Distal Clavicle Fractures

Distal Clavicle

Fractures

2013 AOSSM Meeting

Chicago, IL - July 13, 2013

J.R. Rudzki, MDWashington Orthopaedics & Sports Medicine

Clinical Assistant Professor, Dept. of Orthopaedic Surgery

George Washington University School of Medicine

Disclosure

Arthrex – Consultant

AJSM, JBJS, CORR – Reviewer

AAOS – Evaluation Committee, BOC

AOSSM – Enduring Education Committee

Group I – middle-third fractures

Group II – distal-third fractures

Group III – proximal-third fractures

Type I – minimal displacement

(interligamentous)

Type II – medial to CC ligaments

A. Conoid & trapezoid attached

B. Conoid torn, trapezoid attached

Type III – articular surface fractures

Distal Clavicle Fractures Introduction

Reproduced with permission from

Nuber & Bowen, JAAOS 1997

Type IV–ligaments intact to periosteum

(children), with displacement of

proximal fragment

Type V–comminuted, ligaments not

attached proximally or distally, but

to inferior, comminuted fragment

Similar Concepts to

A-C Injuries

The Critical Concept

Which injuries need to be

treated as fractures by:

• ORIF/osteosynthesis

Which injuries need to be

treated as ligament injuries by:

• Ligament repair/reconstruction

The Critical Concept

Which injuries need both:

• ORIF/osteosynthesis

• Ligament repair/reconstruction

Several methods can achieve

successful outcomes

Limitations of Literature

Difficult to define optimal management

Numerous• Small sample sizes; variable inclusion/exclusion criteria

• Short Follow-Up

• Retrospective Reviews, Case Series, Surveys…• Recall Bias • Selection Bias

• Non-validated Outcomes Instruments• Detection Bias

• Susceptibility Bias

Newer Studies

Better Data

Enhanced Understanding of

Anatomy & Biomechanics

2013

Broader Array of Repair

& Reconstructive Options

Technological

Advances

More impt than ever to be clear on

indications for surgery &

best approach for each patient

Type I• Interligamentous fracture

• Minimally displaced

• Treated non-op with

typically excellent results• Nordqvist, Act Orth Scand,1993

Distal Clavicle Fractures Classification

• Neer described incidence of

osteolysis & AC arthrosis

• Arthroscopic distal clavicle

resection may be performed

if symptoms persistent

Type II - A & B

• Type A: trapezoid & conoid ligaments

are attached to distal fragment

ConoidTrapezoid

Distal Clavicle Fractures Classification

• Type B: fracture plane is between

trapezoid & conoid ligaments, & medial

fragment is displaced.

• Greater risk for non-union due to loss of

restraint of C-C ligament

Type III• Intra-articular AC fracture

• No ligamentous injury

• Potential confusion w/

1st degree AC separation

Distal Clavicle Fractures Classification

Type IV• Displaced fracture, C-C ligaments

remain intact attached

to periosteal sleeve

(childhood injury)

Distal Clavicle Fractures Classification

• Displaced, comminuted

fracture with ligaments

attached to butterfly fragment

Type V

Type IV15 y/o elite male hockey player

Distal Clavicular Physeal Closure

Age 19

- XR ~ 4wks after presumed

AC separation

Indications for Treatment:

Controversy regarding Type II

• Classically, type II injuries

associated with higher rates

of nonunion

• 33% - Neer, J Trauma, 1963

• Several authors have

reported increased rates of

non-union for this injury

pattern:• Edwards DJ, Injury, 1992

• Nordqvist, Acta Orth Scan, 1993

• Robinson, JBJS, 2004~30-40%

Indications for Treatment:

Controversy regarding Type II

• Several authors have advocated

surgical intervention based on:• Degree of displacement

• Age & Activity-Level

• Edwards DJ, Injury, 1992

• Nordqvist, Acta Orth Scan, 1993

• Rokito, Bull HJD, 2002-3

• Robinson, JBJS, 2004

~2-50%

• Despite higher rates of non-

union, incidence of symptoms

& need for delayed surgical

reconstruction is controversial

Ballmer, JBJS-Br, 1991; Edwards, Injury, 1992; Yamaguchi, Int Orth, 1998; Flinkkila, Acta Orth

Scand, 2002; Nourissat, Arthroscopy, 2007; Kalamaras, JSES, 2008; Checchia, JSES, 2008

More data

is needed

20 years, 21 articles, 425 cases: 365 surgical cases & 60 nonop tx

Surgical Tx: Nonop Tx:• CC Stabilization – 105

• Hook Plate – 162

• IM Fixation – 16

• K Wire/Tension Band – 40

1.6% Nonunion

22% Complications

33% Nonunion

6.7% Complications

Complication rate with hook plate or K wire (40 vs 20%)

