Injuries of the Medial Clavicle: A Cohort Analysis in a Level-I-Trauma-Center. Concomitant Injuries. Management. Classification

Treatment of Symptomatic Medial Clavicle Nonunion with Intramedullary Tendon Allograft: A Case Report

CASE

A 67-year-old patient sustained a medial clavicle fracture (MCF) treated with open reduction and fixation with cerclage sutures. A year later, he presented with symptomatic nonunion and skin prominence, which was revised with an intramedullary tendon allograft fixation including the sternoclavicular joint. At 31 months after the procedure, the patient showed no pain or clinical instability.

CONCLUSION

MCF is an uncommon injury. Symptomatic nonunion after the failure of fixation is rarely described. Although the best way to treat this complication is debatable, revision fixation using an intramedullary tendon allograft can be a viable option in elderly patients.

Morphologic Alterations of the Sternoclavicular Joint following Ipsilateral Clavicle Fractures

RATIONALE

To our knowledge, no study has investigated concomitant injuries of the sternoclavicular joint (SCJ) in acute clavicle fractures. The purpose of this study was to determine the effect of an ipsilateral clavicle fracture on the SCJ in a systematic computer tomography (CT) morphologic evaluation.

METHODS

CT scans in the axial and coronal plane of 45 consecutive patients with clavicle fractures were retrospectively analyzed. The scans were assessed regarding anatomic congruence of bilateral SCJs-joint space width (JSW); the position of bilateral medial clavicles (PC); and the non-fusion of epiphyses, arthritis, calcifications, and intra-articular gas.

RESULTS

The mean SCJ JSW was significantly different in the coronal (cJSW; 8.70 mm ± 2.61 mm in affected vs. 7.63 mm ± 2.58 mm in non-affected side; p = 0.001) and axial plane (aJSW; 9.40 mm ± 2.76 mm in affected vs. 9.02 ± 2.99 in non-affected SCJs; p = 0.044). The position of the medial clavicle showed a significant difference in the coronal plane (cPC; 14.31 mm ± 3.66 mm in the affected vs. 13.49 ± 3.34 in the non-affected side; p = 0.011), indicating a superior shift.

CONCLUSION

Acute clavicle fractures may be associated with an enlargement of the ipsilateral SCJ space width and a superior shift of the proximal clavicle. Both morphologic alterations could indicate concomitant injuries of the SCJ as well as a potential increase in the risk of SCJ instability.

Sternoclavicular Joint Reconstruction with Semitendinosus Allograft and Suture Anchors after Recurrent Posterior Dislocation in a Professional North American Football Player

Background:

Posterior sternoclavicular joint dislocations are an extremely rare but potentially life-threatening injury that can occur in sports. A variety of surgical procedures have been proposed, but there is no consensus on the treatment of choice. It is also largely unknown if a safe return to high-risk sports is possible.

Case Presentation:

We present a case of a posterior sternoclavicular joint dislocation in a 22-year-old male professional North American football player who had a recurrent irreducible posterior dislocation after initial injury management by closed reduction. The patient’s desire to return to football presented unique challenges to management. His sternoclavicular joint was subsequently reconstructed with semitendinosus allograft in a figure-of-eight augmented with suture anchors. After recovery, he returned to play as a running back in professional football symptom-free.

Conclusion:

Our patient's successful return to playing professional football after the sternoclavicular joint reconstruction suggests that this should be considered an effective treatment option when managing posterior sternoclavicular dislocation in high level contact sports players.

Surgical Treatment of Clavicular Fractures, Refractures, Delayed and Non-Unions Using a Resorbable, Gentamicin-Eluting Calcium Sulphate/Hydroxyapatite Biocomposite

Objective

This study describes clinical and radiological outcomes following treatment of displaced primary fractures, refractures, delayed unions and non-unions of the clavicle with open reduction and internal fixation (ORIF) with a plate plus filling of the residual bone defect and/or implant augmentation with a gentamicin-loaded bone graft substitute (CERAMENT G, BONESUPPORT).

