J Shoulder Elbow Surg (2014) -, 1-5
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Angular stable fixation of displaced distal-third clavicle fractures with superior precontoured locking plates Mark A. Fleming, FC Orth(SA), MMED*, Robert Dachs, FC Orth(SA), MMED, Sithombo Maqungo, FC Orth(SA), MMED, Jean-Pierre du Plessis, FC Orth(SA), MMED, Basil C. Vrettos, FC Orth(SA), Stephen J.L. Roche, FC Orth(SA) Department of orthopaedic Surgery, University of Cape Town, Groote Schuur Hospital, South Africa Hypothesis: We reviewed the outcome of angular stable plates in addressing displaced lateral-third clavicle fractures. We investigated union, shoulder function, request for implant removal, and return to sport. Our hypothesis was that these implants provide predictable union and return to sports without the negative consequence of leaving plates in situ, reducing the requirement for a second surgery. Methods: We undertook a retrospective review of a consecutive series of patients who underwent this surgery between 2007 and 2010. Nineteen patients with a mean follow-up of 25 months were included. Postoperative follow-up was performed at 2 weeks and monthly thereafter until union was assessed as achieved clinically and radiographically. Two telephone interviews at a mean of 7 months and 25 months postoperatively assessed shoulder function by Oxford Shoulder Score, presence of any plate or scar discomfort, need for implant removal, and return to sport. Results: Nineteen patients achieved union by 4 months (median, 12 weeks; range, 6-16 weeks). The mean Oxford Shoulder Score was 46 (range, 41-48) at a mean of 7 months (range, 3-18 months) and 47 (range, 44-48) at 25 months (range, 18-48 months). Initially, 2 patients requested implant removal; later, however, both declined surgery. No plates have been removed. Four patients complained of mild plate discomfort but did not wish removal. All patients had returned to sporting activities. Conclusion: Angular stable plate fixation of Neer group II, type II clavicle fractures resulted in a 100% union rate with excellent return of function with no mandatory need for removal. Level of evidence: Level IV, Case Series, Treatment Study. Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Lateral clavicle; unstable; fracture; nonunion; locked plate; angular stable fixation; hook plate
The University of Cape Town, Departmental Research Committee, approved this study: Project 2011/040. *Reprint requests: Mark A. Fleming, FC Orth(SA), MMED, H49 OMB, Groote Schuur Hospital, Main Road, Observatory, Cape Town, South Africa 7935. E-mail address: [email protected] (M.A. Fleming).
Distal-third clavicle fractures account for approximately 12% to 15% of all clavicle fractures.4 These typically result from a direct blow to the shoulder. This type of injury is commonplace in sports associated with falling, such as cycling, skiing, and contact sports. Patients involved in these activities are typically young and employed and desire an early return to work and training routines.
1058-2746/$ - see front matter Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2014.09.024
2
M.A. Fleming et al.
Neer classified clavicle fractures into three parts.16 Group II fractures occur in the distal third of the clavicle. These fractures are further divided into type II when there is no residual ligamentous attachments to the medial fragment. These group II, type II injuries are further subdivided into 2 classes: those in which both the conoid and trapezoid ligaments are attached to the distal fragment, and those in which the conoid ligament is ruptured. Type II injury patterns are inherently unstable. Because of the instability created by the unhindered downward pull of the shoulder girdle on the distal fragment and the unimpeded superior pull on the medial fragment by the trapezius muscle, these fractures have a 20% to 44% risk of nonunion.6,14,16 Nowak et al18 have shown the high incidence of symptomatic nonunion when nonoperative management fails. This contradicts other authors who believe that nonunions are often asymptomatic.17,20 Prolonged immobilization is associated with persistent shoulder dysfunction,14 whereas acute stable surgical fixation facilitates early mobilization.14 Significant pain relief due to this stability has been shown to be provided within 12 hours of clavicle fixation.1 Various surgical techniques have been described, including K-wires, threaded pin fixation, tension band wiring, and hook plate fixation. Each fixation technique has its own associated complications, which include wire migration, acromioclavicular joint arthrosis, subacromial impingement/ erosion, and peri-implant fracture.3,8,15,19 Some of these fixation devices require a second surgery for implant removal after union has been achieved. Several authors believe that it is better to manage these cases nonoperatively to avoid the risks of these complications.5,10,12,17,20,21 Precontoured low-profile distal-third locking plates have made angular stable fixation possible. A major advantage over fixation techniques is that neither the acromioclavicular joint nor the subacromial space is violated, thus providing no indication for implant removal.11 The purpose of this study was to determine postoperative shoulder function, union rates, and the need for implant removal.
