6.
1 Scap u la and cla vicle
2 C la v icu la r fra ctu re s and d islo c a tio n s o f a d ja cen t
jo in ts
2.1 E p id em io lo gy
Injury to the clavicle is estim ated to constitute about 4-10%
of skeletal traum a presenting at an emergency departm ent.
The vast m ajority of patients report a direct fall onto the shoul­
der or a direct blow, m ost often sustained during an outdoor
leisure activity. M en outnum ber wom en by 2 to 1 and present
at a younger age (30-year-old versus 39-year-old). M ore than
2/3 of the fractures are located in the m iddle section of the
clavicle. Fractures of the sternal part account for 2%, the rest
involve the acrom ial part [8], Clavicular injuries are generally
treated nonoperatively w ith more than 100 possible options
[12], m ost of which include im m obilization in a sling until
pain ceases. However, complications of nonoperative treat­
m ent (eg, shortening, deform ity and m alunion w ith pain and
physical im pairm ent) and new fixation techniques and im ­
plants have generated renewed interest in operative fixation of
clavicular fractures.
2.2 S u rg ica l anatom y
The clavicle is S-shaped and forms the only bony connection
betw een the upper lim b and the torso. The close proxim ity of
the brachial plexus and the subclavian vessels should be rec­
ognized. During m ovem ent of the arm and shoulder the clav­
icle also rotates around a virtual axis betw een the sternum
and the acrom ion. As a consequence the tension and compres­
sion sides change. This m ay suggest that an intram edullary
im plant would be the best biom echanical choice for fracture
fixation in this short tubular bone.
2.3 C la ss ific a tio n
A llm an divides the clavicle into three parts, group I repre­
senting the m iddle third, group II and III the lateral and m e­
dial third [13]. Three subgroups exist for every group, "a" being
the nondisplaced, "b" the displaced, and "c" the m ultifragm en­
tary fracture type. The OTA classification recognizes the m e­
dial end, the diaphysis and th e lateral end [4]. The diaphysis
counts nine subgroups sim ilar to the subgroups know n from
the M üller AO Classification of fractures—long bones, where
the clavicle is coded bone 15 (Tab 1.5-1).
2.4 A sse ssm e n t and d ia g n o sis
The clavicle is one of the few bones w hich can be exam ined by
palpating its whole length. Hematoma, deform ation, im m i­
nent skin perforation, or unusual m obility are easily detect­
able. Radiological investigations com m only include an AP and
a 30° cranial tilt view. However, if shortening of the clavicle
influences the decision on operative treatm ent, a PA 15° cau­
dal x-ray m ore reliably assesses differences com pared to the
noninjured side [14]. Irrespective of the cause of traum a, as­
sessment of a clavicular injury also includes a neurological and
vascular exam ination of both arms.
2.5 Treatm ent
2.5.1 Treatm ent o f c la v ic u la r sh a ft fractu res
■ Ever since H ippocrates described the nonoperative m an­
agem ent of closed clavicular fractures, im m obilization until
pain ceases has been standard treatment.
5 63
 6 S p e c ific fractu res
There is sufficient evidence showing that imm obilization w ith
a simple sling produces the same results as a figure-of-eight
bandage, but less pain. In addition, the latter requires regular
adjustm ent and causes a lot of inconvenience. Even w ithout
physiotherapy, full recovery of shoulder m obility may be
expected after 6 -8 weeks. In most cases, nonoperative
treatm ent of closed clavicle fractures is highly successful and
uneventful.
Prim ary operative treatm ent is indicated for open fractures,
im m inent skin or pleura perforation by one of the fragments,
and associated or progressive injuries of the neurovascular
bundle. Relative indications for surgery include concom itant
injuries of the ipsilateral upper extrem ity, spinal cord injuries,
or polytraum atized patients. Floating shoulder injuries w ith
severely displaced or unstable ipsilateral scapular neck and
clavicular fractures m ay require operative treatm ent. In these
cases it is usually sufficient to fix the clavicular fracture. De­
pending upon the specific requirem ents of certain patient
populations, operative treatm ent may be considered (eg, pro­
fessional athletes). Furtherm ore, there is a growing num ber of
reports suggesting that the results of nonoperative treatm ent
are less satisfactory th an assum ed [15, 16].
■ Residual pain and functional outcom e seem to correlate
with the am ount of shortening of the clavicle. Therefore,
operative treatm ent should at least be discussed with pa­
tients w ho sustained grossly displaced or m ultifragm entary
fractures.
Exact indications for surgery however, are lacking.
P la tin g
The patient is placed in a beach chair position. Either an infra-
clavicular incision parallel to the long axis of the bone or a
saber-cut incision perpendicular to the long axis is used. The
form er provides a m ore convenient, unlim ited access to the
564
entire length of the bone, whereas advocates of the latter
claim better cosmetic results and less damage to the supracla­
vicular cutaneous nerves. In our experience reducing the te n ­
sion on the skin suture through a m eticulous adaptation of the
platysm a muscle at the end of the operation is m uch more
im portant for a good cosmetic result th an the type of skin
incision.
Plates may be applied to the anterior or superior aspect of the
clavicle. Superior placem ent best avoids detachm ent of the
muscles, since the bone is exposed betw een the insertion of
the trapezius and the pectoralis m ajor and deltoid muscles.
Biomechanically there is no significant advantage for either
plate position. Anterior placem ent should provide better screw
purchase, because of the larger diam eter of bone in the tran s­
verse plane. W ith superior placem ent of the plate, the subcla­
vian vessels are at risk of injury during drilling and screw
insertion, whereas w ith anterior placem ent the structures of
the brachial plexus may be damaged. Depending upon their
biom echanical function either straight 3.5 m m plates (LC-DCP
or LCP) or reconstruction plates 3.5 m ay be used (Fig 6.1-4).
R econstruction plates are easier to apply to the S-shaped bone,
but are m echanically w eaker th a n straight plates and should
be used w ith caution to bridge a com m inuted fracture. They
may safely be used w ith lag screws for neutralization or for
axial compression. The plates should be sufficiently long to
allow three screws to be inserted in each m ain fragment. A n­
atomical reduction and correct rotational alignm ent may be
difficult to achieve. Sometimes it is helpful to reduce and fix
the bigger interm ediate fragments first w ith 2.0 or 2.4 m m lag
screws to one or both m ain fragm ents before applying the
plate. It is im portant to preserve the soft-tissue attachm ents.
Bone grafting in prim ary surgery is not necessary. Due to the
risk of refracture, im plant removal generally is not recom ­
mended before 2 years after ORIF. There are only a few reports
in the literature on the results of ORIF w ith plates. Nonunion
rates of 3-8.3% were noted [17-19],
 6.1 Scap u la and cla vicle

