1. FRACTURE CLAVICLE
When to Operate?
DR.K.ANJANEYULU
CoNsULtANt oRthopAEDiC sURgEoN

2. Anatomy
• strut bet. the the Axial
Skeleton & the Upper
Extremity
• Muscle attachments
• Ligamentous attachments
• Protects Neurovascular
stru.

3. Muscular attachments
• Sternomastoid &
Pectoralis Major
medially
• Trapezius & Deltoid
laterally
• Subclavius inferiorly

4. Neurovascular Structures
• Subclavian Vein
• Subclavian Artery
• Brachial Plexus

6. Mechanism of Injury

7. CLINICAL EXAMINATION
• Ideally in standing position
- shoulder translates & rotates forwards
• From behind - inf.angle of scapula prominence
• Swelling, Bruising, Ecchymosis, Blanching skin
• Deformity, Stepping
• Shortening
• Neurovascular examination

8. Local Examination

10. Shoulder asymmetry
Different levels of A/C Joint

11. Prominence of inf.angle of Scapula

12. X RAY EXAMINATION
AP X Ray of Shoulder for Clavicle in standing
position - gravity – max deformity
Chest Radiograph – Compare with opp. Clavicle for
any shortening
-- assoc. injury to Rib, Glenoid
Scapula
-- Haemo / Pneumothorax

13. Displaced # Clavicle, multiple Rib #s
Pneumothorax

14. CT SCAN
• Medial 1/3 clavicle # cannot be visualised
properly in Plain radiographs
• Fractures of Glenoid in “Floating Shoulder”
• Midshaft #s – rarely required – can demonstrate
complex three dimensional deformity
• Lat 1/3 #s with intra articular extension

15. Clavicle # & Glenoid #

18. Angiography

19. • Although displaced #s can’t be reduced &
maintained in good reduction by cons.Rx
*Cosmesis is acceptable
*Functional results are excellent
• Bony prominence resorbed with time
• Throwing athlets – malunion did not
significantly alter their throwing ability

20. • Traditionally clavicle #s have been managed
non operatively, but recent studies have shown
that union rate for displaced midshaft #s may
not be as favourable as described
• No obvious dif. in the outcome bet. Rx by a sling
or figure of 8 bandage

21. IS THERE A NEED TO
OPERATE A CLAVICLE
FRACTURE ?

22. Indications for Surgery
1. Fracture specific
3. Associated injuries
5. Patient factors

23. Fracture specific
1. Displacement > 2 cms
2. Shortening > 2 cms
3. Increasing comminution > 3 fragments
4. Segmental fractures
5. Open fractures
6. Impending open #s with soft tissue comprom
7. Obvious clinical deformity ( 1 & 2)
8. Scapular malpositioning & winging

24. ASSOCIATED INJURIES
1. Vascular injury requiring repair
2. Progressive neurological deficit
3. Ipsilateral Upper Extremity injuries / fractures
4. Multiple ipsilateral upper rib #s
5. “Floating shoulder”
6. Bilateral clavicle fractures

25. PATIENT FACTORS
1. Polytrauma with requirement for early upper
limb weight bearing / arm usage
3. Patient motivation for rapid return of function
- elite sports
- self employed professionals

26. SURGICAL APPROACH
• Anterosuperior
• Anteroinferior

27. Anterosuperior approach
Advantages: 1. familiar to many
2. extendibility
3. clear fracture view – postop.xray
Disadva: 1. trajectory of screw placement difficult
2. inadvertent plunging of drill may
injure lung & neurovasc. Structures
3. clavicle is narrow in superoinf. direct.
4. hardware prominence - requires removal

28. Anteroinferior approach
Advantages: 1. easier screw trajectory
2. less likely iatrogenic injury
3. wider AP dimension – longer screws
4. less hardware prominence
5. easier to contour a plate along ant.bord
Disadvantages: 1. lack of general familiarity
2. plate obscures # site on x ray

29. Methods of fixation
1. Plate & Screw fixation
anatomic reduction, stable fixation
sugical morbidity is more
4. Intramedullary Pinning
smaller cosmetic skin incision, minimal soft
tissue stripping, decreased hardware
prominence
6. External Fixation
intrinsic healing, no scar, no morbidity,
no retained hardware

30. Plate & Screw Fixation

31. Fracture medial end

32. Plate crossing onto the sternum

33. Badly displaced midshaft #

34. Open Reduction

35. Pre op & Post op X rays

37. Union of # & Implant Removal

38. Fracture Lateral End
fixed with Hooked Plate

42. Malunion (symtomatic)

43. Intra operative
Picture

44. Intra op
&
Post op

45. # Clavicle with Head Injury
Abundant Callus, Venous Obstruction & Brachial
Plexus compression

46. Abundant callus
Excision and Plating
Relief of symptoms

47. Transthoracic displacement
Pseudoaneurysm of Subclavian Art.

48. ORIF WITH PLATE & SCREWS

49. Intramedullary Pinning

50. Comminuted displaced midshaft #
Intramedullary Pinning

51. Intramedullary Pinning

52. Cerclage Wire – Inadequate purchase

53. Implant failure

54. POSTOPERATIVE PROBLEMS
1. Scar
2. Sensitive or Painful # site
3. Hardware irritation / prominence
4. Incisional numbness

55. conclusions
• Majority of fractures heal with non operative Rx with
prompt return of near normal funct.
• Poor prognostic signs – increasing displ.of frag
- increasing commi.with
number of fragments
• Young active pts. – completely displaced midshaft #s
– superior results-primary fixation
• Operative plate fixation - more rapid return to a
superior level of function - low compli.rate

56. conclusions
• Antero inferior plating better than superior plating in
terms of soft tissue irritation
• Intramedullary fixation has many theoritical adv. and
high rate of success in skilled hands
• Scapular winging – conservative Rx - symptomatic
• Malunion is a definite clinical entity – benefits from
corrective osteotomy

57. THANK
YOU