaluation; however, it is imperative to be patient and repeat the examination as often as necessary to obtain the necessary information.

Because of the location of the subclavian vessel, a thorough vascular examination is also necessary, especially in patients involved in high-energy mechanisms of injury. The vessel can spasm or have a thrombosis from blunt trauma. Assessment of the radial pulse should be symmetric and if there is any concern for injury of the vessel, further diagnostic evaluation with advanced imaging should be performed.

Imaging and Other Diagnostic Studies for Midshaft Clavicle Fractures

Initial imaging of a suspected clavicle fracture includes plain radiographs of the clavicle in two projections. Typically, a standard anteroposterior (AP) radiograph and a 45-degree cephalic tilt view are obtained (Fig. 22-3). These images provide visualization of the shoulder girdle region as well as the upper lung fields, both of which should be assessed for additional injuries. However, if clinical suspicion is present for additional injuries, dedicated series of the suspected part(s) should be obtained. Rarely is advanced imaging necessary to evaluate the clavicle fracture as displacement, the fracture pattern, and any presence of comminution can be assessed on the plain films. In cases of high-energy mechanisms, the trauma team typically obtains a chest CT scan which can be used to further evaluate the clavicle fracture.

Classification of Midshaft Clavicle Fractures

Clavicle fractures are usually described based on the location of the fracture, the fracture pattern, and the presence or absence of displacement. Thus, clavicle fractures are either medial, midshaft, or lateral; nondisplaced or displaced; open or closed; comminuted or simple. Additional classification schemes have been proposed to evaluate adult clavicle fractures but none are widely utilized, as they are either purely descriptive of fracture location³ or cumbersome with multiple types and subtypes.^43,123

Outcome Measures for MIdshaft Clavicle Fractures

No outcome scores are specifically utilized to assess results following pediatric clavicle fractures. Outcome measures utilized are typically patient satisfaction, range of motion, pain, fracture union, and complications. Additional outcome measures assessed have included the Disability of the Arm, Shoulder, and Hand (DASH) Score, the QuickDASH, the simple shoulder test, and the Constant Shoulder Score. Radiographic criteria evaluating shortening and/or vertical displacement have also been utilized to assess results.

PATHOANATOMY AND APPLIED ANATOMY RELATING TO MIDSHAFT CLAVICLE FRACTURES

The clavicle, also referred to as the collar bone, is an S-shaped bone that lies along the subcutaneous border of the anterior aspect of the shoulder girdle. An anterior convexity is present medially to permit the passage of the brachial plexus and axillary vessels from the neck region into the upper arm, whereas laterally there is an anterior concavity.

Development of the clavicle begins at five and a half weeks’ gestation via intramembranous ossification and by 8 weeks, the bone has developed into its S shape configuration.⁴⁵ Postnatally, the clavicle continues to grow at a steady rate until age 12, increasing approximately 8.4 mm per year.⁹² After 12 years of age, the clavicle grows approximately 2.6 mm per year in females and 5.4 mm per year in males. Thus, 80% of the final clavicle length is reached by age 9 in females and age 12 in males.⁹²

Medially the clavicle articulates with the sternum, forming the sternoclavicular joint, whereas laterally the bone ends in an articulation with the acromion, forming the AC joint. The medial inferior aspect of the clavicle is the site of attachment of the costoclavicular ligament, whereas laterally on the inferior aspect there is the conoid tubercle and trapezoid line, the sites of attachment for the conoid and trapezoid ligaments, respectively. All of these ligaments slant posteriorly as they approach the clavicle and therefore when the clavicle elevates and the ligaments are put on stretch, the clavicle rotates posteriorly. In addition, these ligaments provide significant stability at both ends of the clavicle, thus making fractures in the middle third of the clavicle more likely.

The pectoralis major originates from the medial aspect of the clavicle as well as the sternum and inserts onto the humerus at the intertubercular groove whereas the deltoid originates from the lateral aspect of the clavicle as well as the acromion and scapular spine to insert onto the humerus at the deltoid tuberosity. In addition, the sternocleidomastoid and sternohyoid muscles originate from the clavicle whereas the trapezius and subclavius insert onto the clavicle.