hold the distal comminuted fragments together and the use of a marker needle (Fig. 2) placed in the acromioclavicular joint and confirmed with a single fluoroscopic anteroposterior view to prevent inadvertent screw penetration during screw insertion, our principle being that placing the needle in the joint gives one a visual clue as to the lateral extent of plate positioning, thereby saving time and exposure to radiation by avoiding constant checking with fluoroscopy. Intraoperative fluoroscopy was used to confirm appropriate screw placement, aiming to achieve bicortical fixation and fracture reduction. The image intensifier is positioned obliquely from the opposite side of the patient so that it may be rotated to give anteroposterior as well as 30 upshot views (Fig. 3). A shoulder immobilizer was used after surgery for the first 2 to 4 weeks (depending on the surgeon’s impression of strength of fixation). A retrospective review of radiographs and clinical notes was performed to assess time to radiographic union and to note any early complications (Fig. 4). A telephone questionnaire was performed at a mean of 7 months postoperatively (range, 3-18 months). This included an Oxford Shoulder Score (OSS) and further questions including presence of plate and skin discomfort, any desire for hardware removal, and whether there had been return to the preinjury level of sport participation (Table I). The same telephone interview was repeated at a mean of 25 months postoperatively (range, 18-48 months).
Materials and methods
Results
Nineteen consecutive patients who were operated on from 2007 until 2010 were included. Seven surgeons (6 authors and 1 trainee) from the same academic department performed the surgeries. All had displaced group II, type II clavicle fractures (Fig. 1). Surgical fixation with superior distal-third precontoured locking plates was employed in all patients irrespective of degree of comminution of the distal extent. These were Acumed (Hillsboro, OR, USA) or Synthes (Solothurn, Switzerland) plates. In our earlier cases, we used Acumed plates; later, Synthes plates were favored because they are made from stainless steel and have more lateral screw positions. Surgical technique has been described adequately by Lee et al13 with the beach chair position. Our only modification of this technique is the use of a cerclage suture to
The cohort consisted of 19 patients; 17 patients were men. Average age was 44 years (range, 29-55 years). All 19 patients were followed up until union. All patients had radiographic union within 16 weeks (median, 12 weeks; range, 6-16 weeks) after surgery. There were no early complications. One screw was noted to penetrate the acromioclavicular joint but was asymptomatic (Fig. 5). At initial telephone interview at a mean of 7 months postoperatively (range, 3-18 months), 15 respondents were included; 4 patients were unobtainable. The OSS (mean, 46; range, 41-48) revealed satisfactory shoulder function. Two patients (13%) experienced plate discomfort and
Figure 1 The 30 upshot (A) and anteroposterior (B) radiographs of a group II, type II displaced clavicle.
Locked plating of lateral-third clavicle fractures
3
Figure 2 (A and B) Operative photographs showing a 16-gauge needle placed in the acromioclavicular joint as a marker before application of the superior plate to prevent inadvertent violation with lateral screws.
Figure 3 Intraoperative imaging including a 30 upshot (A) and an anteroposterior view (B). These demonstrate an unviolated acromioclavicular joint, satisfactory reduction, and inclusion of the inferior bone fragment (attached to the trapezoid ligament) in the construct.
Table I
Figure 4
Radiograph showing fully united fracture.
would consider plate removal when the treating physician agreed that sufficient healing had taken place. Three patients (20%) considered themselves not back to their normal participation in sporting activities. A second telephone interview was performed at a mean of 25 months (range, 18-41 months); 12 respondents were included, and 7 patients were not available. The OSS revealed satisfactory shoulder function with a mean score of 47 (range, 44-48). Four patients (30%) described mild discomfort when carrying heavy backpacks. Of these 4 patients, 1 patient (8%) experienced ongoing mild scar discomfort, and 1 patient (8%) wished to have the plate removed; interestingly, this was despite having previously chosen not to have this done. Two patients (17%) stated that
Topics covered during telephone interviews
Telephone interview questions
Outcome
Oxford Shoulder Score (shoulder function) Does the plate cause discomfort? Does the scar cause discomfort? Do you want your plate removed? Have you returned to your sports?
Satisfactory, mild, moderate, severe Yes/no Yes/no Yes/no Yes/no
their overhead function was not back to normal, reducing their OSS by 2 points each; however, the OSS was still within satisfactory range. One of these patients had a concurrent rotator cuff tear diagnosed 4 months after injury with ultrasonography. The other had prolonged rehabilitation because of an undisplaced greater tuberosity fracture diagnosed on magnetic resonance imaging at 3 months. Both of these patients were managed nonsurgically. They both had delayed recovery compared with the group and despite having good long-term OSS scores (44 and 46, respectively) subjectively reported that they had not returned to normal sporting participation.
