Clavicle Fractures: Non-op or Surgery?

Clavicle Fractures: Non-op or Surgery?

Questions to ask the patient:

  • Mechanism (story)

  • Pain locations

  • Numbness or tingling?

  • I like to always ask the same ROS for billing purposes and picking up on the more dangerous things chest pain, shortness of breath, nausea, vomiting, fevers, chills. Add on pertinent ROS to injuries if you can think of them (You need a documented 10 point ROS for billing, instead of taking the time to ask the whole thing you can infer some of the ROS from discussion with the patient)

  • Medical history: Diabetes, bleeding, clotting problems, blood thinners, stents or problems with anesthesia in the past, allergies, these are important surgical factors, baseline mental status

  • Surgical history: Previous shoulder injuries or surgeries? Other ortho surgeries? What is the date and who performed those ortho surgeries? Good time to ask about problems with anesthesia or bleeding.

  • Social history: Smoking, alcohol, drugs; all are very important factors for you to be able to identify healing problems

  • Dominant hand? 

  • Occupation: Helps you to know their activity level and functional status

  • Uses a walking assist device? (Walker, cane, wheelchair?)

  • If needs surgery: DNR status, last food intake


What to look for on an Ortho exam:

  • Look for skin tenting

    • Look for cap refill of skin over tented area

    • Reason: no cap refill could indicate impending skin breakdown


  • Check sensation to light touch

    • Over deltoid (axillary)

    • Dorsal aspect of index and long fingers/radial dorsum of hand (radial)

    • Palmar side of index and long fingers (median)

    • Pinky and lateral hand (ulnar nerve)


  • Check motor

    • Isolate interphalangeal joint of thumb for flexion, this doubles as checking flexor pollicis longus (FPL) (anterior interosseous nerve (AIN))

    • Isolate index finger distal interphalangeal (DIP) joint for flexion with other fingers in flexed position, have patient flex DIP of index finger

      • To check AIN with both FDP and FPL at the same time have patient make the okay sign

    • Have patient cross fingers or “cut like scissors to check finger adduction (ulnar nerve)

    • Have patient abduct fingers against resistance (ulnar nerve)

    • If suspicious for tendon rupture: Check tenodesis effect (DIP and IP joint flexion with wrist extension) – Differentiates motor from tendon rupture, if fingers don’t flex with wrist extension, tendon could be ruptured


  • Check vascular

    • Check radial pulse and compare to contralateral side, finger cap refill (should be less than 2 seconds)


One of the most important things to know while on call is to be able to decide whether a clavicle can be treated nonoperatively or not. 

Non-operative clavicle fractures 

  • What is the nonoperative treatment?

    • Sling for comfort and non weight bearing (NWB) on the injured side

  • Indications

    • < 2cm shortening and displacement

    • < 1cm displacement of the superior shoulder suspensory complex

      • Important to know, but from our experience this isn’t commonly discussed when deciding between nonoperative vs. operative for clavicle fractures by themselves

      • Always important to consider floating shoulder (glenoid separated from the body either through ligament disruption at the acromioclavicular (AC) joint or clavicle fracture plus a scapula fracture (this will be discussed in a future post)

    • No neurovascular injury

  • Outcomes (These are important to talk to patients about when explaining outcomes of non operative management)

    • Nonunion (1-5%)

      • See risk factors below: Smoking is a big one

    • Poor cosmesis

    • Decreased shoulder strength and endurance

        • Found in healed clavicle fractures with >2cm of shortening


Superior Shoulder Suspensory Complex

Credit: Orthobullets


  • Non-op Complications

    • Nonoperative treatment

      • Nonunion (10-15%)

        • Risk factors

          • Fracture comminution (Z deformity)

          • Female gender

          • Advanced age

          • Smoker

          • > 2cm shortening

          • > 100% displacement

        • Treatment

          • If asymptomatic, no treatment necessary

          • If symptomatic, ORIF with plate and bone graft

      • Malunion

        • Definition

          • Shortening >3cm

          • Angulation >30degrees

          • Translation >1cm

        • Presentation

          • Increased fatigue with overhead activities

          • Thoracic outlet syndrome

          • Dissatisfaction with appearance

          • Difficulty with shoulder straps, backpacks

        • Treatment

          • Clavicle osteotomy with bone grafting, if symptomatic


The clavicle can be broken up into 3 sections: Distal third, middle third, and medial third clavicle fractures. We are going to first talk about midshaft clavicles.

