Open Reduction and Internal Fixation of Clavicular Fractures
J. Todd R. Lawrence
R. Justin Mistovich
DEFINITION
The clavicle, from the Latin clavicula, which means “little branch,” is possibly named for the similarly bent hoopstick Roman children used to trundle a hoop.
Pediatric clavicle fractures are one of the most common childhood injuries and the most common obstetric fracture.10, 13, 15
Clavicle fractures are classified by anatomic region: proximal third, middle third, and distal third.
ANATOMY
The clavicle forms through intramembranous ossification laterally and endochondral ossification medially.
Ossification begins at 4 to 6 weeks of gestation.
The medial secondary ossification center appears at 18 to 20 years of age and does not fuse until approximately 25 years of age.4
Thus, the clavicle is the first bone to ossify and the last bone to fuse.
The middle third of the clavicle is the thinnest portion of the bone and subsequently is most likely to fracture.3
The platysma muscle covers the clavicle.
The subclavius, sternocleidomastoid, and pectoralis major insert onto the medial end of the clavicle, whereas the trapezius and deltoid insert onto the lateral end.
The acromioclavicular, coracoclavicular, costoclavicular, and sternoclavicular ligaments stabilize the clavicle and assist in its role as a strut connecting the axial and appendicular skeleton.
The supraclavicular nerves are deep to the platysma, providing sensation to the anterior chest wall.
The subclavian artery, subclavian vein, and brachial plexus are intimately associated with the inferior aspect of the medial clavicle.
PATHOGENESIS
Clavicle fractures most often result from a direct impact to the apex of the shoulder causing a lateral to medial compression.4
Because both the thinnest part of the bone and the change in shape from convex to concave occur in the middle third of the clavicle, fractures occur most commonly at this location.3
Obstetric-related fractures result from axial compression during birth and are correlated with higher birth weight and forceps delivery.7
NATURAL HISTORY
Controversy remains in the literature regarding nonoperative treatment versus operative fixation of displaced midshaft clavicle fractures in the adolescent patient with studies supporting both modalities.2, 4, 5, 6, 8, 10, 12, 14, 16
Adult studies have demonstrated measurable shoulder dysfunction associated with shortening greater than 15 to 20 mm.
Some studies in adolescents have demonstrated no nonunions and no significant negative clinical results from nonoperative treatment even with greater than 2 cm of shortening.
Other studies in adolescents, however, have demonstrated negative effects on overall satisfaction, functional, and cosmetic scores when patients with shortened fractures were treated nonoperatively.
The risks and benefits as well as the most current literature should be discussed with patients and their families to reach a consensus regarding preferred treatment.
Nonoperative treatment may result in a bump at the site of union. This typically remodels over the subsequent 1 or 2 years but may remain prominent in some cases (FIG 1).Related posts:
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