Discussion Union rates in displaced Neer group II, type II fractures are lower than in other clavicle fractures, carrying a 20% to 44% risk of nonunion.6,7,14 The significance of these nonunions has been greatly debated in the past. Nordqvist
4
Figure 5 Radiograph showing a single case with a screw in the acromioclavicular joint.
et al17 supported nonsurgical management, stating that these nonunions are well tolerated in their 15-year followup study. However, looking a little closer at their data, 26% of their 23 displaced group II, type II injuries were still symptomatic. Nowak et al18 showed that 100% of nonunions were symptomatic at 6 months. This has been our view; to counter this, we perform acute surgery. This economically active patient cohort benefits from an early return to both work and physical pursuits, with the high risk of morbidity associated with nonunion offset by the lowrisk profile associated with this type of surgery. Jupiter14 has shown that prolonged immobilization leads to muscle wasting and resultant scapulothoracic dyskinesia. Restoration of these kinetics takes extensive physiotherapy and biokinetic training, which is expensive and timeconsuming. Acute surgery with stable fixation possibly allows the patient to maintain conditioning, important in the sporting individuals. Surgical complications are specific to each method of fixation.2,9,14 The angular stable precontoured lateral locked plate design avoids the acromioclavicular joint and subacromial space, preventing arthrosis and subacromial impingement, respectively. We have never abandoned the use of this plating principle in favor of a hook plate. We have found that irrespective of degree of comminution, the use of a cerclage suture holding the comminuted bone together combined with the use of small angular stable diverging screws has provided satisfactory bone purchase, similar to the roots of a tree preventing soil erosion. Our standard imaging is with anteroposterior and 30 upshot radiographs. All of the patients in this study are young with good bone density, not requiring further imaging. Angular stable fixation with multiple diverging lateral screws provides improved pullout strength, providing reliable stable fixation that facilitates early shoulder movement. We think that because the acromioclavicular joint is not bridged, natural rotation of the clavicle is maintained, reducing risk of implant-associated failure noted with the use of hook plates. One patient in whom there appeared to be one screw penetrating the acromioclavicular joint space on a
M.A. Fleming et al. postoperative radiograph was managed expectantly; the joint never became painful, so the plate was left in situ. The technique described with a needle as a visual marker of the acromioclavicular joint is particularly helpful to prevent inadvertent screw penetration. Second surgery is required in other techniques, such as pins, wiring, hook plates, and Bosworth screws. This is usually performed at 3 months, once bone union has been confirmed. Complications associated with these techniques may lead to early removal of the implant, thus compromising union rates as described in case reports.10 The use of a permanently implanted low-profile locking plate addresses this problem. Neither of the 2 patients wishing for plate removal at 3 months returned for removal after 6 months. Only 1 patient requested implant removal at long-term follow-up. Plate prominence may be noticeable in thin individuals; mild plate discomfort was noted by 4 patients while carrying heavy backpacks. None of these individuals was sufficiently symptomatic to request a second surgery. Shoulder conditioning therapy may be maintained while waiting for union to take place, enabling the athlete to return to sports sooner than with other fixation methods that require prolonged immobilization. Our shoulder rehabilitation is based on maintaining range and rotator cuff strength. For the first 2 weeks after surgery, the patient is advised to wear a shoulder immobilizer taken off to facilitate elbow extension and shoulder pendular exercises. After this time, the shoulder immobilizer is worn only in public places, used mainly as a means to stop the patient from carrying heavy items in that hand. We permit open chain strengthening by 6 weeks, noncontact sports by 8 weeks, and contact sports after radiographic union. All patients should routinely be advised of the risk of plate discomfort during the early postoperative phase and the possible need for removal. Longer term follow-up of these patients reveals that there have been no complications associated with other techniques, such as hook plates and pins. There are limitations to this retrospective case series. Despite all patients being followed up to union, the questionnaire was performed on only 15 patients at 7 months and 12 patients at 25 months because of contact details having changed. Our telephone questionnaire assesses only subjective patient reporting of return to sporting level; this is likely to be biased. There was no control group for this cohort, so comparative observations are difficult to make.
Conclusion In this small series, there was a 100% union rate for group II, type II fractures treated with angular stable superior plates. Only 1 patient requested removal of hardware at medium- to long-term follow-up. All patients returned to preinjury sporting activity participation (mean, 4 months), with the exception of 2 patients who
Locked plating of lateral-third clavicle fractures had delayed recovery because of a concurrent rotator cuff tear and tuberosity fracture. There were no complications. Mandatory second surgery is avoided in this technique, reducing cost and recovery time.