Patients and Methods

Patients who underwent surgical treatment either for displaced clavicle fractures, refractures, delayed unions or non-unions between June 2018 and May 2021 were enrolled in this retrospective study. Bony consolidation, complication rate, and functional outcomes, including overall health, were assessed.

Results

A total of 26 clavicles in 25 patients with a mean age of 50.7 (16–85) years, 16 male and 9 female, were enrolled in the study. The mean follow-up was 14.9 (6–31) months. There were 18 cases of displaced clavicle fractures, four refractures, two delayed unions and two non-unions. The majority of the clavicle lesions were located at the middle third (17/26, 65.4%), seven at the lateral third (26.9%) and two at the medial third (7.7%) of the clavicle. A mean Goldberg score of 7 indicated complete bony union and remodeling of the bone graft substitute in all cases. No complications occurred. The mean University of California at Los Angeles Shoulder Score and the mean Quick Disability of the Arm, Shoulder and Hand Score were 34.6±0.8 (32–35) points and 0.6±1.6 (0–5.4) points, respectively, and revealed excellent functional results. The mean 12-item Short-Form Survey physical component questionnaire was 57.7±1.7 (54.1–58.9) points, and no patient experienced any pain at the last follow-up.

Conclusion

Our initial experience suggests that ORIF using a plate plus bone defect filling and/or implant augmentation with a gentamicin-eluting bone graft substitute may be useful not only for complication management after clavicle fractures but also in the initial treatment of challenging clavicular fractures.

Monopolar and Bipolar Combination Injuries of the Clavicle: Retrospective Incidence Analysis and Proposal of a New Classification System

Clavicle injuries are common, but only few case reports describe combined clavicular injuries (CCI). CCI include combinations between clavicular fractures and acromioclavicular/sternoclavicular joint dislocations (SCJD). We present the first general therapeutic recommendations for CCI based on a new classification and their distribution. A retrospective, epidemiological, big data analysis was based on ICD-10 diagnoses from 2012 to 2014 provided by the German Federal Statistical Office. CCI represent 0.7% of all clavicle-related injuries (n = 814 out of 114,003). SCJD show by far the highest proportion of combination injuries (13.2% of all SCJD were part of CCI) while the proportion of CCI in relation to the other injury entities was significantly less (p < 0.023). CCIs were classified depending on (1) the polarity (monopolar type I, 92.2% versus bipolar type II, 7.8%). Monopolar type I was further differentiated depending on (2) the positional relationship between the combined injuries: Ia two injuries directly at the respective pole versus Ib with an injury at one end plus an additional midshaft clavicle fracture. Type II was further differentiated depending on (3) the injured structures: IIa ligamento-osseous, type IIb purely ligamentous (rarest with 0.6%). According to our classification, the CCI severity increases from type Ia to IIb. CCI are more important than previously believed and seen as an indication for surgery. The exclusion of further, contra-polar injuries in the event of a clavicle injury is clinically relevant and should be focused.

Excellent clinical and radiological outcome following locking compression plate fixation of displaced medial clavicle fractures

BACKGROUND

Treatment of medial clavicle fractures is still controversially discussed in the community of upper extremity surgeons. An increasing number of symptomatic non-unions following conservative treatment of displaced fractures led to the development of various surgical approaches. Aim of this study was to evaluate the clinical and radiological outcome following operative treatment of displaced medial end clavicle fractures.

METHODS

Patients who presented with a displaced fracture of the medial clavicle between September 2012 and December 2019 were retrospectively enrolled in this study. All patients were operatively treated with open reduction and internal fixation (ORIF) using an anatomically precontoured locking compression plate (LCP) originally designed for the lateral clavicle (Synthes®, Umkirch, Germany). Functional outcome was recorded using the American Shoulder and Elbow Surgeons (ASES) Score, the Munich Shoulder Questionnaire (MSQ), Shoulder Pain and Disability Index (SPADI) and Constant Score.