TREATMENT OPTIONS FOR MIDSHAFT CLAVICLE FRACTURES

Nonoperative Treatment of Midshaft Clavicle Fractures

Indications/Contraindications

The mainstay of treatment of pediatric and adolescent clavicle fractures is nonoperative, allowing the fracture to form callous and heal in situ, even if significant displacement is present (Fig. 22-4).⁸ It is well agreed upon that nondisplaced or minimally displaced fractures, defined as displacement less than 1.5 to 2 cm, should be treated nonoperatively. Fractures that should proceed directly to operative intervention include open fractures, fractures with associated skin tenting, and fractures with associated neurovascular injury (Table 22-1).

Techniques

Nonoperative treatment of clavicle fractures is performed by immobilizing the child’s shoulder girdle, typically with a sling. Alternatively, a figure-of-eight dressing or shoulder immobilizer can be utilized; however, these are more cumbersome and have not been shown to provide improved results. Neonates who sustain a clavicular fracture during the birthing process, can have immobilization performed utilizing a swath technique, such as placing Webril followed by an ACE bandage around the torso and arm.

Follow-up radiographs are obtained at 4-week intervals until fracture union occurs. Once union is present and the child’s motion and strength have returned to normal, the child is permitted to resume activities as tolerated. Calder et al. have suggested that follow-up radiographs are unnecessary in pediatric patients given the near universal expected fracture healing rate in a child. However, we routinely obtain radiographs until union is established to assess return to sports with decreased refracture risk.²⁵

Outcomes

Despite the high incidence of pediatric clavicle fractures and the fact that the vast majority of these fractures are treated nonoperatively, little data exist regarding the outcomes of these injuries. Union rates from 95% to 100% have been reported with nonoperative treatment.^52,74,138 Most nondisplaced fractures have union by 4 to 8 weeks of time, whereas displaced fractures take longer, approximately 10 weeks.¹³⁸

Overall, the vast majority of patients have excellent outcomes and are able to return to their activities without limitations. A small percentage of patients treated nonoperatively with significant fracture displacement may have subjective complaints of pain with prolonged activity, easy fatigability, axillary pain, or drooping shoulders with bony prominence.¹³⁸ Bae et al. evaluated a group of 16 patients with displaced (>2 cm) mid-diaphyseal clavicle fractures treated nonoperatively. All fractures united with no meaningful loss of shoulder motion or abduction–adduction strength by isokinetic testing. The vast majority of patients had low DASH and pain Visual Analog Scores (VAS) that were very low, means of 4.9 and 1.6 respectively. Only one patient out of 16 required a corrective osteotomy.⁸ The authors concluded that routine surgical fixation for displaced, nonsegmental clavicle fractures may not be justified based upon concerns regarding shoulder motion and strength alone. Further investigation is required to determine the risk factors and causes of pain and functional compromise in the minority of pediatric patients with symptomatic malunions. In contrast, the adult literature has shown that patients with significantly displaced midshaft fractures treated nonoperatively compared to plate fixation have significantly worse Constant shoulder scores, DASH scores, higher rates of nonunion, longer times to union, and more symptomatic malunions.²⁶

Operative Treatment of Midshaft Clavicle Fractures

Indications/Contraindications

Absolute indications for operative treatment of clavicle fractures in the pediatric and adolescent population is limited but includes open fractures, fractures with significant skin tenting/compromise (Fig. 22-5), comminuted fractures in which the central fragment is markedly displaced, and fractures associated with neurovascular injury. Additional relative indications may include floating shoulder injuries and fractures associated with polytrauma. Floating shoulder injuries involving midshaft clavicle fractures and fractures of the glenoid neck can be treated by ORIF of the clavicle alone as ligamentotaxis will reduce the other fracture via the coracoclavicular ligament.⁹

Fractures with significant displacement that are treated nonoperatively in adults have been shown to subsequently heal with a malunion that can cause changes to shoulder mechanics. These alterations have been shown at times to lead to pain with overhead activities, decreased strength, and decreased endurance.^58,93 Therefore, multiple studies have investigated the benefit of operative fixation versus nonoperative management of displaced midshaft clavicle fractures. A recent meta-analysis evaluating the results of randomized clinical trials that compared nonoperative and operative treatment in adults found a significantly higher nonunion and symptomatic malunion rate in the nonoperative group. In addition, patients treated with operative intervention had earlier functional return.⁹⁴ It is unclear whether this data is transferable to the adolescent. Clearly the young child, especially less than age 8 years, has the potential to remodel a foreshortened, displaced fracture.