Disclaimer The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
References 1. Ali Khan MA, Lucas HK. Plating of fractures of the middle third of the clavicle. Injury 1977;9:263-7. 2. Ballmer F, Gerber C. Coracoclavicular screw fixation for unstable fractures of the distal clavicle. A report of five cases. J Bone Joint Surg Br 1991;73:291-4. 3. Charity RM, Haidar SG, Ghosh S, Tillu AB. Fixation failure of the clavicular hook plate: a report of three cases. J Orthop Surg 2006;14: 333-5. 4. Craig EV. Fractures of the clavicle. In: Rockwood CA Jr, Matsen FA III, editors. The shoulder. Philadelphia: Saunders; 1990. p. 367-401. 5. Deafenbaugh MK, Dugdale TW, Staeheli JW, Nielsen R. Nonoperative treatment of Neer type II distal clavicle fractures: a prospective study. Contemp Orthop 1990;4:405. 6. Edwards DJ, Kavanagh TG, Flannery MC. Fractures of the distal clavicle: a case for fixation. Injury 1992;23:44-6. 7. Fann CY, Chiu FY, Chuang TY, Chen CM, Chen TH. Transacromial Knowles pin in the treatment of Neer type 2 distal clavicle fractures: a prospective evaluation of 32 cases. J Trauma 2004;56:1102-5. http:// dx.doi.org/10.1097/01.TA.0000082649.57981.F9
5 8. Flinkkil€a T, Ristiniemi J, Lakovaara M, Hyv€onen P, Leppilahti J. Hook-plate fixation of unstable lateral clavicle fractures: a report on 63 patients. Acta Orthop 2006;77:644-9. http://dx.doi.org/10.1080/ 17453670610012737 9. Kashii M, Inui H, Yamamoto K. Surgical treatment of distal clavicle fractures using the clavicular hook plate. Clin Orthop Relat Res 2006; 447:158-64. 10. Khan LA, Bradnock TJ, Scott C, Robinson CM. Fractures of the clavicle. J Bone Joint Surg Am 2009;91:447-60. http://dx.doi.org/10. 2106/JBJS.H.00034 11. Klein SM, Badman BL, Keating CJ, Devinney DS, Frankle MA, Mighell MA. Results of surgical treatment for unstable distal clavicular fractures. J Shoulder Elbow Surg 2010;19:1049-55. http://dx.doi. org/10.1016/j.jse.2009.11.056 12. Kona LT, Bosse MJ, Staeheli JW, Rosseau RL. Type II distal clavicle fractures: a retrospective review of surgical treatment. J Orthop Trauma 1990;4:115-20. 13. Lee SK, Lee JW, Song DG, Choy WS. Precontoured locking plate fixation for displaced lateral clavicle fractures. Orthopedics 2013;36: 801-7. http://dx.doi.org/10.3928/01477447-20130523-28 14. Leffert R, Jupiter JB. Non-union of the clavicle. Associated complications and surgical management. J Bone Joint Surg Am 1987;69: 753-60. 15. Liberski J, Ficek K. Kirschner wire migration from the clavicle to the cervical spine. Int J Case Reports Images 2013;4:4-7. http://dx.doi.org/ 10.5348/ijcri-2013-06-319-CR-4 16. Neer CS 2nd. Fractures of the distal third of the clavicle. Clin Orthop Relat Res 1968;58:43-50. 17. Nordqvist A, Petersson C, Redlund-Johnell I. The natural course of lateral clavicle fracture. 15 (11-21) year follow-up of 110 cases. Acta Orthop Scand 1993;64:87-91. 18. Nowak J, Holgersson M, Larsson S. Sequelae from clavicular fractures are common: a prospective study of 222 patients. Acta Orthop 2005; 76:496-502. http://dx.doi.org/10.1080/17453670510041475 19. Ransen PF, Ourgeois SB, Ommens JR. Kirschner wire migration causing spinal cord injury one year after internal fixation of clavicle fracture. Acta Orthop Belg 2007;73:390-2. 20. Robinson CM, Cairns DA. Primary nonoperative treatment of displaced lateral fractures of the clavicle. J Bone Joint Surg Am 2004;86: 778-82. 21. Rokito AS, Zuckerman JD, Shaari JM, Eisenberg DP, Cuomo F, Gallagher MA. A comparison of nonoperative and operative treatment of type II distal clavicle fractures. Bull Hosp Jt Dis 2002;61:2-32.
