Acta Orthop. 2012 Feb ;83 (1):65-73 22248169
Department of Orthopaedics and Traumatology, Helsinki University Central Hospital, Finland. email@example.com
BACKGROUND AND PURPOSE Traditionally, clavicle fractures have been treated nonoperatively. However, many recent studies have concentrated on the results of operative treatment. We assessed and compared the outcomes of operative and nonoperative treatment for acute clavicle fractures in adults. METHODS We performed a systematic search of the medical literature from 1966 until the end of March 2011. We included randomized controlled trials and controlled clinical trials comparing operative and nonoperative treatment and studies comparing different operative and nonoperative treatments. We required that there should be at least 30 adult patients and a follow-up of at least 6 months in each individual trial. We used the GRADE method to assess the quality of evidence. RESULTS 6 randomized controlled trials (n = 631) and 7 controlled clinical trials (n = 559) were included. There was moderate-quality evidence (i.e. of grade B)(1) that surgery has considerable effectiveness on better function and less disability at short follow-up,(2) of similar risk of relatively mild complications after operative or nonoperative treatment,(3) that delayed union and nonunion were more common in patients who were treated nonoperatively than in those treated operatively, and (4) that the osteosynthesis method had no effect on the incidence of delayed union or nonunion. Only 1 controlled clinical trial was found on lateral clavicle fractures with very limited (grade D) evidence. INTERPRETATION Patients treated operatively have slightly better function and less disability than those treated nonoperatively at short follow-up, but then the effectiveness diminishes and is weak at 6 months. The different operative techniques may not differ in effectiveness or in adverse effects, but the evidence is very limited or conflicting. Surgery could be considered for active patients who require recovery to the previous level of activity in the shortest possible time.
Steadman Philippon Research Institute, Vail, CO 81657, USA. firstname.lastname@example.org
Clavicle fractures are common in adults and children. Most commonly, these fractures occur within the middle third of the clavicle and exhibit some degree of displacement. Whereas many midshaft clavicle fractures can be treated nonsurgically, recent evidence suggests that more severe fracture types exhibit higher rates of symptomatic nonunion or malunion. Although the indications for surgical fixation of midshaft clavicle fractures remain controversial, they appear to be broadening. Most fractures of the medial or lateral end of the clavicle can be treated nonsurgically if fracture fragments remain stable. Surgical intervention may be required in cases of neurovascular compromise or significant fracture displacement. In children and adolescents, these injuries mostly consist of physeal separations, which have a large healing potential and can therefore be managed conservatively. Current concepts of clavicle fracture management are discussed including surgical indications, techniques, and results.
Department of Orthopaedic Surgery, University of California, San Francisco, CA, USA.
Clavicle fractures are common, and it is important for primary care physicians to be familiar with basic principles of evaluation and management in order to initiate treatment as well as discuss these injuries with patients and consulting orthopedic surgeons. These injuries are almost always the result of trauma (often a direct blow to the shoulder) and occur most often in the young male population. Evaluation begins with a thorough history and physical examination and typically progresses to plain radiographs identifying the fracture site and pattern. These fractures have been classified by Allman into groups I (mid-shaft), II (lateral), and III (medial); this classification, along with fracture characteristics (eg, displacement and comminution) is used to assist with determining the strategy for management. Although nondisplaced fractures continue to be treated conservatively with a simple sling until the fracture is healed according to radiographs and clinical assessment, various forms of open reduction and internal fixation are now commonly used to treat fractures with little or no cortical contact between fragments. Open reduction and internal fixation has shown superior results compared with conservative management in recent trials of management of displaced fractures. Nonunion and malunion are rare, but may be symptomatic in a subset of patients. These complications may be addressed with open reduction and internal fixation, bone grafting, and osteotomy as needed.
Nottingham Shoulder and Elbow Unit, City Hospital Campus, Nottingham, UK.
J Trauma. 2011 Jul 15;: 21768908
Keisuke Oe, Leander Gaul, Christian Hierholzer, Alexander Woltmann, Masahiko Miwa, Masahiro Kurosaka, Volker Buehren
From the Department of Orthopedic Surgery (K.O., M.M., M.K.), Kobe University Graduate School of Medicine, Kobe, Japan; and Trauma Center Murnau (L.G., C.H., A.W., V.B.), Murnau, Germany.