Surgical Procedure for Midshaft Clavicle Fractures

Preoperative Planning

As with any procedure that will utilize implants, it is imperative to have the desired hardware available before proceeding to the operating room. Options for treatment of pediatric and adolescent clavicle fractures include anatomically designed clavicle plates, standard nonlocking and locking plates, and intramedullary devices including pins, wires, screws, and elastic nails.

Intramedullary fixation has the potential benefits of requiring less soft tissue stripping at the fracture site, better cosmesis with smaller skin incisions, easier hardware removal, less potential for hardware irritation, and less bony weakness following hardware removal compared to plate fixation. However, the ability to resist torsional forces is less with intramedullary fixation compared to plating which can result in fracture of the intramedullary implant (Fig. 22-6). Furthermore, the potential for the intramedullary device to migrate is a major concern for many surgeons, thus limiting usage.

If plate fixation is being planned, one must determine what the preferred location of the plate will be, anteroinferior or superior. Anteroinferior plates have the advantage of performing drilling in a posterosuperior direction, thus the drill is not directed toward the surrounding neurovascular structures. In addition, the plate is less prominent in this location. Superior placement of the plate is technically easier and allows for better resistance of the biomechanical forces acting to displace the fracture (Table 22-2).

Positioning

Options for positioning during open reduction and internal fixation or intramedullary fixation of clavicle fractures include utilizing the beach chair position or having the patient supine. With either position, a bump is placed behind the scapula to aid in reducing the fracture.

Surgical Approach(es)

Open reduction and internal fixation is performed via a direct surgical approach to the clavicle is performed by utilizing a skin incision that follows Langer lines. In an attempt to avoid wound problems, by having the incision directly over the plate, and to improve cosmesis, one can incise the skin on the inferior aspect of the clavicle.³² Once the skin is incised, electrocautery is utilized to divide the platysma, fascia, and periosteum in line with the skin incision. During this process, it is important to identify and protect the cutaneous supraclavicular nerves as they cross the clavicle. Subperiosteal dissection is then carried out to expose the fracture site while ensuring maintenance of the soft tissue attachments to any malrotated or segmental fracture fragments.

Intramedullary fixation is performed by making a similar approach utilizing a small incision over the fracture site to expose only the ends of fracture fragments. An additional percutaneous incision is placed over the superolateral part of the clavicle to place the intramedullary device in an antegrade manner.

Technique

Once the fracture site and fragments are exposed, bone holding forceps are utilized to reduce the fracture. If there is a segmental fracture, a separate interfragmentary screw may be used to reduce the fracture from three-parts to two-parts. The fracture is then anatomically reduced and clamped. Areas of comminution are accounted for. Either an anatomic clavicle plate or a small pelvic reconstruction plate is contoured to allow for rigid internal fixation. The plate is subsequently applied in the desired location and either direct visualization alone or fluoroscopic imaging in multiple planes is utilized to assess the reduction, screw placement and length. Following placement of the plate, the periosteum is closed while still protecting the supraclavicular nerves. Layered closure including a meticulous skin closure is then performed to reduce the chance of wound complications and permit the best cosmetic outcome possible. The patient is then placed in a sling or shoulder immobilizer.

Intramedullary fixation is performed by exposing the fracture ends and then drilling the distal segment retrograde through the canal, exiting the posterior lateral cortex. Drilling of the medial segment is then performed, ensuring no violation of the anterior medial cortex occurs. The device can be placed retrograde through the canal to exit through the posterior-lateral hole and subsequently the skin. Fracture reduction can now be performed and the intramedullary device can be advanced antegrade across the fracture site. Many devices have mechanisms, such as washers or nuts, that can now be applied in an attempt to prevent migration of the device or allow for fracture compression.