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Angular stable fixation of displaced distal-third clavicle fractures with superior precontoured locking plates Mark A. Fleming, FC Orth(SA), MMED*, Robert Dachs, FC Orth(SA), MMED, Sithombo Maqungo, FC Orth(SA), MMED, Jean-Pierre du Plessis, FC Orth(SA), MMED, Basil C. Vrettos, FC Orth(SA), Stephen J.L. Roche, FC Orth(SA) Department of orthopaedic Surgery, University of Cape Town, Groote Schuur Hospital, South Africa Hypothesis: We reviewed the outcome of angular stable plates in addressing displaced lateral-third clavicle fractures. We investigated union, shoulder function, request for implant removal, and return to sport. Our hypothesis was that these implants provide predictable union and return to sports without the negative consequence of leaving plates in situ, reducing the requirement for a second surgery. Methods: We undertook a retrospective review of a consecutive series of patients who underwent this surgery between 2007 and 2010. Nineteen patients with a mean follow-up of 25 months were included. Postoperative follow-up was performed at 2 weeks and monthly thereafter until union was assessed as achieved clinically and radiographically. Two telephone interviews at a mean of 7 months and 25 months postoperatively assessed shoulder function by Oxford Shoulder Score, presence of any plate or scar discomfort, need for implant removal, and return to sport. Results: Nineteen patients achieved union by 4 months (median, 12 weeks; range, 6-16 weeks). The mean Oxford Shoulder Score was 46 (range, 41-48) at a mean of 7 months (range, 3-18 months) and 47 (range, 44-48) at 25 months (range, 18-48 months). Initially, 2 patients requested implant removal; later, however, both declined surgery. No plates have been removed. Four patients complained of mild plate discomfort but did not wish removal. All patients had returned to sporting activities. Conclusion: Angular stable plate fixation of Neer group II, type II clavicle fractures resulted in a 100% union rate with excellent return of function with no mandatory need for removal. Level of evidence: Level IV, Case Series, Treatment Study. Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Lateral clavicle; unstable; fracture; nonunion; locked plate; angular stable fixation; hook plate
The University of Cape Town, Departmental Research Committee, approved this study: Project 2011/040. *Reprint requests: Mark A. Fleming, FC Orth(SA), MMED, H49 OMB, Groote Schuur Hospital, Main Road, Observatory, Cape Town, South Africa 7935. E-mail address: [email protected] (M.A. Fleming).
Distal-third clavicle fractures account for approximately 12% to 15% of all clavicle fractures.4 These typically result from a direct blow to the shoulder. This type of injury is commonplace in sports associated with falling, such as cycling, skiing, and contact sports. Patients involved in these activities are typically young and employed and desire an early return to work and training routines.
1058-2746/$ - see front matter Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2014.09.024
2
M.A. Fleming et al.
Neer classified clavicle fractures into three parts.16 Group II fractures occur in the distal third of the clavicle. These fractures are further divided into type II when there is no residual ligamentous attachments to the medial fragment. These group II, type II injuries are further subdivided into 2 classes: those in which both the conoid and trapezoid ligaments are attached to the distal fragment, and those in which the conoid ligament is ruptured. Type II injury patterns are inherently unstable. Because of the instability created by the unhindered downward pull of the shoulder girdle on the distal fragment and the unimpeded superior pull on the medial fragment by the trapezius muscle, these fractures have a 20% to 44% risk of nonunion.6,14,16 Nowak et al18 have shown the high incidence of symptomatic nonunion when nonoperative management fails. This contradicts other authors who believe that nonunions are often asymptomatic.17,20 Prolonged immobilization is associated with persistent shoulder dysfunction,14 whereas acute stable surgical fixation facilitates early mobilization.14 Significant pain relief due to this stability has been shown to be provided within 12 hours of clavicle fixation.1 Various surgical techniques have been described, including K-wires, threaded pin fixation, tension band wiring, and hook plate fixation. Each fixation technique has its own associated complications, which include wire migration, acromioclavicular joint arthrosis, subacromial impingement/ erosion, and peri-implant fracture.3,8,15,19 Some of these fixation devices require a second surgery for implant removal after union has been achieved. Several authors believe that it is better to manage these cases nonoperatively to avoid the risks of these complications.5,10,12,17,20,21 Precontoured low-profile distal-third locking plates have made angular stable fixation possible. A major advantage over fixation techniques is that neither the acromioclavicular joint nor the subacromial space is violated, thus providing no indication for implant removal.11 The purpose of this study was to determine postoperative shoulder function, union rates, and the need for implant removal.
