Fractures of the Lateral Third of the Clavicle: An Anatomic Approach to Treatment

Noncomminuted lateral end clavicle fractures associated with coracoclavicular ligament disruption: Technical considerations for optimal anatomic fixation and stability

Distal clavicle fractures associated with coracoclavicular ligament disruption are potentially unstable and necessitate surgical treatment. Current fixation techniques are nonanatomic and do not address relevant aspects of the pathoanatomy. We have developed a technique that uses a unique combination of implants; this permits minimally invasive fixation and stable reduction with a lateral fragment size as small as 5 mm. The surgical technique consists of (1) neutralization of muscular forces on the proximal fragment using a minimally invasive ligament repair device (TightRope™, Arthrex, FL, USA) and (2) internal fixation using a contour-matched locking plate (2.4 mm LCP^® Distal radius plates, Synthes, USA). Technical tips to optimize this new procedure are discussed. The technique can be extended to an “arthroscopic-assisted” method involving arthroscopic coracoclavicular fixation followed by a mini-open plate fixation of the clavicular fragments.

Treatment of Neer type II fractures of the lateral clavicle using distal radius locking plates combined with TightRope augmentation of the coraco-clavicular ligaments

INTRODUCTION

Neer type II lateral clavicle fractures are inherently unstable and debate continues regarding optimal treatment. The purpose of this study was to review the outcome of Neer type II lateral clavicle fractures treated using a novel technique, which incorporates a superiorly placed distal radius locking plate combined with TightRope™ fixation to augment the coraco-clavicular ligaments.

METHODS

Between 2007 and 2010, a total of 31 Neer type II fractures were managed operatively at our institution. Clinical outcomes were assessed using the SPADI, DASH, Constant, and Taft scores. Subjects were evaluated at 6 weeks, 3, 6 months, and 1 year. For the latest follow-up (mean 38.7 months), all patients were telephoned by an independent research associate and interviewed to establish SPADI and DASH scores. Radiological union was evaluated using standard views including an antero-posterior view, an angled (Zanca) view, and a trans-scapular view.

RESULTS

Bony union was achieved at a mean follow-up of 6.3 ± 4.1 weeks. At the 1-year follow-up, the AC joint remained reduced radiologically in all cases. At 1 year, the mean Constant score was 95.6 ± 4.82, the DASH score was 3.45 ± 3.02, and the SPADI score was 2.58 + 1.94. At the latest follow-up, at a mean of 38.7 + 14.8 months, the DASH score was 0.6 ± 2.1 and the SPADI score was 0.6 ± 2.

CONCLUSION

Surgical fixation of Neer type II lateral clavicle fractures using a 2.4-mm distal radius locking plate in combination with TightRope™ suture augmentation results in a predictable outcome, preserving excellent shoulder function while maintaining a low complication rate.

Hook plate fixation of acute displaced lateral clavicle fractures: mid-term results and a brief literature overview

Background

The clavicle hook plate achieves like most other operative techniques, a high percentage of union and a low percentage of complications however concerns about long term complications still exist, particularly the involvement of the acromioclavicular joint.

Methods

To evaluate the results and long term effects in use of this plate we performed a retrospective analysis with a mean follow up of 65 months (5.4 years) of 28 consecutive patients with acute displaced lateral clavicle fractures, treated with the clavicle hook plate.

Results

Short term functional results in all patients were good to excellent. All but one patient had a united fracture (96%). Nine patients (32%) developed impingement symptoms and in 7 patients (25%) subacromial osteolysis was found. These findings resolved after plate removal. Twenty-four patients were re-evaluated at a mean follow-up period of 5.4 years. The Constant-Murley score was 97 and the DASH score was 3.5. Four patients (14%) developed acromioclavicular joint arthrosis of which one was symptomatic. Three patients (11%) had extra articular ossifications of which one was symptomatic. There was no relation between the impingement symptoms, subacromial osteolysis and development of acromioclavicular joint arthrosis or extra articular ossifications.

Conclusions

The clavicle hook plate is a good primary treatment option for the acute displaced lateral clavicle fracture with few complications. At mid term the results are excellent and no long term complications can be addressed to the use of the plate.

Treatment of distal clavicle fracture: a systematic review of treatment modalities in 425 fractures

The Neer type II distal clavicle fracture is notorious for its high nonunion rate, and surgical treatment is usually recommended. We reviewed articles from January 1990 to September 2009, and among them, 425 cases from 21 studies were included. According to the 425 cases in the literature, sixty patients were treated nonsurgically and 365 surgically. From 365 patients who were treated surgically, 105 were identified as receiving the coracoclavicular stabilization, 162 hook plate, 42 intramedullary fixation, 16 interfragmentary fixation, and 40 K-wire plus tension band wiring. The nonsurgical treatment resulted in 20 (33.3%) nonunions and 4 (6.7%) other complications. The surgical treatment resulted in 6 (1.6%) nonunions, 81 (22.2%) complications other than nonunion. The nonunion rate was significantly high with nonsurgical treatment (p < 0.001), and the complication rate was statistically high with surgery (p = 0.002). With surgical treatment, the nonunion rate was not significantly different among the modalities (p = 0.391). The complication rate was significantly higher in cases of the hook plate (40.7%) and the K-wire plus tension band wiring (20.0%) than those of the coracoclavicular stabilization (4.8%), the intramedullary (2.4%) and the interfragmentary fixation (6.3%). For the nonsurgical treatment, the functional outcomes were generally acceptable despite the high nonunion rate. The nonsurgical treatment could be considered as the first line treatment after sufficient counsel with the patient. The nonunion rate is high, however, the functional outcome is acceptable in most of the cases with nonunion. If the surgical treatment is considered, the intramedullary screw fixation, CC stabilization and interfragmentary fixation would be preferred because of their low complication rate.

Double-plate fixation in lateral clavicle fractures-a new strategy

BACKGROUND

Lateral clavicle fractures Neer type II often lead to the dislocation of the medial fragment and an increased rate of nonunion after conservative treatment. Therefore, most authors recommend an open reduction and internal fixation. Double-plate fixation is a common technique in the treatment of complex radius fractures. The authors use it as a routine procedure in the treatment of lateral clavicle fractures Neer type II. In this article, we present our experiences.

METHODS

From January 2006 to June 2008, 11 patients with lateral clavicle fractures of Neer type II were treated with an open reduction and internal fixation using the double-plate technique.

RESULTS

All patients showed osseous union on radiographs after 10 weeks to 16 weeks. In eight of nine cases, the operated shoulder regained full range of motion. In all patients, we observed immediate postoperative recovery without severe complications. One female patient complained about slight pain and restricted motion in abduction of > 90°. In two patients, we observed the migration of one screw. It was removed under local anesthesia 9 weeks and 26 weeks after surgery.

CONCLUSIONS

This study, for the first time, describes the technique of double-plate fixation for the treatment of lateral clavicle fractures. This technique provides a stable fixation even in small and comminuted distal fragments.