BACKGROUND:: The periarticular medial clavicle fracture is a rare injury and can be treated conservatively in the majority of cases. However, up to 8% of the patients develop symptomatic nonunion, and fracture dislocation correlates with the number of poor functional results. Operative treatment may be beneficial in these cases. Studies with large series of operated patients are still missing. METHODS:: We investigated 10 patients with operative treatment of periarticular medial clavicle fractures. Preoperative X-ray or computed tomography scan was obtained, and follow-up assessment was performed at determined intervals, including physical examination and X-ray evaluation of bone healing. Finally, functional assessment was carried out from September 2009 to July 2010 using the Disabilities of the Arm, Shoulder and Hand score. RESULTS:: All operated patients had displaced periarticular medial clavicle fractures. A direct surgical approach was performed, and denudation of the bone fragments was avoided. In 8 of 10 cases, we used locking plates, preferentially the T-locking plate. In 6 of 10 patients, three screws were placed in the medial fragment or the sternum. The arm was immobilized in a sling for 2 weeks to 3 weeks, followed by careful passive and increasing active motion exercises. In 9 of 10 operated patients, we observed fracture healing and good functional results. Two patients with paraplegia/tetraplegia were excluded from final assessment but demonstrated fracture healing. In one case, we observed early material loosening caused by misused locking system and wound infection. CONCLUSIONS:: Operative treatment can be considered for periarticular, dislocated medial-end clavicle fractures. Computed tomography scan can be useful for operative planning and is mostly performed in patients with multiple injuries. Locking plates, such as the T-locking plate or the pilon reconstruction plate, are preferred devices. For rigid fixation, at least three locking screws should be placed in the medial bone fragment. The plate can be removed 18 months after osteosynthesis.
J Trauma. 2011 Mar 3;: 21378586
Outcome of Exact Anatomic Repair and Coracoclavicular Cortical Lag Screw in Acute Acromioclavicular Dislocations.
From the Orthopaedic Department, Sohag Faculty of Medicine, Sohag University, Sohag, Egypt.
BACKGROUND:: The optimal surgical approach for acute acromioclavicular (AC) dislocations is still controversial. The purpose of this study is to analyze the outcome of anatomic repair or approximation of intra-articular and extra-articular damage. METHODS:: Fifty-six patients with Rockwood type-III, IV, and V acute AC dislocations followed up for an average of 76.6 months were evaluated. Direct repair of clavicular muscle attachments, AC joint, and repair or approximation of coracoclavicular (CC) ligaments was done. A CC of 4.5-mm cortical lag screw was used to protect the repair for 60 days. At the final follow-up, clinical assessment, radiographic analysis, function according to American Shoulder and Elbow Surgeons score, University of California-Los Angeles (UCLA) Shoulder Scale, Disabilities of Arm, Shoulder and Hand score, and the ability to return to previous work were used for evaluation. RESULTS:: At the time of final follow-up, the mean values of American Shoulder and Elbow Surgeons score, University of California-Los Angeles, and Disabilities of Arm, Shoulder and Hand scores were 91.3 ± 6.1, 31.5 ± 2.3, and 2.8 ± 2.1, respectively. Reduction was maintained in all but two patients, and CC distance was not statistically different from that on the healthy side. Five patients had occasional pain during daily activities and one developed AC osteoarthritis. All patients maintained their previous jobs. CONCLUSIONS:: The anatomic repair of damage in AC dislocations is a reliable treatment although it is not always feasible. Approximating torn ligaments can still produce good results under the rigid CC screw protection.
The Steadman Clinic, Vail, CO.
Acromioclavicular (AC) joint injuries are common in athletic populations and account for 40% to 50% of shoulder injuries in many contact sports, including lacrosse, hockey, rugby and football. The AC joint is stabilized by static and dynamic restraints, including the coracoclavicular (CC) ligaments. Knowledge of these supporting structures is important when identifying injury and directing treatment. Management of AC injuries should be guided by severity of injury, duration of injury and symptoms, and individual patient factors. These help determine how best to guide management, and whether patients should be treated surgically or nonsurgically. Treatment options for AC injuries continue to expand, and include arthroscopic-assisted anatomic reconstruction of the CC ligaments. The purpose of this article is to review the anatomy, diagnostic methods, and treatment options for AC joint injuries. In addition, the authors' preferred reconstruction technique and outcomes are presented.