hold the distal comminuted fragments together and the use of a marker needle (Fig. 2) placed in the acromioclavicular joint and confirmed with a single fluoroscopic anteroposterior view to prevent inadvertent screw penetration during screw insertion, our principle being that placing the needle in the joint gives one a visual clue as to the lateral extent of plate positioning, thereby saving time and exposure to radiation by avoiding constant checking with fluoroscopy. Intraoperative fluoroscopy was used to confirm appropriate screw placement, aiming to achieve bicortical fixation and fracture reduction. The image intensifier is positioned obliquely from the opposite side of the patient so that it may be rotated to give anteroposterior as well as 30 upshot views (Fig. 3). A shoulder immobilizer was used after surgery for the first 2 to 4 weeks (depending on the surgeon’s impression of strength of fixation). A retrospective review of radiographs and clinical notes was performed to assess time to radiographic union and to note any early complications (Fig. 4). A telephone questionnaire was performed at a mean of 7 months postoperatively (range, 3-18 months). This included an Oxford Shoulder Score (OSS) and further questions including presence of plate and skin discomfort, any desire for hardware removal, and whether there had been return to the preinjury level of sport participation (Table I). The same telephone interview was repeated at a mean of 25 months postoperatively (range, 18-48 months).
Materials and methods
Results
Nineteen consecutive patients who were operated on from 2007 until 2010 were included. Seven surgeons (6 authors and 1 trainee) from the same academic department performed the surgeries. All had displaced group II, type II clavicle fractures (Fig. 1). Surgical fixation with superior distal-third precontoured locking plates was employed in all patients irrespective of degree of comminution of the distal extent. These were Acumed (Hillsboro, OR, USA) or Synthes (Solothurn, Switzerland) plates. In our earlier cases, we used Acumed plates; later, Synthes plates were favored because they are made from stainless steel and have more lateral screw positions. Surgical technique has been described adequately by Lee et al13 with the beach chair position. Our only modification of this technique is the use of a cerclage suture to
The cohort consisted of 19 patients; 17 patients were men. Average age was 44 years (range, 29-55 years). All 19 patients were followed up until union. All patients had radiographic union within 16 weeks (median, 12 weeks; range, 6-16 weeks) after surgery. There were no early complications. One screw was noted to penetrate the acromioclavicular joint but was asymptomatic (Fig. 5). At initial telephone interview at a mean of 7 months postoperatively (range, 3-18 months), 15 respondents were included; 4 patients were unobtainable. The OSS (mean, 46; range, 41-48) revealed satisfactory shoulder function. Two patients (13%) experienced plate discomfort and
Figure 1 The 30 upshot (A) and anteroposterior (B) radiographs of a group II, type II displaced clavicle.
Locked plating of lateral-third clavicle fractures
3
Figure 2 (A and B) Operative photographs showing a 16-gauge needle placed in the acromioclavicular joint as a marker before application of the superior plate to prevent inadvertent violation with lateral screws.
Figure 3 Intraoperative imaging including a 30 upshot (A) and an anteroposterior view (B). These demonstrate an unviolated acromioclavicular joint, satisfactory reduction, and inclusion of the inferior bone fragment (attached to the trapezoid ligament) in the construct.
Table I
Figure 4
Radiograph showing fully united fracture.
would consider plate removal when the treating physician agreed that sufficient healing had taken place. Three patients (20%) considered themselves not back to their normal participation in sporting activities. A second telephone interview was performed at a mean of 25 months (range, 18-41 months); 12 respondents were included, and 7 patients were not available. The OSS revealed satisfactory shoulder function with a mean score of 47 (range, 44-48). Four patients (30%) described mild discomfort when carrying heavy backpacks. Of these 4 patients, 1 patient (8%) experienced ongoing mild scar discomfort, and 1 patient (8%) wished to have the plate removed; interestingly, this was despite having previously chosen not to have this done. Two patients (17%) stated that
Topics covered during telephone interviews
Telephone interview questions
Outcome
Oxford Shoulder Score (shoulder function) Does the plate cause discomfort? Does the scar cause discomfort? Do you want your plate removed? Have you returned to your sports?
Satisfactory, mild, moderate, severe Yes/no Yes/no Yes/no Yes/no
their overhead function was not back to normal, reducing their OSS by 2 points each; however, the OSS was still within satisfactory range. One of these patients had a concurrent rotator cuff tear diagnosed 4 months after injury with ultrasonography. The other had prolonged rehabilitation because of an undisplaced greater tuberosity fracture diagnosed on magnetic resonance imaging at 3 months. Both of these patients were managed nonsurgically. They both had delayed recovery compared with the group and despite having good long-term OSS scores (44 and 46, respectively) subjectively reported that they had not returned to normal sporting participation.