RESULTS

Overall 18 patients with a mean age of 54.5 ± 23.5 years suffering from a displaced fracture of the medial clavicle were identified. The mean follow-up was 40.9 ± 26.2 months. The mean ASES accounted for 88.3 ± 20.8 points, the mean MSQ was 83.1 ± 21.7 points, the mean SPADI was 85.6 ± 22.5 and a mean normative age- and sex-specific Constant Score of 77.5 ± 19.1 points resulted. No minor or major complications were observed. Radiologic fracture consolidation was achieved in all patients after a mean of 6.4 months.

CONCLUSION

Surgical treatment of displaced medial clavicle fractures using an anatomically precontoured locking plate originally designed for the lateral clavicle led to very good to excellent clinical and functional results.

TRIAL REGISTRATION

No: DRKS00024813 , retrospectively registered 19.03.2021 ( www.drks.de ).

Dislocations of the acromioclavicular and sternoclavicular joint in children and adolescents: A retrospective clinical study and big data analysis of routine data

Background

Dislocations of the sternoclavicular joint (anterior/posterior) and acromioclavicular joint (SCJ and ACJ, respectively) are rare injuries in childhood/adolescence, each having its own special characteristics. In posterior SCJ dislocation, the concomitant injuries in the upper mediastinum are most important complication, while in anterior SCJ dislocation there is a risk of permanent or recurrent instability.

Methods

In a retrospective analysis from seven pediatric trauma centers under the leadership of the Section of Pediatric Traumatology of the German Trauma Society, children (<18 years) were analyzed with focus on age, gender, trauma mechanism, diagnostics, treatment strategy and follow-up results. Additional epidemiological big data analysis from routine data was done.

Results

In total 24 cases with an average age of 14.4 years (23 boys, 1 girl) could be evaluated (7x ACJ dislocation type ≥ Rockwood III; 17x SCJ dislocation type Allman III, including 12 posterior). All ACJ dislocations were treated surgically. Postoperative immobilization lasted 3–6 weeks, after which a movement limit of 90 degrees was recommended until implant removal. Patients with SCJ dislocation were posterior dislocations in 75%, and 15 of 17 were treated surgically. One patient had a tendency toward sub-dislocation and another had a relapse. Conservatively treated injuries healed without complications. Compared to adults, SCJ injuries were equally rarely found in children (< 1% of clavicle-associated injuries), while pediatric ACJ dislocations were significantly less frequent (p<0.001).

Conclusions

In cases of SCJ dislocations, our cohort analysis confirmed both the heterogeneous spectrum of the treatment strategies in addition to the problems/complications based on previous literature. The indication for the operative or conservative approach and for the specific method is not standardized. In order to be able to create evidence-based standards, a prospective, multicenter-study with a sufficiently long follow-up time would be necessary due to the rarity of these injuries in children. The rarity was emphasized by our routine data analysis.

Acromioclavicular and sternoclavicular joint dislocations indicate severe concomitant thoracic and upper extremity injuries in severely injured patients