Fig 6.1 -4 a -e Midshaft fractures of the clavicle.

a -c Wedge fracture fixed with a 7-hole reconstruction plate 3.5 on top. One independent 2.4 mm lag screw.

d -e Bridging plate for multifragmentary fractures. Anterior placement of a LC-DCP 3.5 for better purchase of the screws.
 6 S p e c ific fractu res

los clavos rigidos o los alambres k gruesos

no son satisfactorios
In tram e d u llary n a ilin g
- In these cases the fragments are exposed through a 2 cm inci­
Stiff pins or thick K-wires are not satisfactory because of the
risk of im plant m igration and damage to nearby neurovascular
structures. However, the titanium elastic nails (TEN) have
opened new perspectives for percutaneous intram edullary
fixation (elastic stable intram edullary nailing, ESIN) of the
clavicle (Fig 6.1-5). The patient is placed in a supine position on
a radiolucent table. A 2 cm skin incision is m ade over the ster­
nal end of the clavicle. A 2.5 m m drill hole is m ade in the
anterior cortex. The entry point is then enlarged w ith an awl
in a slightly lateral direction. A 2.0-3.5 m m titanium elastic
nail (TEN) is inserted w ith oscillating movem ents and—under
image intensification— advanced across the fracture site. In
about 50% of the cases closed reduction cannot be achieved.
sion over the fracture site enabling direct m anipulation and
reduction. The tip of the TEN is advanced as far laterally as
possible w ithout perforating the cortex. The medial end of the
intram edullary nail is then cut off and should be buried sub-
cutaneously [20]. The new, blunt endcaps (Fig 6.1-5d) prevent
backing out of the TEN. Postoperative imm obilization is not
necessary. If this technique is used in m ultifragm entary frac­
tures, abduction of the shoulder is lim ited to 90° for the first
3 weeks. Hardware removal is not m andatory but can be done
after 8 m onths (at the earliest) through the initial sternal inci­
sion. First results of this technique are prom ising, w ith good
pain relief and significant im provem ent of shoulder function.
Patients w ith an additional injury of the lower lim b are able to

Fig 6.1-5a-d
a -c Titanium elastic nail (TEN) for displaced clavicular fracture. Medial entry point. Closed reduction is possible in about 5 0% of cases,
d Endcap to be slippped over the cut end of the nail and anchored in the bone by the thread.

566
 6.1 Scap u la and cla vicle

walk w ith crutches w ithin the first week. Possible complica­
tions include painful skin irritation from the protruding end
of the TEN (6%). In a comparative study, the nonunion rate
was lower and the cosmetic and functional result better than
w ith nonoperative treatm ent. Secondary shortening of the
fracture may occur and in com m inuted fractures plate osteo­
synthesis is still preferred.
2.5 .2 Treatm ent of fra ctu re s of the late ral end o f the
cla v icle
Treatm ent of fractures of the lateral end of the clavicle has
been a m atter of debate for a long tim e. There is recent evi­
dence th at nonoperative treatm ent is a safe and effective policy
[21]. This applies to displaced fractures of the lateral end of the
clavicle if there are neither compromised soft tissues nor an
ipsilateral disruption of the superior shoulder suspension
complex [22],
Prim ary operative stabilization is m andatory in open frac­
tures, in a double disruption of the SSSC, or w ith severe skin
involvement. N onunion of displaced fractures at this site is
fairly com m on and m ay be an indication for surgery. Treat­
m ent options include banding of the clavicle to the coracoid
process w ith stitches made of strong resorbable or nonresorb-
able m aterials, Bosworth screw technique [23], plate fixation
using LCP T-plates 3.5 (Fig 6.1-6) or a hook plate (modified
Balser plate), w hich hooks under the acrom ion (Fig 6.1-7).
There is no evidence to support the superiority of any of these

Fig 6.1-6a-d
a Displaced fracture of the distal clavicle with rupture of the coracoclavicular ligament.
b -c Fixation with a lag screw (through the plate) and a 45° oblique LCP T-plate 3.5 using locking head screws.
d The plate should be carefully contoured so that the locked screws are not parallel but converge.
If a fragment is not large enough to use a lag screw, it is probably not appropriate to use this plate.