Discussion Union rates in displaced Neer group II, type II fractures are lower than in other clavicle fractures, carrying a 20% to 44% risk of nonunion.6,7,14 The significance of these nonunions has been greatly debated in the past. Nordqvist
4
Figure 5 Radiograph showing a single case with a screw in the acromioclavicular joint.
et al17 supported nonsurgical management, stating that these nonunions are well tolerated in their 15-year followup study. However, looking a little closer at their data, 26% of their 23 displaced group II, type II injuries were still symptomatic. Nowak et al18 showed that 100% of nonunions were symptomatic at 6 months. This has been our view; to counter this, we perform acute surgery. This economically active patient cohort benefits from an early return to both work and physical pursuits, with the high risk of morbidity associated with nonunion offset by the lowrisk profile associated with this type of surgery. Jupiter14 has shown that prolonged immobilization leads to muscle wasting and resultant scapulothoracic dyskinesia. Restoration of these kinetics takes extensive physiotherapy and biokinetic training, which is expensive and timeconsuming. Acute surgery with stable fixation possibly allows the patient to maintain conditioning, important in the sporting individuals. Surgical complications are specific to each method of fixation.2,9,14 The angular stable precontoured lateral locked plate design avoids the acromioclavicular joint and subacromial space, preventing arthrosis and subacromial impingement, respectively. We have never abandoned the use of this plating principle in favor of a hook plate. We have found that irrespective of degree of comminution, the use of a cerclage suture holding the comminuted bone together combined with the use of small angular stable diverging screws has provided satisfactory bone purchase, similar to the roots of a tree preventing soil erosion. Our standard imaging is with anteroposterior and 30 upshot radiographs. All of the patients in this study are young with good bone density, not requiring further imaging. Angular stable fixation with multiple diverging lateral screws provides improved pullout strength, providing reliable stable fixation that facilitates early shoulder movement. We think that because the acromioclavicular joint is not bridged, natural rotation of the clavicle is maintained, reducing risk of implant-associated failure noted with the use of hook plates. One patient in whom there appeared to be one screw penetrating the acromioclavicular joint space on a
M.A. Fleming et al. postoperative radiograph was managed expectantly; the joint never became painful, so the plate was left in situ. The technique described with a needle as a visual marker of the acromioclavicular joint is particularly helpful to prevent inadvertent screw penetration. Second surgery is required in other techniques, such as pins, wiring, hook plates, and Bosworth screws. This is usually performed at 3 months, once bone union has been confirmed. Complications associated with these techniques may lead to early removal of the implant, thus compromising union rates as described in case reports.10 The use of a permanently implanted low-profile locking plate addresses this problem. Neither of the 2 patients wishing for plate removal at 3 months returned for removal after 6 months. Only 1 patient requested implant removal at long-term follow-up. Plate prominence may be noticeable in thin individuals; mild plate discomfort was noted by 4 patients while carrying heavy backpacks. None of these individuals was sufficiently symptomatic to request a second surgery. Shoulder conditioning therapy may be maintained while waiting for union to take place, enabling the athlete to return to sports sooner than with other fixation methods that require prolonged immobilization. Our shoulder rehabilitation is based on maintaining range and rotator cuff strength. For the first 2 weeks after surgery, the patient is advised to wear a shoulder immobilizer taken off to facilitate elbow extension and shoulder pendular exercises. After this time, the shoulder immobilizer is worn only in public places, used mainly as a means to stop the patient from carrying heavy items in that hand. We permit open chain strengthening by 6 weeks, noncontact sports by 8 weeks, and contact sports after radiographic union. All patients should routinely be advised of the risk of plate discomfort during the early postoperative phase and the possible need for removal. Longer term follow-up of these patients reveals that there have been no complications associated with other techniques, such as hook plates and pins. There are limitations to this retrospective case series. Despite all patients being followed up to union, the questionnaire was performed on only 15 patients at 7 months and 12 patients at 25 months because of contact details having changed. Our telephone questionnaire assesses only subjective patient reporting of return to sporting level; this is likely to be biased. There was no control group for this cohort, so comparative observations are difficult to make.
Conclusion In this small series, there was a 100% union rate for group II, type II fractures treated with angular stable superior plates. Only 1 patient requested removal of hardware at medium- to long-term follow-up. All patients returned to preinjury sporting activity participation (mean, 4 months), with the exception of 2 patients who
Locked plating of lateral-third clavicle fractures had delayed recovery because of a concurrent rotator cuff tear and tuberosity fracture. There were no complications. Mandatory second surgery is avoided in this technique, reducing cost and recovery time.