Preliminary studies show that clavicle fractures (CF) are known as an indicator in the severely injured for overall injury severity that are associated with relevant concomitant injuries in the thorax and upper extremity. In this regard, little data is available for the rarer injuries of the sternoclavicular and acromioclavicular joints (SCJ and ACJ, respectively). Our study will answer whether clavicular joint injuries (CJI), by analogy, have a similar relevance for the severely injured. We performed an analysis from the TraumaRegister DGU (TR-DGU). The inclusion criterion was an Injury Severity Score (ISS) of at least 16. In the TR-DGU, the CJI were registered as one entity. The CJI group was compared with the CF and control groups (those without any clavicular injuries). Concomitant injuries were distinguished using the Abbreviated Injury Scale according to their severity. The inclusion criteria were met by n = 114,595 patients. In the case of CJI, n = 1228 patients (1.1%) were found to be less severely injured than the controls in terms of overall injury severity. Compared to the CF group (n = 12,030; 10.5%) with higher ISS than the controls, CJI cannot be assumed as an indicator for a more severe trauma; however, CF can. Concomitant injuries were more common for severe thoracic and moderate upper extremity injuries than other body parts for CJI. This finding confirms our hypothesis that CJI could be an indicator of further specific severe concomitant injuries. Despite the rather lower relevance of the CJI in the cohort of severely injured with regard to the overall injury severity, these injuries have their importance in relation to the indicator effect for thoracic concomitant injuries and concomitant injuries of the upper extremity. A limitation is the collective registration of SCJ and ACJ injuries as one entity in the TR-DGU. A distorted picture of the CJI in favor of ACJ injuries could arise from the significantly higher incidence of the ACJ dislocation compared to the SCJ. Therefore, these two injury entities should be recorded separately in the future, and prospective studies should be carried out in order to derive a standardized treatment strategy for the care of severely injured with the respective CJI.

Clavicle fractures: Associated trauma and morbidity

BACKGROUND

Clavicle fractures are frequently associated with trauma to regions beyond the immediate zone of injury. In order to provide surgeons with information on injury prevalence to prevent delays in diagnosis and management, we describe the epidemiology of concomitant injuries in patients with clavicle fractures and identify differences between those with open and closed fractures. Methods:The Nationwide Inpatient Sample (NIS) 2001-2013 database was queried for adult patients discharged with a diagnosis of a clavicle fracture using ICD-9 codes. A "common" injury was defined as prevalence ≥4.0% in our study population. We analyzed data for injury locations associated with open vs. closed clavicle fractures with chi square and independent samples t-tests.

RESULTS

A total of 41,1612 patients were included in our study population. The majority of patients had closed clavicle fractures (98.2%). The most common concomitant fracture was that of the rib, followed by the spine. The most common non-vascular, non-nervous injury was a hemo/pneumothorax followed by a lung, bronchus, or diaphragm injury. Fractures of the humerus, rib, scapula, pelvis, tibia or fibula, and facial bones as well as concussion, pneumo/hemothorax, other pulmonary, and splenic injuries were more common in patients with open clavicle fractures. Patients with open clavicle fractures were, on average, 11.8 years younger than those with closed fractures.

CONCLUSION

There is a significant association between clavicle fractures and concussion, splenic, and thoracic injuries, as well as increased rate of complications with open fractures. Clinicians may use this information to perform risk assessments prevent delays in diagnosis.

Medial injuries of the clavicle: more prevalent than expected? A big data analysis of incidence, age, and gender distribution based on nationwide routine data

Purpose

Although shoulder-girdle injuries occur frequently, injuries of the medial part remain widely unexplored. This study overviews these rare injuries with a focus on incidence, age, and sex distribution in Germany.

Methods

The data are based on diagnoses according to ICD-10 in all German hospitals provided by the German Federal Statistical Office. ICD-10 codes S42.01 (medial clavicle fracture, MCF) and S43.2 (sternoclavicular joint dislocation, SCJD) were evaluated in detail between 2012 and 2014.

Results

We identified 14,264 cases with medial clavicle injuries (MCIs). MCFs occurred more often (11.6% of all clavicle-related shoulder-girdle injuries vs. 0.6% for SCJD). Mean ages of MCI were significantly different between males (43.7 years) and females (57.1 years) (p < 0.01). Age demonstrated a bimodal distribution with peaks at 20 and 50 years, which were predominantly associated with males. Females showed more injuries at age beyond 70 years. This applies to both SCJD and MCF. The incidence rate of these shoulder-girdle injuries was 47.0 per 100,000 person-years, for MCIs overall 5.9 (4.1 for men, 1.8 for women). This indicates disparity with a significant predominance of male patients over females as for all shoulder-girdle injuries (p < 0.01). Among children (< 16 years old), the incidence rate showed no significant difference in gender ratio.

