Fracture of Clavicle (Collerbone)
THE CLAVICLE SPEAKS
• I’m the first bone to ossify in the body.
• I ossify from two primary centers.
• I’m the only long bone in the body lying horizontal.
• I’m the only long bone ossifying from a membrane.
• I’m the only link between the appendicular and the axial skeleton.
• I’m the most common bone to be fractured in children.
• I invariably end up maluniting after the fracture.
Functions of Clavicle
• It increases the arm strength mechanism.
• It protects the neurovascular bundle consisting of subclavian vessels and brachial plexus.
• It gives attachments to big muscles round the shoulder.
• During rest and motion it braces the shoulder back (Strut function).
Mechanism of Injury
Due to fall on the purpose of the shoulder. This is the foremost common mode of injury accounting for 91 percent of the cases.
Direct trauma over the clavicle thanks to RTA (Road Traffic Accident), direct injury, etc. accounts for 8 percent of the cases.
Indirect fall on the outstretched hands cause 1 percent of the cases.
Sites of Fracture
• 85% of the fracture clavicle occurs at the junction of middle and outer third.
• one-hundredth at the medial end of the clavicle (5%).
• Lateral end fracture is rare (About 10%) (Distal 1/3rd).
Classification of Fracture Clavicle (Allman’s)
Group I is fractures involving middle one-third of the shaft.
Group II is fractures involving the lateral third distal to the attachment of the coracoclavicular ligament. This is again further subdivided into two subgroups. (Proposed by Neer):
• Type A: Coracoclavicular ligament intact.
• Type B: Coracoclavicular ligament ruptured.
• Type C: Intra-articular extension into ACM joint. Group III are medial third fractures.
The patient presents with pain, swelling, deformity and inability to boost the shoulder. Rarely, the patient may present pseudo paralysis with the affected arm.
The following views are recommended.
• Routine AP view of the clavicle.
• Lordotic view if the fracture is doubtful.
• Distal clavicle requires special radiography technique.
Principles of Treatment
Before proceeding to the treatment proper one must understand the 2 distracting forces working on the fracture fragments in clavicle making the treatment difficult. The sternocleidomastoid pulls up the medial end of the clavicle and therefore the musculus pectoralis major muscle and gravity acting through the arm pull down the lateral end.
This is the treatment of choice in fracture clavicle and consists of the subsequent methods:
- Cuff and collar sling for undisplaced fractures.
|Collar and cuff sling with adhesive plaster|
- Strapping of the fracture site after reduction of the fracture by elevating the arm and bracing the shoulder upwards and backwards gives good leads to both children and adults.
- Sabre method consists of rigid dressing over the fracture. This is no longer used.
- Billington Yoke method uses a plaster of Paris over a well-padded figure of ‘8’ dressing.Figure of ‘8’ is popularly used and it acts by retracting the shoulder girdle, minimizes the overlap and allows more anatomical healing. It doesn’t immobilize the fracture but acts by serving as a reminder to the patient to carry the shoulder up and back neutralizing the forces mentioned above. If they permit the shoulder to slump forward, then the support cuts into the anterior axilla and reminds them to carry the shoulders back.
|Figure of 8 bandages|
To perambulatory Newborn children: Treated symptomatically, bind arm to the chest.
Ambulatory stage are (2-12 yr): Figure of ‘8’ bandages, tightened after three days and later one week.
12 years to maturity: Commercially available figure of ‘8’ harness.
Surgery is never indicated and consists of open reduction and rigid internal fixation.
Methods of Internal Fixation
• Intramedullary fixation with K-wires.
• screw fixation and Rigid plate with AO semitubular or pelvic reconstruction plate.
Injury to neurovascular bundle,Open fractures, if the fracture is threatening to penetrate the skin, nonunion, fracture near acromioclavicular joint, floating shoulder, soft tissue interposition and displaced epiphysis in children.
More Specific Indications for Open Reduction and Internal Fixation of Clavicle Fracture are
• Shortening of fragment or distraction of fragments for more than 2 cm.
• More than 100 percent displacement or fragmentation.
• Bilateral fractures.
Complications of Fracture Clavicle
Neurovascular injury could also be immediate thanks to direct force or delayed thanks to a really large callus. The structures commonly injured are subclavian vessels and therefore the medial cord of the plexus brachialis through which the cubital nerve springs . This occurs in fractures of the center one-third of the clavicle, which is that the commonest .
Malunion is extremely common thanks to difficulty in holding the fracture fragments in position due to the distracting forces already explained. It causes only a cosmetic problem and doesn’t usually impair function. Hence, no treatment is required.
Problems Posed by Malunion Clavicle
• Cosmetic complaints—mentioned above.
• Orthopedic complaints—frequent episodes of shoulder fatigue.
• Sleep problems—the patient complains of inability to sleep on the sides.
• Neurological problems—features of thoracic outlet syndrome.
Nonunion is rare and requires open reduction, internal fixation and bone grafting.
|Internal fixtion clacivle fracture|