|Year : 2013 | Volume
| Issue : 1 | Page : 15-17
Open reduction and internal fixation of distal clavicle fractures
Ajit Swamy1, Amit Swamy2
1 Department of Orthopedics, Prof D. Y. Patil Medical College, Pune, Maharashtra, India
2 Department of Orthopedics, Talegaon Medical College, Pimpri, Pune, Maharashtra, India
|Date of Web Publication||13-Mar-2013|
D. Y. Patil Medical College, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Objective: Clavicle fractures have been treated in the past by conservative means such as figure of eight bandage, sling and swathe etc. Although, acceptable for middle and medial fractures, distal clavicle fractures often require open reduction and internal fixation.Current literature supports both operative fixation and non-operative treatment for distal clavicular fractures and some middle third fractures with displacement. The objective of this present study was to determine the results of operative stabilization of distal clavicle fractures.
Materials and Methods: We present the results of 11 cases treated with open reduction and internal fixation with Kirschner wires. This study was carried out in Sebha Medical Centre, Sebha, Libya.
Results: Ten patients achieved union and 1 patient developed painless non-union.
Conclusions: Operative treatment of lateral clavicular fractures is recommended for early rehabilitation and affords adequate results.
Keywords: Distal clavicle, fracture, kirschner wires, open reduction and internal fixation
|How to cite this article:|
Swamy A, Swamy A. Open reduction and internal fixation of distal clavicle fractures. J NTR Univ Health Sci 2013;2:15-7
| Introduction|| |
Clavicle fractures have been looked upon with disdain by the majority of orthopedic surgeons, often leaving it to the juniormost specialist/trainee. Although, a large majority of middle and medial clavicle fractures can still be treated conservatively, displaced distal clavicle fractures often require open reduction and internal fixation for near normal anatomical and physiological restoration. Current literature supports both, operative and non-operativeintervention for distal displaced clavicle fractures. Open reduction and internal fixation has even been extended for displaced midshaft clavicle fractures. 
| Materials and Methods|| |
A total of 13 patients underwent open reduction and internal fixation for distal clavicle fracture at the Sebha Medical Centre, Sebha in Libya. Eleven were available for follow-up and formed the study group. Nine were males and 2 were females. The commonest cause was direct fall on shoulder- 8 cases, road traffic accident - 2 cases and fall on outstretched hand - 1 case. The Neer modification of All man classification was used. , All fractures were type-2 distal fractures. Seven were type 2-A and 4 were type 2-B distal clavicle fractures [Figure 1].
Patients were positioned in beach chair semi upright position with a sandbag under the affected scapula. Longitudinal incision was taken along the distal end of clavicle on to the acromion. Fracture reduction was done under vision and two stout 2 mm Kirschner wires were introduced from the lateral end of acromion in to the reduced clavicle.
Open reduction was performed and trans acromial Kirschner wire (K-wire) fixation was done for all fractures [Figure 2]. The K-wires were bent outside and fixed with gauze and sticking plaster to avoid medial migration and to prevent back-out. In 3 cases, supplemental tension band wiring with figure of 8 technique was done. Shoulder arm sling was given for post-operative support. Pendulum exercises were started on 3 rd post-operative day. Other ranges of motion and abduction exercises were started in 2-3 weeks time. K-wires were removed at 12-16 weeks. Patients were evaluated at 3 monthly intervals and were subjected to physiotherapy.
| Results|| |
Eleven patients were available for follow-up at the end of one year [Table 1]. 10 patients had radiological union (90%). One patient (9%) had non-union but no functional disability. All 11 patients had near normal range of motion of the shoulder with terminal restriction of abduction in only 3 patients (27%). Ten patients (90%) were totally pain free and were satisfied with the procedure. One patient had persistent pain but no limitation of range of movement. There was no case of K-wire backing out or medial migration. Shoulder function was evaluated using Constant Score. Mean constant score was 79.4.
| Discussion|| |
There has beenliterature on clavicle fractures with proponents of conservative care for distal clavicle fractures.  Others favor a more aggressive policy of operative fixation of distal clavicle fractures. ,
The rate of non-union in conservatively treated fractures is close to 30%. Neer concluded that distal clavicle fractures, though accounting for only around 15% of all clavicular fractures, accounted for nearly half of all clavicular non-unions.  Even so non-union of distal clavicular fractures does not necessarily mean symptomatic disability; however, a few patients can develop pain and arthrosis.
Various methods of fixation have been reported but the ideal technique is not yet clear. ,, Kashii has reported good results with the clavicular hook plate.Kirschner wires do have their own complications  and caution is recommended during the surgery and follow-up. Kao also has reported good results with K-wire and tension band technique.  Franke  also has reported good results with K-wire fixation for lateral clavicle fractures. The surgeon should decide the appropriate technique in which he is trained and confident.
The literature has both proponents of conservative care and surgical stabilization.
Proponents of conservative care argue that the functional disability is not too great and Bajuri et al.  has reported good constant scores for lateral fractures even. However, one limitation which the authors submit is a low sample size for lateral fractures.
We believe that the prolonged period of immobilization required in conservative management is certainly a disadvantage. Also, given the high rate of non-union in conservatively treated cases, operative fixation fordisplaced distal clavicle fractures could be recommended.
| Conclusions|| |
We agree that the sample size is not adequate to make a generalized recommendation. Also, some more study is required to evaluate the statistical significance of clavicular non-union and symptomatology before operative fixation can be stamped as routine treatment for lateral clavicle fractures.
However, Bajuri et al.  has reported lower constant scores for displacements more than 21mm. However, they have generalized the results and had less number of lateral fractures. In our study, we have got good constant score and we would like to point out that operative fixation could be considered for displaced, lateral clavicular fractures.
| References|| |
|1.||Altamimi SA, McKee MD and Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaftclavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am 2007;89:1-10. |
|2.||Allman FL Jr. Fracturesand ligamentous injuries of the clavicle and its articulation. J Bone Joint Surg Am 1967;49:774-84. |
|3.||Neer CS 2 nd . Fractures of the distal third of the clavicle. Clin Orthop Relat Res 1968;58:43-50. |
|4.||Smekal V, Irenberger A, Struve P,Wambacher M, Krappinger D, Kralinger FS. Elastic stable intramedullary nailing versus nonoperative treatment of displaced midshaftclavicular fractures-a randomized, controlled, clinical trial. J Orthop Trauma 2009;23:106-12. |
|5.||Kao FC, Chao EK, Chen CH, Yu SW, Chen CY, Yen CY. Treatment of distal clavicle fracture using Kirschner Wires and tension - band wires. J Trauma 2001;51:522-5. |
|6.||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. |
|7.||Neer CS 2nd. Nonunion of the clavicle. J Am Med Assoc 1960;172:1006-11. |
|8.||Chen CH, Chen WJ, Shih CH. Surgical treatment for distal clavicle fracture with coracoclavicular ligament disruption. J Trauma 2002;52:72-8. |
|9.||Regel JP, Pospiech J, Aalders TA, Ruchholtz S. Intraspinal migration of a Kirshnerwire 3 months after clavicular fracture fixation. Neurosurg Rev 2002;25:110-2. |
|10.||Krüger-Franke M, Kohne G, Rosemeyer B. Results of operatively treated lateral clavicle fracture. J Orthop Trauma 2001;15:149 |
|11.||Bajuri MY, Maidin S, Rauf A, Baharuddin M, Harjeet S.Functional outcomes of conservatively treated clavicle fractures. Clinics (Sao Paulo) 2011;66:635-9. |
[Figure 1], [Figure 2]