FRACTURES OF THE CLAVICLE
AND SCAPULA
Fractures of the distal third of the
clavicle are classified as those involving the lateralmost portion of the
clavicle. A type I fracture involves the clavicle distal to the
corticoclavicular ligaments and is without significant displacement. Type II
fractures involve the distal third of the clavicle in the region of the
corticoclavicular ligaments. These fractures are often displaced based on the
location of the fracture relevant to the corticoclavicular ligaments. Those
fractures that are medial to the corticoclavicular ligaments have a stable
lateral fracture fragment, whereas those that have involvement of the fracture
lateral to the ligaments with disruption of the corticoclavicular ligaments
result in a displaced clavicle segment. Type III fractures involve a contusion
or compression fracture of the distal third of the fracture at its articular
surface. Type I fractures are often treated by nonoperative measures. Type II
fractures with minimal displacement can likewise be treated with nonoperative
treatment, whereas those with significant displacement will often require
fixation of the fracture and reconstruction of the corticoclavicular ligaments
by either direct suture or ligament substitution. Type III fractures are often
treated nonoperatively, but in many cases post-traumatic arthritis will result.
Midclavicular fractures involve the
middle third segment. These are very common fractures in all age groups and one
of the most common fractures throughout the body. In many cases, these
fractures can be treated nonoperatively. Only when there is significant
comminution and displacement of the middle third fractures is early surgical
treatment indicated. In severely displaced fractures, significant malunion,
nonunion, or compromise of the neurovascular structures can result. In cases in
which nonoperative treatment is
appropriate, use of a figure-of-eight
harness or sling is an effective means to decrease the use of the shoulder and
to place the shoulder in a more favorable position. A figure-of-eight harness
places the shoulder in a position of scapula retraction and helps to support
the fracture and lengthen the clavicle to aid in reduction of the fracture
fragments. Fracture healing with and without internal fixation will result in
callus formation with a residual deformity in the area of the clavicle. Minor
deformities often remodel over time, resulting in an acceptable appearance to
the contour of the shoulder.
Fractures Of The Clavicle In
Children
Fractures of the clavicle are among
the most common fractures in children and can be caused by both direct trauma to the clavicle or indirect trauma
from a fall onto an outstretched arm. The clavicle in the children has great
healing potential, and even with comminution or deformity these fractures heal
and remodel better than the same fracture type in adults. Most children without
a closed clavicular fracture without neurovascular injury will be
successfully treated with closed non-operative management. Use of a
figure-of-eight brace maintains a comfortable position of the fracture and
allows for healing. True fracture immobilization is not achieved with this type
of fracture, and pain management is largely a matter of decreased activity
level and analgesic medication. In the child, early fracture healing and decreased
mobility of the fracture fragments occurs within 4 to 6 weeks after fracture.
Solid fracture healing takes considerably longer, and these patients should
avoid participation in any sports for 3 months and in any contact-type sport
for 4 to 6 months.
Fractures Of The Scapula
Scapular fractures often result from
high-velocity trauma to the chest wall. These fractures can often be associated
with other visceral or thoracic trauma, including rib fractures. Glenoid rim
fractures can occur as a result of traumatic dislocations of the shoulder. The
anterior glenoid rim fractures often result from anterior dislocation, and
posterior rim fractures occur from posterior dislocation of the shoulder. Early
surgery should be performed for reduction of the fragment and internal fixation
when larger in size and displaced. When these are isolated fragments, this can
be done by arthroscopic surgery.
Acromial fractures often result from
trauma to the superior aspect of the shoulder by direct trauma. Nonfused
growth centers of the acromion can occur and appear to be fractures but are not
related to trauma. This entity is more commonly associated with chronic rotator
cuff problems and is called an os acromiale. These growth abnormalities are
shown in Plate 1-39.
Fracture fragments can include
multiple portions of the scapula body. Scapular body fractures or scapular neck
fractures that are not displaced or only moderately displaced are most often
treated by nonoperative measures. Those fracture fragments that involve the articular
surface of the glenoid with displacement are often treated by surgical means,
particularly those that are associated with anterior or posterior dislocation
of the shoulder. These fracture fragments often will result in persistent
instability of the shoulder. Displaced fractures of the glenoid fossa can
also result in significant post-traumatic arthritis.