AUTHOR’S PREFERRED TREATMENT OF MIDSHAFT CLAVICLE FRACTURES

MANAGEMENT OF EXPECTED ADVERSE OUTCOMES AND UNEXPECTED COMPLICATIONS RELATED TO MIDSHAFT CLAVICLE FRACTURES

Patients who have prominence of their hardware can be successfully treated by removal of their hardware.^95,101,138 If a patient initially treated by nonoperative measures develops a symptomatic malunion, corrective osteotomy has been shown to be successful in eliminating symptoms (Fig. 22-8).¹³⁸ In the Vander Have series, all patients who underwent corrective osteotomy of their malunion went on to union and resolution of their symptoms.¹³⁸ Only one nonunion has been reported in the pediatric and adolescent literature to date.¹⁰⁷ Treatment can be successfully performed by subsequent open reduction and internal fixation with a stable construct. On rare occasion, a vascularized bone or corticoperiosteal flap may be necessary (Fig. 22-9, Table 22-3).

SUMMARY, CONTROVERSIES, AND FUTURE DIRECTIONS RELATED TO MIDSHAFT CLAVICLE FRACTURES

The vast majority of pediatric and adolescent midshaft clavicle fractures can be treated successfully with nonoperative measures. Open reduction and internal fixation should be performed for open fractures, fractures with skin compromise, and fractures with nerve or vascular injury. In addition, recent literature has suggested a faster return to activities utilizing open reduction and internal fixation of markedly displaced (>2 cm) or segmental fractures in older patients. Future prospective studies will need to be performed to determine the potential benefits and complications of operative fixation versus nonoperative treatment in adolescents.

INTRODUCTION TO DISTAL CLAVICLE FRACTURES

Distal clavicle fractures account for 10% to 30% of all clavicle fractures, thus making it the second most common site for a clavicle fracture.¹²⁴ Minimal studies exist regarding the treatment and outcomes of these fractures for pediatric and adolescent patients. Therefore, the information presented here will mainly be extrapolated from the adult literature and our experience.

ASSESSMENT OF DISTAL CLAVICLE FRACTURES

Mechanisms of Injury for Distal Clavicle Fractures

Akin to midshaft clavicle fractures, distal clavicle fractures are typically the result of a direct blow to the shoulder girdle or a fall onto the distal aspect of the clavicle.^124,131 Direct blows typically occur in adolescents involved in collision-type sports such as football or lacrosse. When a fall is the mechanism of injury, direct contact from the ground is made against the acromion with the arm typically held in an adducted position. The force is transmitted from the acromion across the AC joint to the distal end of the clavicle.

Associated Injuries with Distal Clavicle Fractures

Common injuries associated with distal clavicle fractures include additional fractures about the shoulder girdle including proximal humerus and scapular fractures, thus constituting a floating shoulder-type injury. In addition, rib fractures, lung injuries including contusions, and brachial plexus injuries may occur concomitantly. Lastly, cervical spine injuries must be ruled out in collision or high-energy mechanisms of injury.

Signs and Symptoms of Distal Clavicle Fractures

Patients who sustain distal clavicle fractures present with pain about the involved shoulder especially with any attempt at movement of the arm. Paresthesias may be present if a concomitant brachial plexus injury occurred or there is swelling causing injury to the supraclavicular nerves.

Physical examination should begin by observing for obvious swelling, ecchymosis, and/or skin tenting. Palpation of the entire upper extremity, hemithorax, and cervical spine should be performed to identify the location of maximal tenderness as well as additional areas that may have sustained a concomitant injury. A complete neurovascular examination should be performed to evaluate for rare brachial plexus injury. Patients involved in high-energy mechanisms should have a complete head-to-toe survey performed by the orthopedic physician as well as either a member of the trauma team or the emergency room physician.

Imaging and Other Diagnostic Studies for Distal Clavicle Fractures

Initial imaging should be performed by obtaining plain radiographs of the shoulder including a true AP view and an axillary lateral view. In addition, a Zanca view can be obtained to better assess the AC joint for intra-articular involvement. This is performed by aiming the x-ray beam in 10 to 15 degrees of cephalic tilt.¹⁴⁹ A CT scan will be diagnostic of intra-articular fractures, which may require operative intervention for best results.

Classification of Distal Clavicle Fractures

The most commonly utilized classification scheme for distal clavicle fractures is that proposed by Neer and modified by Craig.^33,104 This classification scheme includes five types based on the relationship of the fracture line to the coracoclavicular ligaments, the AC ligaments, and the physis. Most lateral clavicle fractures in the skeletally immature are periosteal disruptions in which the bone displaces away from the periosteal sleeve whereas the ligaments remain attached to the intact inferior portion of the periosteum.