Conclusion

MCIs appear more frequently than estimated so far and are distinguished from other clavicle fractures in that they occur more at higher age and peaking around 50 years. Further work on possible prevention strategies should focus on the most frequently affected groups of men around 20 and 50 years old.

Shoulder girdle injuries involving the medial clavicle differ from lateral clavicle injuries with a focus on concomitant injuries and management strategies: A retrospective study based on nationwide routine data

Introduction

Although shoulder girdle injuries are frequent, those of the medial part are widely unexplored. Our aim is to improve the knowledge of this rare injury and its management in Germany by big data analysis.

Methods

The data are based on ICD-10 codes of all German hospitals as provided by the German Federal Statistical Office. Based on the ICD-10 codes S42.01 (medial clavicle fracture, MCF) and S43.2 (sternoclavicular joint dislocation, SCJD), anonymized patient data from 2012 to 2014 were evaluated retrospectively for epidemiologic issues. We analyzed especially the concomitant injuries and therapy strategies.

Results

A total of 114,003 cases with a clavicle involving shoulder girdle injury were identified with 12.5% of medial clavicle injuries (MCI). These were accompanied by concomitant injuries, most of which were thoracic and craniocerebral injuries as well as injuries at the shoulder/upper arm. A significant difference between MCF and SCJD concerning concomitant injuries only appears for head injuries (p = 0.003). If MCI is the main diagnosis, soft tissue injuries typically occur as secondary diagnoses. The MCI are significantly more often associated with concomitant injuries (p < 0.001) for almost each anatomic region compared with lateral clavicle injuries (LCI). The main differences were found for thoracic and upper extremity injuries. Different treatment strategies were used, most frequently plate osteosynthesis in more than 50% of MCF cases. Surgery on SCJD was performed with K-wires, tension flange or absorbable materials, fewer by plate osteosynthesis.

Conclusions

We proved that MCI are rare injuries, which might be why they are treated by inhomogeneous treatment strategies. No standard procedure has yet been established. MCI can occur in cases of severely injured patients, often associated with severe thoracic or other concomitant injuries. Therefore, MCI appear to be more complex than LCI. Further studies are required regarding the development of standard treatment strategy and representative clinical studies.

Displaced Medial-End Clavicle Fractures Treated with Locking Plate Osteosynthesis

Background

The purpose of this study was to evaluate clinical efficacy of the medial-end clavicle fractures with a reversed lateral locking clavicle plate.

Material/Methods

Eleven male patients age 28 to 66 years old with medial-end clavicle fractures were included in the present study from October 2014 and October 2017. All the patients received operation of fixed with reversed lateral locking clavicle plates. In the operation, a curved incision approximately 8 to 10 cm in length was made, and after the reduction, the fracture was fixed by a reversed lateral locking clavicle plate. Postoperative follow-up was performed in order to evaluate the efficacy of the treatment. Disabilities of the Arm, Shoulder and Hand (DASH) score was used in evaluation the shoulder function post-operation. The functional assessment was performed by using the DASH score.

Results

No intraoperative complications were found during the operation. All patients’ incisions achieved healing after operations. Eleven cases were scored by DASH scoring after the operation; Of these, 9 patients were rated excellent, and 2 patients were rated good. There were no neurovascular injuries, nor were there any hemopneumothorax or internal fixation failures.

Conclusions

The fixation of with reversed lateral locking clavicle plates is effective safe patients with medial-end clavicle fractures.