Disclaimer The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
References 1. Ali Khan MA, Lucas HK. Plating of fractures of the middle third of the clavicle. Injury 1977;9:263-7. 2. Ballmer F, Gerber C. Coracoclavicular screw fixation for unstable fractures of the distal clavicle. A report of five cases. J Bone Joint Surg Br 1991;73:291-4. 3. Charity RM, Haidar SG, Ghosh S, Tillu AB. Fixation failure of the clavicular hook plate: a report of three cases. J Orthop Surg 2006;14: 333-5. 4. Craig EV. Fractures of the clavicle. In: Rockwood CA Jr, Matsen FA III, editors. The shoulder. Philadelphia: Saunders; 1990. p. 367-401. 5. Deafenbaugh MK, Dugdale TW, Staeheli JW, Nielsen R. Nonoperative treatment of Neer type II distal clavicle fractures: a prospective study. Contemp Orthop 1990;4:405. 6. Edwards DJ, Kavanagh TG, Flannery MC. Fractures of the distal clavicle: a case for fixation. Injury 1992;23:44-6. 7. Fann CY, Chiu FY, Chuang TY, Chen CM, Chen TH. Transacromial Knowles pin in the treatment of Neer type 2 distal clavicle fractures: a prospective evaluation of 32 cases. J Trauma 2004;56:1102-5. http:// dx.doi.org/10.1097/01.TA.0000082649.57981.F9
5 8. Flinkkil€a T, Ristiniemi J, Lakovaara M, Hyv€onen P, Leppilahti J. Hook-plate fixation of unstable lateral clavicle fractures: a report on 63 patients. Acta Orthop 2006;77:644-9. http://dx.doi.org/10.1080/ 17453670610012737 9. Kashii M, Inui H, Yamamoto K. Surgical treatment of distal clavicle fractures using the clavicular hook plate. Clin Orthop Relat Res 2006; 447:158-64. 10. Khan LA, Bradnock TJ, Scott C, Robinson CM. Fractures of the clavicle. J Bone Joint Surg Am 2009;91:447-60. http://dx.doi.org/10. 2106/JBJS.H.00034 11. Klein SM, Badman BL, Keating CJ, Devinney DS, Frankle MA, Mighell MA. Results of surgical treatment for unstable distal clavicular fractures. J Shoulder Elbow Surg 2010;19:1049-55. http://dx.doi. org/10.1016/j.jse.2009.11.056 12. Kona LT, Bosse MJ, Staeheli JW, Rosseau RL. Type II distal clavicle fractures: a retrospective review of surgical treatment. J Orthop Trauma 1990;4:115-20. 13. Lee SK, Lee JW, Song DG, Choy WS. Precontoured locking plate fixation for displaced lateral clavicle fractures. Orthopedics 2013;36: 801-7. http://dx.doi.org/10.3928/01477447-20130523-28 14. Leffert R, Jupiter JB. Non-union of the clavicle. Associated complications and surgical management. J Bone Joint Surg Am 1987;69: 753-60. 15. Liberski J, Ficek K. Kirschner wire migration from the clavicle to the cervical spine. Int J Case Reports Images 2013;4:4-7. http://dx.doi.org/ 10.5348/ijcri-2013-06-319-CR-4 16. Neer CS 2nd. Fractures of the distal third of the clavicle. Clin Orthop Relat Res 1968;58:43-50. 17. Nordqvist A, Petersson C, Redlund-Johnell I. The natural course of lateral clavicle fracture. 15 (11-21) year follow-up of 110 cases. Acta Orthop Scand 1993;64:87-91. 18. Nowak J, Holgersson M, Larsson S. Sequelae from clavicular fractures are common: a prospective study of 222 patients. Acta Orthop 2005; 76:496-502. http://dx.doi.org/10.1080/17453670510041475 19. Ransen PF, Ourgeois SB, Ommens JR. Kirschner wire migration causing spinal cord injury one year after internal fixation of clavicle fracture. Acta Orthop Belg 2007;73:390-2. 20. Robinson CM, Cairns DA. Primary nonoperative treatment of displaced lateral fractures of the clavicle. J Bone Joint Surg Am 2004;86: 778-82. 21. Rokito AS, Zuckerman JD, Shaari JM, Eisenberg DP, Cuomo F, Gallagher MA. A comparison of nonoperative and operative treatment of type II distal clavicle fractures. Bull Hosp Jt Dis 2002;61:2-32.