Type I fractures occur distal to the coracoclavicular ligaments but do not involve the AC joint. Minimal displacement occurs due to the proximal fragment being stabilized by the intact coracoclavicular ligaments and the distal fragment being stabilized by the AC joint capsule, the AC ligaments, and the deltotrapezial fascia.

Type II fractures are subdivided into type IIA and type IIB fractures, with type IIA fractures occurring medial to the coracoclavicular ligaments and type IIB fractures occurring between the coracoclavicular ligaments with concomitant injury to the conoid ligament. In type IIA injuries, the proximal fragment loses the stability provided by the coracoclavicular ligaments and displaces superiorly out of the periosteal sleeve. In contrast, the distal fragment remains stable because of the attachments of the AC joint capsule, AC ligaments, and the coracoclavicular ligament(s). This remains true for type IIB fractures as well, because even though the conoid ligament is disrupted, the trapezoid ligament remains attached.

Type III fractures occur distal to the coracoclavicular ligaments and extend into the AC joint. As these fractures do not disrupt the ligamentous structures, minimal displacement is the norm.

Type IV fractures occur in skeletally immature patients and involve a fracture medial to the physis. The epiphysis and physis remain uninjured and attached to the AC joint. However, significant displacement can occur between the physis and metaphyseal fragment, as the coracoclavicular ligaments are attached to the physis. This is especially true if the periosteal sleeve is disrupted. In essence, this is analogous to a type IIA fracture.

Type V fractures have a fracture line that leaves a free-floating inferior cortical fragment attached to the coracoclavicular ligaments with an additional fracture line dividing the distal clavicle from the remainder of the clavicle. Therefore, neither the proximal nor distal fragment is attached to the coracoclavicular ligaments. The end result is instability with the potential for significant displacement of the distal end of the proximal fragment.

Outcome Measures for Distal Clavicle Fractures

No specific outcome score exists in isolation for distal clavicle fractures. Therefore, outcomes are described based on union rates and subjective patient outcomes. Adult-oriented outcome measures have been individually utilized in various studies, including the Constant Score, the American Shoulder and Elbow Surgeons (ASES) score, and the Medical Outcomes Study 36-Item Short Form. However these have not been used universally and none of them have been validated in the pediatric or adolescent populations.

PATHOANATOMY AND APPLIED ANATOMY RELATING TO DISTAL CLAVICLE FRACTURES

The distal aspect of the clavicle forms the articulation with the scapula via the AC joint. Ligamentous connections between this portion of the clavicle and the scapula include the AC ligaments and coracoclavicular ligaments. The coracoclavicular ligaments include the trapezoid ligament, located more laterally with an attachment to the distal clavicle approximately 2 cm from the AC joint, and the conoid ligament, located more medially with an attachment to the distal clavicle approximately 4 cm from the AC joint.¹²⁰ The presence of these ligamentous attachments and the acromioclavicular joint capsule permit fluid scapulothoracic motion.¹¹

Stability of the clavicle in the horizontal/AP plane is provided by the AC ligaments whereas stability in the vertical/superoinferior plane is provided by the coracoclavicular ligaments.⁴⁴ This stability permits the definition of the coracoclavicular space, the space between the coracoid process and the undersurface of the clavicle, which should be 1.1 to 1.3 cm.¹⁶

TREATMENT OPTIONS FOR DISTAL CLAVICLE FRACTURES

Nonoperative Treatment of Distal Clavicle Fractures

Indications/Contraindications

The majority of distal clavicle fractures in the pediatric and adolescent population can be managed nonoperatively with immobilization alone as long as significant displacement is not present. Typically, this is universally true for type I and type III fractures. However, types II, IV, and V fractures may have significant displacement with subsequent skin tenting or instability present about the shoulder girdle. Contraindications to nonsurgical management include open fractures, fractures associated with skin compromise, and fractures with concomitant neurovascular injury requiring surgical intervention. Displaced fractures in the pediatric and adolescent population (types II, IV, and V) should be treated on an individual basis depending on the patient’s age, the amount of displacement, and the patient’s activities (Table 22-4).

Techniques

Patients are placed in either a sling or shoulder immobilizer for approximately 3 to 4 weeks and then allowed to begin active range of motion. Radiographs are taken at the 3- to 4-week follow-up visit to ensure adequate healing is occurring and there has been no further displacement.