Mil Med. 2011 Feb ;176 (2):236-9 21366092
Orthopaedic Surgery, Madigan Army Medical Center, 9040A Fitzsimmons Drive, Ft Lewis, WA 98431, USA.
We present a series of distal clavicle fractures in which the coracoclavicular ligaments remain intact to the proximal segment, but the distal aspect of the clavicle is displaced superiorly. The fractures sustained in this series are not described in any of the multiple classification systems currently in use for clavicular fractures. We present a series of 2 active-duty patients who sustained nearly identical distal clavicle fractures during Army combatives training. A 23-year-old male was treated successfully with nonoperative therapy and returned to deployment within 2 months. A 23-year-old female failed nonoperative treatment and was successfully treated with an operative open distal clavicle resection. This rare fracture attributed to a specific mechanism of injury has a potential to be commonly encountered in active-duty patients taking part in mandatory combatives programs.
Cardinal Orthopaedics, Columbus, OH, USA.
Surgical versus conservative interventions for treating acromioclavicular dislocation of the shoulder in adults.
Marcel Jun S Tamaoki, João Carlos Belloti, Mário Lenza, Marcelo Hide Matsumoto, Joao Baptista Gomes Dos Santos, Flávio Faloppa
Department of Orthopaedics and Traumatology, Universidade Federal de São Paulo, Rua Borges Lagoa, 783 - 5th Floor, São Paulo, São Paulo, Brazil, 04038-032.
BACKGROUND: Dislocation of the acromioclavicular joint is one of the most common shoulder problems in general orthopaedic practice. The question of whether surgery should be used remains controversial. OBJECTIVES: To assess the relative effects of surgical versus conservative (non-surgical) interventions for treating acromioclavicular dislocations in adults. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (to February 2009), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2009, Issue 1), MEDLINE (1966 to February 2009), EMBASE (1988 to February 2009), and LILACS (1982 to February 2009), trial registries and reference lists of articles. There were no restrictions based on language or publication status. SELECTION CRITERIA: All randomised and quasi-randomised trials that compared surgical with conservative treatment of acromioclavicular dislocation in adults were included. DATA COLLECTION AND ANALYSIS: All review authors independently performed study selection. Two authors independently assessed the included trials and performed data extraction. MAIN RESULTS: Three trials were included in this review. These involved a total of 174 mainly male participants. Two trials were randomised and one was quasi-randomised. None used validated measures for assessing functional outcome.Fixation of the acromioclavicular joint using coracoclavicular screws, acromioclavicular pins or, usually threaded, wires was compared with supporting the arm in a sling or similar device. There were no significant differences between the two groups in unsatisfactory longer-term (one year) shoulder function based on a composite measure including pain, movement and strength or function (risk ratio 1.49, 95% confidence interval 0.75 to 2.95), nor in treatment failure that generally required an operation (risk ratio 1.72, 95% confidence interval 0.72 to 4.12). However, there were fixation failures in all three trials. Particularly, the trial using wires reported a high incidence of wire breakage (16/39 (41%)). Two trials reported that surgery significantly delayed the return to work. The methods used in the three trials also meant a routine second operation for implant removal was necessary. AUTHORS' CONCLUSIONS: There is insufficient evidence from randomised controlled trials to determine when surgical treatment is indicated for acromioclavicular dislocation in adults in current practice. Sufficiently powered, good quality, well-reported randomised trials of currently-used surgical interventions versus conservative treatment for well-defined injuries are required.
Other papers by authors:
J Sports Med. ;2 (5):295-6 4468349
Kerner-Quarterback Sports Medicine Institute, University of Alabama at Birmingham.
Athletes participating in noncontact sports involving abduction and external rotation of the shoulder (e.g., throwing) may develop occult recurrent subluxation manifested only as pain. The lack of contact trauma preceding symptoms, the failure of the athlete to appreciate the instability, the relative rarity that the lesion has been previously recognized and reported, and the lack of objective evidence of instability often lead to incorrect diagnosis by the physician. We report 30 shoulders in 28 patients with this lesion. Nineteen of these patients had been originally seen by other physicians prior to presenting to us and misdiagnosed. The newly described apical oblique roentgenographic projection revealed Hill-Sach's lesions in 23 of 28 patients in this series. In addition, two of the five patients without Hill-Sach's lesions had bony changes pathognomonic for the Bankart lesion on the apical oblique projection. A total of 25 of the 28 patients had objective roentgenographic evidence of previous anterior subluxation. Eleven of the patients had arthroscopic examinations confirming various pathology consistent with anterior subluxation, including anterior or inferior labral tears, Hill-Sach's lesions, anterior inferior glenoid articular cartilaginous erosion, or Bankart lesions. Two of the twenty-eight patients had pathology in addition to evidence of previous occult subluxation which may have played a role in their symptoms, one having had osteolysis of the distal end of the clavicle and another having subacromical adhesions.