Complication rate with CC

stabilization (4.8%)

JSES, 2010

38 patients treated with hook plate or locked plate & suture

• Union achieved in 95%

• Complication rate 15.8%

Hook plate patients treated in

delayed fashion had higher rate

of complications P = <0.05

Type IIA&B Operative

Surgical Treatment Options:

• Modified Weaver-Dunn

• Transacromial K-wire fixation

• Knowles Pins/Malleolar Screws

• CC Ligament Slings– Mersilene Tape, PDS Braids, FiberTape

• Bosworth CC Screw Fixation

• Plate Fixation

• Arthroscopic Endobutton FixationNourissat, Arthroscopy, 2007

Kalamaras, JSES, 2008

Checchia, JSES, 2008

Type IIA&B Operative Outcomes

Treatment

Clavicular plates for large

distal fragments• Flinkkila, 2002: compared K-wire versus hook

plate fixation - same union rate; higher

complication rate with K-wires

• Tambe, 2005: 10% non-union rate with plate

fixation & 28% rate of acromial osteolysis

• Muramatsu, 2007: 100% union rate @ 4 mos.

w/ hook-plate, Mean Constant Score = 89

CC ligament slings• Mersiline tape: associated w/ clavicle & coracoid fx

• PDS suture: associated w/ loss of reduction Clayer, 1997

• Suture Anchor/Ethibond Sling & K-Wires: Bezer, 2005

Bosworth Screw• Yamaguchi, 1998:

• 11 pts, 100% union @ 10 wks

• 100% return of shoulder fxn to

pre-injury level

• Requires Screw Removal

Type IIA&B Operative Outcomes

Treatment

Modified Weaver-Dunn

• Removal of distal fragment

• Transfer of CA ligament to

clavicle

• Can reinforce with palmaris

or semi-tendonosis graft,

suture anchor, or screw

Type IIA&B Operative Outcomes

Treatment

Non-anatomic Procedure

Severely displaced

5mm;

no bony contact

Mild to moderate

displacement

Acute fixation/stabilization

Large distal fragment

ORIF

Small fragment

• Locking or Hook Plate ORIF• Consider Tendon Graft, suture or

endobutton CC reinforcement

• Open Anatomic Reconstruction

• Arthroscopic Endobutton

• Modified Weaver-Dunn

Union Non-union

Asymptomatic

Mod Weaver-Dunn,

Anatomic, or Arthroscopic

CC Reconstrxn

+ Graft

Pain

or limited

function

Conservative Mgmt

Type II Distal Clavicle Fractures

Better understanding of anatomy, numerous techniques

available, better plates, arthroscopic approaches

Why not fix all of them?

Operative Management Complications

• Loss of Reduction

• Implant Migration

• Clavicle & Coracoid Fracture

• Articular Injury

• Nonunion, Malunion

• Infection

• Neurovascular Injury

• Stiffness

• Hardware Prominence?

• Need for Removal?

Why not fix all of them?

Operative Management Complications

55 y/o RHD male physician went over handlebars of bike

Treatment Options:

• Hook Plate

• Combined Clavicle/Coracoid

Fixation Device

• Transacromial Fixation

• ? +/- Graft Augment ?

Arthroscopic Procedure

4 week follow-up

JSES, 2013

21 specimens: • 7 tightrope

• 7 locking plate

• 7 plate & tightrope

Increased: - stiffness

- max. resistance to compression

Decreased displacement

Further Study is Needed

Arthroscopic Endobutton Fixation

Checchia SL, et al. J Shoulder Elbow Surg, 2008

Nourissat G, et al. Arthroscopy, 2007

5 year follow-up

Sling for 4-6 Weeks

Passive Supine ER & ER with

elbow supported begin immediately

Passive Supine Fwd Elev

Pendulums at 6 wks

Pulleys when Passive Fwd Elev =

90°

Operative Management Rehab Considerations

Key Take-Home Points

Distal Clavicle Fractures Summary

• Distal clavicle fractures are less common• Important to consider in young athletes when

assessing AC joint injury

• Majority can be treated conservatively

• Some displaced type IIb fractures may

warrant surgical intervention • Important to consider potential complications,

need for hardware removal, & re-injury when

choosing surgical approach

2013 AOSSM Meeting

Chicago, IL - July 13, 2013

J.R. Rudzki, MDClinical Assistant Professor, Dept. of Orthopaedic Surgery

George Washington University School of Medicine

Thank You

Distal Clavicle Fractures

JSES, 201112 pts, 100% union

JSES, 2003