Distal Clavicle Fractures
•Download as PPTX, PDF•
13 likes•7,424 views
Distal clavicle fractures are classified into 5 types based on the location and involvement of ligaments. Type I fractures involve minimal displacement and are treated non-operatively. Type II fractures have greater controversy in management, with some advocating surgery for Type II fractures that have medial displacement of the distal fragment. Surgical options include plate fixation, CC ligament reconstruction, and arthroscopic techniques. While surgery aims to improve union rates, it also carries risks of complications that must be weighed against non-operative treatment. Further research is still needed to determine the optimal treatment approach for different types of distal clavicle fractures.
Report
Share
More Related Content
What's hot
What's hot (20)
Similar to Distal Clavicle Fractures
Similar to Distal Clavicle Fractures (20)
More from washingtonortho
More from washingtonortho (20)
Recently uploaded
Recently uploaded (20)
Distal Clavicle Fractures
- 1. Distal Clavicle Fractures 2013 AOSSM Meeting Chicago, IL - July 13, 2013 J.R. Rudzki, MD Washington Orthopaedics & Sports Medicine Clinical Assistant Professor, Dept. of Orthopaedic Surgery George Washington University School of Medicine
- 2. Disclosure Arthrex – Consultant AJSM, JBJS, CORR – Reviewer AAOS – Evaluation Committee, BOC AOSSM – Enduring Education Committee
- 3. 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
- 4. 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
- 5. The Critical Concept Which injuries need both: • ORIF/osteosynthesis • Ligament repair/reconstruction Several methods can achieve successful outcomes
- 6. 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
- 7. 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
- 8. 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
- 9. Type II - A & B • Type A: trapezoid & conoid ligaments are attached to distal fragment Conoid Trapezoid 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
- 10. Type III • Intra-articular AC fracture • No ligamentous injury • Potential confusion w/ 1st degree AC separation Distal Clavicle Fractures Classification
- 11. 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
- 12. Type IV 15 y/o elite male hockey player Distal Clavicular Physeal Closure Age 19 - XR ~ 4wks after presumed AC separation
- 13. 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%
- 14. 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
- 15. 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%)
- 16. 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
- 17. 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 Fixation Nourissat, Arthroscopy, 2007 Kalamaras, JSES, 2008 Checchia, JSES, 2008
- 18. 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
- 19. 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
- 20. 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
- 21. 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
- 22. 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?
- 23. Why not fix all of them? Operative Management Complications
- 24. 55 y/o RHD male physician went over handlebars of bike Treatment Options: • Hook Plate • Combined Clavicle/Coracoid Fixation Device • Transacromial Fixation • ? +/- Graft Augment ?
- 27. 4 week follow-up
- 28. JSES, 2013 21 specimens: • 7 tightrope • 7 locking plate • 7 plate & tightrope Increased: - stiffness - max. resistance to compression Decreased displacement Further Study is Needed
- 29. Arthroscopic Endobutton Fixation Checchia SL, et al. J Shoulder Elbow Surg, 2008 Nourissat G, et al. Arthroscopy, 2007
- 30. 5 year follow-up
- 31. 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
- 32. 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
- 33. 2013 AOSSM Meeting Chicago, IL - July 13, 2013 J.R. Rudzki, MD Clinical Assistant Professor, Dept. of Orthopaedic Surgery George Washington University School of Medicine Thank You Distal Clavicle Fractures
- 36. JSES, 201112 pts, 100% union
- 37. JSES, 2003