567
 6 S p e c ific fractu res

techniques. In m issed or "delayed" cases an alternative may be
excision of the lateral end of the clavicle w ith stabilization of
the coracoclavicular ligam ents (W eaver-Dunn procedure).
2.5 .3 Treatm ent of a cro m io cla v icu la r jo in t d is lo ca tio n
The Tossy and A llm ann classification modified by Rockwood
seems to be the m ost appropriate [22]. He identifies six sub­
groups, of w hich type I (sprain of the acrom ioclavicular liga­
ment) and II (acrom ioclavicular joint disruption w ith sprain
of the coracoclavicular ligaments) are treated nonoperatively.
Type III (dislocation of the joint w ith rupture of the acrom io­
clavicular and coracoclavicular ligaments) may initially be
treated nonoperatively. Persisting complaints m ight later be an
indication for a lateral clavicle resection or fixation w ith a hook
plate. In type IV injuries the lateral end of the clavicle pro­
trudes posteriorly through the trapezius muscle, w hich will
perm anently ham per realignm ent of the joint and therefore
should be operated. Dislocations of type V variety (acromio­
clavicular and coracoclavicular ligam ents disrupted, deltoid
and trapezius muscles detached from the lateral end of the
clavicle, gross disparity betw een clavicle and scapula) should
be operated upon primarily. Finally, type VI dislocation is a
very rare case in w hich there is an anteroinferior dislocation
of the lateral end of the clavicle underneath the coracoid pro­
cess, w hich requires an open reduction.

Fig 6.1-7a-b The clavicular hook plate. Superior approach to the distal clavicle,
a Fracture reduction and identification of the acromioclavicular joint allows introduction of
the hook plate into the subacromial space,
b Proximal fixation provides stability and allows early postoperative mobilization.
Some degree of shoulder impingement is inevitable and these plates always need to be
removed.

568
 6.1 Scap u la and cla vicle

M any different techniques have been proposed for operative
treatm ent. The lateral end of the clavicle can either be fixed to
the acrom ion or the coracoid process or to both, using m odi­
fied tension band techniques w ith w ires or resorbable bands,
a single screw (Bosworth technique, Fig 6.1-8) or a hook plate
(modified Balser plate) [23-25].
2.5 .4 Treatm ent o f s te rn o cla v icu la r jo in t d islo ca tio n
The sternal end of the clavicle is the last grow thplate in the
clavicle to completely ossify so that a sternoclavicular dis­
location may still be a physeal injury, either Salter-Harris type
I or I I . Diagnosis on plain x-rays can be very difficult and care­
ful physical exam ination for tenderness and asym m etry is

Fig 6.1-8a-b Acromioclavicular dislocation type III. Treatment with a Bosworth screw,
a Through a saber-cut incision, the remnants of the coracoclavicular ligament are identified and—if fea­
sible-prepared for suture.
b After temporary fixation of the reduced acromioclavicular joint with a K-wire, a 3.2 mm hole is drilled
centrally through the clavicle into the coracoid. Both cortices of the clavicle are overdrilled and a 6.5
mm cancellous bone screw is placed with a washer. The shaft of the screw should only be in loose
contact with the clavicle to allow for some movement of the shoulder girdle. The transfixing K-wire must
be removed.

569
 6 S p e c ific fractu res
essential. Only a CT scan will provide sufficient inform ation
on the extent of the dislocation and possible associated bone
injury. Dislocations are either anterior or posterior, the latter
of w hich m ight lead to respiratory problems. Posterior disloca­
tions are corrected by closed reduction or w ith a percutane-
ously applied pointed bone-holding forceps. Normally they are
stable after reduction and w ill not require additional fixation.
In contrast, anterior dislocations may be reduced easily but are
unstable. Prim ary operative treatm ent, however, is only indi­
cated for cosmetic reasons, since persistent dislocation does
not lead to any functional im pairm ent. If indicated, the sternal
end of the clavicle is fixed to the sternum in a modified tension
band technique using resorbable cords, bands, or a free tendon
graft (eg, palm aris longus muscle) in addition to the suturing
of the torn capsular ligam entous structures. Fixation w ith
I<-wires is dangerous because there is a high risk of im plant
m igration even if the ends of the w ires are bent after insertion.
M ost publications report a high incidence of cosmetic im pair­
m ent due to the postoperative scar and up to 50% of patients
suffer from recurrent dislocations [26],
570
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