Disorders of the Shoulder: Trauma by Joseph D. Zuckerman

Author:Joseph D. Zuckerman
Language: eng
Format: epub
Publisher: Lippincott Williams & Wilkins

COMPLICATIONS OF MEDIAL CLAVICLE FRACTURES

Fractures of the medial third of the clavicle are uncommon accounting for only 2% to 3% of all clavicle fractures and are frequently associated with high-energy trauma, most often motor vehicle collisions.122 Most medial clavicle fractures are non-displaced and extra-articular. Non-operative treatment with or without sling immobilization is generally appropriate. Although non-operative treatment of medial clavicle fractures is usually successful, patients may experience significant pain and a feeling of motion and instability at the fracture site. In these very unusual situations, operative management may be required using the techniques described below. Late complications of non-operative treatment of medial clavicle fractures include the development of post-traumatic arthritis of the sternoclavicular joint (SC), and compromise of mediastinal structures due to exuberant callous formation causing compression.84

Acute posterior displacement of a medial clavicle fracture can occur with injury to the SC ligaments, or from injury through the physis (typically in patients <25), or from displacement of the lateral fragment. Although rare, posterior displacement can compromise the function of superior mediastinal structures leading to life and limb threatening sequelae. Symptoms may include syncope, dyspnea, asymmetric radial pulse, cyanosis of the upper extremity, and motor or sensory changes of the upper extremity. Symptoms can manifest acutely or in a delayed fashion from 2 weeks to 7 years after initial injury.42,44,84 More unusual is a direct injury or compression of the trachea, innominate vein, and subclavian or carotid arteries.84,93 Patients with these symptoms should be evaluated with a CT scan to identify the degree of clavicle displacement and the mediastinal structures that may be affected. Further evaluation with duplex ultrasonography or angiography is indicated when vascular compromise is suspected. The patient should then be taken to the operative suite expeditiously for ORIF of the fracture with a thoracic and/or vascular surgeon available to assist and repair or bypass damaged mediastinal structures. Stabilization can be achieved with sutures passed through drill holes for sternal physeal disruptions or fractures with limited medial bone.42 A modified Balser (hook) plate with the hook inserted posterior to the sternum has also been described as an effective treatment of medial third fractures with small medial fragments.38 One series reported the use of T-shaped locking plates fixed medially to the sternum and laterally across the clavicle fracture.91 Nine out of 10 fractures healed and most patients had good to excellent functional results. The one patient who failed to heal was later treated with resection of the medial two-thirds of the clavicle. Eight out of 10 plates were eventually removed.91

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