Outcomes

Nonoperative treatment of nondisplaced or minimally displaced distal clavicle fractures typically has excellent outcomes with successful union occurring and patients able to return to full activities. However, types I and III fractures have been shown to go on to delayed-onset symptomatic AC joint arthrosis in the adult literature.¹⁰³

Treatment of significantly displaced distal clavicle fractures is somewhat controversial due to a relatively high nonunion rate reported in the adult literature. In a retrospective review performed by Neer,¹⁰² he documented that all patients with type II distal clavicle fractures treated nonoperatively, had either a delayed union (67%) or a nonunion (33%). Edwards et al.³⁷ treated 20 patients with type II distal clavicle fractures nonoperatively and had a 45% delayed union rate and a 30% nonunion rate. Additional studies have shown similar nonunion rates ranging from 25% to 44% for type II fractures treated nonoperatively.^{110,124,125,127} In contrast, all type II fractures treated surgically with open reduction and internal fixation have gone on to union.^37,102,127

Operative Treatment of Distal Clavicle Fractures

Indications/Contraindications

Absolute indications for operative treatment of distal clavicle fractures include open fractures, fractures with significant skin compromise, displaced intra-articular extension, and fractures with associated neurovascular injuries that require operative intervention. Additional relative indications may include significantly displaced fractures in competitive athletes and adolescents, entrapment in the trapezius muscle, floating shoulder-type injuries, and patients with polytrauma.

Surgical Procedure for Distal Clavicle Fractures

Preoperative Planning

It is necessary to determine preoperatively what the plan for fixation is going to be as numerous techniques can be performed to stabilize the distal clavicle. Ideally, multiple options are available at the time of surgical intervention including various nonabsorbable suture options, Dacron tape, and locking plates, such as anatomic clavicle plates and hook plates. The position the patient will be in during the procedure needs to be discussed with the anesthesiologist and operating room staff, especially if the beach chair position is being utilized (Table 22-5).

Positioning

The patient can be positioned in either the beach chair position with the head and neck tilted away or supine on a radiolucent table. With either position, a bump should be placed behind the scapula. The entire shoulder girdle, beginning at the medial edge of the clavicle, and entire limb should be prepped and draped in the operative field to allow for movement of the limb which facilitates fracture reduction and fixation. A sterile area above the shoulder adjacent to the head is maintained to allow for the surgeon to work both inferior and superior to the clavicle and shoulder.

Surgical Approach(es)

A slightly curved incision in Langer skin lines over the distal third of the clavicle and AC joint should be made. Once the skin is divided, the subcutaneous tissue, fascia, and periosteum are incised to maintain a thick flap. Subperiosteal dissection is then carried out from nonfractured clavicle out to the fracture site to expose the fracture fragments.

Technique

Fixation with low-profile anatomic distal locking plates or hook plates can be utilized for skeletally mature adolescents as appropriate (Fig. 22-10). Younger patients may require utilization of modular hand instrumentation or mini-fragment locking plates (Synthes, Inc., West Chester, PA). Distal radius plate fixation has also been suggested by placement of the 2.4-mm locking screws in the distal clavicle fragment.⁶⁸

The implant choice will depend on the age and size of the patient, as well as the size and location of the fracture fragments. Larger patients and fragments will permit fixation with low-profile locking plates, whereas smaller fragments may require fixation with suture, Kirschner wire fixation, or even a hook plate. Kirschner wire fixation should be supplemented with a dorsal tension band, utilizing either suture or wire. Threaded wires are used to lessen the risk of migration.^6,69,82,87

Additional fixation of the coracoclavicular ligaments has been suggested to decrease the chance of nonunion in adults. This has been performed utilizing suture or Dacron tape with or without additional fixation.^47,143 In addition, arthroscopic techniques, utilizing suture, the Tightrope system (Arthrex, Naples, FL) or a double-button device, to stabilize the coracoclavicular ligaments have also been reported in adults.^{14,29,111,117} Some authors have proposed placement of a screw between the coracoid and clavicle, however this requires screw removal following fracture union.^{10,37,39,65,86,148} Neither of these techniques are used very often in children or adolescents because of the periosteal insertion of the ligaments. Once the periosteum is repaired, the ligaments usually are stable (Table 22-6).

AUTHOR’S PREFERRED TREATMENT OF DISTAL CLAVICLE FRACTURES

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