Sports-related sternoclavicular joint injuries

Sports-related injuries to the shoulder are common causes of disability. Injuries to the sternoclavicular joint (SCJ) in sports are more rare, though have been reported in a small number of cases. SCJ injury classification is determined by the degree of joint displacement and direction of clavicular displacement. Direction of displacement is particularly important due to risk of injury to intrathoracic structures, which has the potential to result in fatal outcomes. These injuries are important to identify in athletes and can be difficult to assess on the field. Specific radiographic views and use of ultrasound can improve accuracy of diagnosis. Reduction of acute traumatic SCJ dislocations is recommended and may require open reduction in the case of posteriorly displaced dislocations. Surgical treatment is indicated in cases of persistent pain or significant compression to intrathoracic soft tissue structures. Long-term outcomes are generally favorable, and athletes are able to return to sport without functional limitations.

Injuries of the sternoclavicular region indicate concomitant lesions and need distinguished imaging

PURPOSE

To evaluate injuries of the sternoclavicular region as indicator injury for relevant concomitant injuries and to evaluate the modalities of initial imaging. We hypothesised a high incidence of concomitant injuries as well as a deficiency of X-ray as the initial gold standard.

METHODS

We retrospectively analysed patients suffering from injuries of the sternoclavicular region between 2002 and 2017. We analysed amongst injury type and severity, initial imaging (X-ray vs. CT scan of the sternoclavicular region vs. whole-body scan), and complement of imaging with regard to defined concomitant injury localisations and the resulting necessity and urgency of surgery.

RESULTS

We included n = 61 patients. The mean ISS was 13.5 ± 17, n = 13 (21.3%) cases were classified as "severely injured" (ISS ≥ 16). N = 29 (47.5%) achieved an initial X-ray, n = 10 (16.4%) an initial CT scan of the sternoclavicular region, and n = 22 (36%) an initial whole-body CT scan. Initial imaging correlated significantly with ISS. In n = 21 (72.4%) cases of the X-ray group a significant complement from X-ray to CT scan of the sternoclavicular region was indicated (p ≤ 0.001). N = 31 (50.8%) patients suffered from concomitant injuries. N = 39 (63.9%) of all patients underwent any kind of surgery, thereof n = 23 (37.7%) related to their sternoclavicular injuries.

CONCLUSION

Injuries of the sternoclavicular complex are indicators for the presence of multiple injuries. A CT scan of the sternoclavicular region including ipsilateral apex of the lung and upper rib cage comprised a large proportion of concomitant injuries. Mapping those injuries during initial imaging improves treatment process, avoids underdiagnostic, and decreases uncertainties.

Acute medial clavicle fracture in adults: a systematic review of demographics, clinical features and treatment outcomes in 220 patients

Background

Medial third clavicle fractures are rare injuries, with limited information available on their characteristics or treatment results.

Materials and methods

We performed a systematic review according to PRISMA guidelines to evaluate the demographics, clinical profile, management and treatment outcome. Electronic searches of the MEDLINE, EMBASE and Cochrane databases were performed.

Results

Seventeen studies were included, consisting of 7 case series and 10 case reports. Two hundred twenty fractures were identified. Seventy-eight percent of fractures occurred in men with mean age of 48 years (16–94 years). Road traffic accident was the most common mechanism of injury (64%). Associated injuries occurred in 81% of patients, with thoracic trauma being the most common (47%). The most common fracture type was extra-articular, with no or minimal displacement (60%). In 9% of patients the fracture was segmental. One hundred ninety-one patients received nonoperative treatment. Twenty-nine patients were treated operatively. The overall nonunion rate was 5% (7/137). The nonunion rate following nonoperative management was 4.6% (5/108). The functional result following nonoperative treatment indicated overall “good” functional outcome. There was no report of catastrophic intraoperative complication amongst patients undergoing surgical fixation.

Conclusion

Medial third clavicle fractures represent a distinct subgroup of clavicle fractures. Nonoperative treatment of these fracture seems to result in high union rate and overall favourable functional outcome. Further high-quality research in this area is warranted to investigate the outcomes and indication for nonoperative versus operative management of these fractures.

Level of evidence

IV.