Clavicle Fractures

  • Operative clavicle fractures

    • Often treated with open reduction internal fixation (ORIF), (Closed reduction intramedullary fixation is more rarely done depending on which program you are at).


Clavicle ORIF Example

Credit: Synthes Technique Guide

      • Indications

        • Absolute (Definitely needs to be fixed)

          • Open fractures

          • Displaced fracture with skin tenting

            • Skin tenting is when the fracture piece pushes on the skin. If the skin is blanchable, meaning you can press on the skin and you can see the color change from pale to pink visualizing that capillary refill. Then the overlying skin is likely safe from breakdown.

          • Subclavian artery or vein injury

          • Floating shoulder (Both clavicle and scapular neck fracture)

          • Symptomatic nonunion

          • Symptomatic malunion

        • Relative and controversial

          • Displaced with >2cm shortening (for midshaft clavicle fractures)

            • Attendings may be more likely to fix in athletes

          • Bilateral displaced clavicle fractures

          • Brachial plexus injury (66% have spontaneous return)

          • Closed head injury

          • Seizure disorder

            • Risk for future displacement with subsequent seizures

          • Polytrauma patient

            • Thought is to try to help the patient ambulate with consideration for using a walker and needing both upper extremities or at least one good arm


      • Summary of operative clavicle fracture based on type

        • Distal clavicle fractures (Always look at the conoid and trapezoid ligaments where the clavicle meets the coracoid)

          • Displaced fracture medial to the conoid and trapezoid ligaments or separation of clavicle from the the ligaments

          • Type IIA and IIB and Type V fractures (highlighted in red boxes below)

            • Type IV is non operative because it is a physeal fracture in pediatrics

Neer Classification for Distal Clavicle fractures

Credit: Orthobullets


        • Midshaft Clavicle fractures

          • Neer Classification: 100% displaced clavicle fractures

          • AO Classification: Type C Complex


        • Medial Clavicle fractures

          • Generally treated nonoperatively 

          • May need CT scan for posterior dislocation of sternoclavicular joint for damage to underlying neurovascular structures (more commonly a trauma surgery/ CT surgery problem)


      • Contraindications for surgery (Reminder: The clavicle does not have much overlying skin so anything that will negatively affect healing should be carefully considered)

        • Infection

        • Severe skin condition (acne)

        • Stroke patient with little extremity usage


    • Operative Complications

      • Hardware prominence

      • Neurovascular injury

      • Nonunion

        • Risk factors (Things that affect blood flow or healing)

          • Smoking

      • Infection

        • Risk factors

          • Illicit drug use

          • Diabetes

          • Previous shoulder surgery

      • Mechanical failure

        • Whenever you see a plate or nail break you have to think about the bone not healing. The plate or nail can only flex with normal body weight so many times before breaking. Where if the bone heals appropriately, the plate or nail is less likely to break.

      • Pneumothorax

      • Adhesive capsulitis


References:

https://www.orthobullets.com/trauma/1011/midshaft-clavicle-fractures

https://www.orthobullets.com/trauma/12770/distal-clavicle-fractures?expandLeftMenu=true

http://synthes.vo.llnwd.net/o16/Mobile/Synthes%20North%20America/Product%20Support%20Materials/Technique%20Guides/SUSA/SUTG3.5LCPSuperiorClvJ9486D.pdf


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