Dr Pamudji Utomo SpOT (K)

1. WHEN AND HOW TO OPERATE A DISPLACED LATERAL CLAVICLE FRACTURE Dr PamudjiUtomoSpOT (K)

2. Background Epidemiology • Clavicle fractures --> 2.6 % - 12 % of all fractures • Clavicle fractures --> 44 % - 66 % of shoulder fractures • Middle third fractures --> 80 % of all clavicle fractures • Proximal third fractures  5 % • Lateral / distal third  15 % (Koval K, Zuckerman JD. 2010)

3. Topographic Anatomy The clavicle is narrowest in its midportion,  high incidence of fractures in this area. (Lazarus MD, Seon C. 2006)

4. Clavicle Functions The clavicle function as a strut, bracing the shoulder from the trunk and allowing the shoulder to function at optimal strength. The medial one third protect the brachial plexus, the subclavian and axillary vessels, and the superior lung. (Koval K, Zuckerman JD. 2010) (https://online .epocrates.com)

5. Mechanism of Injury • A fall on the shoulder or the outstretched hand • A fall directly on the shoulder (87%) • Secondary to muscle contraction  seizure or stress fracture (rare) (Cole A, pavlou P, Warwick D. 2010) (Jackson J. 2011)

6. Fracture Classification • Neer Classification

7. 15-C: Location: Lateral End 15-C2 : Clavicle, Lateral End, Intra-articular 15-C1: Clavicle, Lateral End, Extra Articular • AO Classification Groups 15-C1.1: Impacted (C-C Ligament Intact) 15-C2.1: With slight displacement (C-C Ligament Intact) Subgroups 15-C1.2 : Noncomminuted (C-C Ligament disrupted) 15-C2.2: Noncomminuted (C-C Ligament disrupted) 15-C1.3 : Comminuted (C-C Ligament disrupted) 15-C2.3: Comminuted (C-C Ligament disrupted) (Ruedi TP, Murphy WM. 2000)

8. Treatment of lateral clavicle fractures • Conservative or Operative • Problem: • Traditionally, nonsurgical management has been favored as the initial treatment. • Recent evidence suggests that specific subsets of patients may be at high risk for nonunion, shoulder dysfunction, or residual pain after nonsurgical management. • (Tiren D, Vroemen JPAM. 2013)

9. Treatment of type I and type III Neer Classification fractures does not appear to be debated • Mostly conservative + physiotherapy • Neer type II: • Wide variety of treatment • Particular deformity + lack of stability • High risk of complications  ORIF (Dugdale D et al. 1990)

10. Treatment Options Nonoperative Sling Brace Surgical Plate Fixation Screw or Pin Fixation K-Wire Suture and sling techniques (Van derMeijden OA, Gaskill TR, Millett PJ. 2011)

11. Surgical treatment indication of lateral-third clavicle fracture: • CC ligament disruption  displacement of the medial clavicle  lead to high risk of nonunion (28%) • Open Fractures or with Soft-tissue compromise • Multiple trauma • ‘‘floating shoulder’’ injuries are present. (Van derMeijden OA, Gaskill TR, Millett PJ. 2011)

12. Surgical Treatment Options Plate and Screw Several plates have been described in the literature including the Balser plate, the Wolter plate, the AO clavicular hook plate Wolter Plate (http://eorif.com) Balser Plate (Bansal M, et al. 2010)

13. Hook Plate • stability of the fracture is preserved without disturbing the biomechanics of the AC joint • Complications: fracture of the plate’s hook, cut-out, enlargement of the hook’s hole in the acromion. (Charity RM, Haidar SG, Ghosh S, Tillu AB. 2007)

14. Locking Plate Madsen et al.  Addition of a suture anchor for coracoclavicular fixation to a superior locking plate improves stability of type IIB distal clavicle fractures. (Madsen, 2013)

15. Screw or Pin Fixation • Coracoclavicular Screw Belmer and Gelber (1991) Coracoclavicular fixation provided and maintained reduction of the fracture. According to their study, healing occurred uneventfully within nine weeks in all cases.  (Fazal MA, Saksena J, Haddad FS.2007)

16. Coracoclavicular Screw and Loop suture (Lazarus MD, Seon C. 2006)

17. Lin HH et al (2013) evaluated effects of a single cortical screw (4.5-mm diameter, 60-mm length)  All patients had good to excellent final Constant-Murley functional results.

18. IM Pin Fixation (Wheeles CR. 2013)

19. Loop Suture Soliman et al: Under-coracoid-around-clavicle (UCAC) loop rigid fixation and lead to bony union, provides adequate stability with excellent results. (Soliman O, et al. 2013)

20. Keith M. Baumgarten (2008) presented an arthroscopic fixation of type II-variant, unstable distal clavicle fracture. Figure 2: Arthroscopic view through the anterolateral portal showing the base of the coracoid with the inferior button of the TightRope device deployed. Figure 3: AP radiograph 6 months postoperatively, revealing osseous union of the distal clavicle. Figure 4: Symmetric anatomic appearance of the right acromioclavicular joint and distal clavicle 6 months postoperatively (Baumgarten KM. 2008)

21. K-wire and Tension Band Wiring (Wu K et al. 2013)

22. K-wire by closed technique

23. Comparison Study Bishop JY et al  No significant difference in ultimate load to failure was found in a biomechanic comparison study among 4 groups : suture fixation with a cerclage suture and coracoclavicular suture, distal clavicle locking plate, distal clavicle locking plates with suture augmentation, and distal clavicle hook plate. (Bishop JY. et al, 2013)

24. Comparison Study Karl Wu et al  hook plate fixation of unstable lateral clavicle fractures was associated with statistically better shoulder function and earlier implant removal than K-wire tension band fixation. (Wu K et al. 2013)

25. Comparison Study • Sylvia et al. reported a meta analysis of Surgical treatment of Neer type-II fractures of the distal clavicle (21 studies, 350 patients). Functional outcome was similar between the treatment modalities (plate, suture, and pin). (Stegeman SA et al. 2013)

26. Conclusion • Lateral clavicle fracture can be treated conservatively or operatively. • Many surgical techniques has been proposed for lateral clavicle fracture.  Specific treatment should be individualized based on fracture characteristics and patient expectations

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