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JAAPA. 2006 Sep ;19 (9):50, 53-4, 56 16999288
Department of Orthopaedics, Berkshire Medical Center, Pittsfield, Mass, USA.
Middlesex & University College Hospitals NHS Trust, London W1N 8AA.
Sports Medicine Fellow, University of Pittsburgh, Center for Sports Medicine, Pittsburgh, Pennsylvania, USA.
Shoulder injuries are common in the athletic population. Injuries can be a result of repetitive overhead use or from direct trauma. Common injury sites include the rotator cuff, glenohumeral joint, acromioclavicular joint, biceps tendon, scapulothoracic articulation, and sternoclavicular joint. The identification, physical exam, and treatment options of these conditions will be discussed.
Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan. email@example.com
BACKGROUND Surgical reconstruction is usually indicated for distal clavicle fractures with coracoclavicular ligament disruption due to a high rate of nonunion and delayed union. We report the outcome of a surgical technique for this type of fracture. METHODS The procedures consist of coracoclavicular reconstruction with a Mersilene tape, repair of torn coracoclavicular ligament, and wire fixation of the fracture fragments. From 1993 through 1998, this technique has been used on 13 patients with distal clavicle fracture and associated coracoclavicular ligament disruption. Eleven patients with at least 18 months of complete postoperative follow-up were included for functional and radiographic evaluation. RESULTS After 18 to 48 months' follow-up, the clinical outcome has been encouraging. Solid union of the fracture could be achieved at 3 months after operation in 10 patients. The remaining one fracture achieved bony union at 6 months. Ten patients could return to the same or a higher level of preinjury activity. Good and excellent results were obtained in 10 patients. CONCLUSION The advantages of this technique include that the disrupted coracoclavicular articulation is rigidly restored and then the fracture site can be easily reduced and fixed with a wire. This technique allows for stable fixation with early mobilization and early return to work and sports.
Department of Orthopedics, Chita Kosei Hospital, Aichi, Japan.
Ipsilateral clavicle fracture, sternoclavicular joint subluxation, and long thoracic nerve injury: an unusual constellation of injuries sustained during wrestling.
Department of Orthopaedic Surgery, University of South Alabama Medical Center, Mobile 36617-2293, USA.
University of Wisconsin Medical School, Madison, USA.
Fractures of the humerus, scapula and clavicle usually result from a direct blow or a fall onto an outstretched hand. Most can be treated by immobilization. Dislocation of the humerus, strain or sprain of the acromioclavicular and sternoclavicular joints, and rotator cuff injury often can be managed conservatively. Recurrence is a problem with humerus dislocation, and surgical management may be indicated if conservative treatment fails. Rotator cuff tears are often hard to diagnose because of muscle atrophy that impairs the patient's ability to perform diagnostic maneuvers. Chronic shoulder problems usually fall into one of several categories, which include impingement syndrome, frozen shoulder and biceps tendonitis. Other causes of chronic shoulder pain are labral injury, osteoarthritis of the glenohumeral or acromioclavicular joint and, rarely, osteolysis of the distal clavicle.
Department of Orthopaedic Surgery, University of Pennsylvania School of Medicine, Philadelphia 19104, USA.
Injuries to the sternoclavicular joint are rare because of its strong ligamentous support. Because of the strong forces involved and the proximity of the joint to the great vessels and other mediastinal structures, however, sternoclavicular injuries can be very serious and potentially life threatening. Sternoclavicular injuries include traumatic sprains and dislocations, atraumatic spontaneous dislocations, and epiphyseal fractures in patients under 25 years of age. Diagnosis is made by history, physical examination, and radiographic studies such as the CT scan. Conservative management consists of benign neglect and closed or percutaneous reduction and immobilization. If the injury is treated acutely, conservative management often produces good long-term results.