Clavicle fracture

from Wikipedia, the free encyclopedia
Classification according to ICD-10
S42.0 Fracture of the clavicle
ICD-10 online (WHO version 2019)
Tangential (approx. 30–45 ° obliquely from below) radiograph of a fracture in the middle area of ​​the clavicle
Dislocated collarbone fracture with three fragments

Clavicle fracture or collarbone fracture is a fracture of the collarbone ( Latin clavicula ) and the second most common bone fracture in adults after the fracture of the spoke . The cause is usually a fall on the shoulder , less often on the outstretched arm , or an often only slight, direct force of force on the collarbone. Vascular or nerve injuries are rare complications.

Occurrence

This type of fracture occurs most frequently in children - with around half of all clavicle fractures - and in adolescents. Exercising physical contact-based sports such as American football or handball represents an increased risk, and accidents while skiing, snowboarding, cycling and riding are a common cause of this injury. When riding a motorcycle, a fall can break the collarbone from the lower edge of the helmet.

A broken collarbone can also occur at birth .

According to Allman, the collarbone fractures are divided into three types according to the location of the fracture. A fracture in the middle third (a shaft fracture) is the most common with 80%, an "acromial" fracture at the lateral end near the acromion and the shoulder joint (fracture of the distal / lateral third) with 15% less common, and a "sternal" fracture of the proximal third near the sternum is rare at 5%.

In a Scottish case series with 941 shaft fractures in adults, the mean age was 37 years, two out of three patients were men. The most common causes were simple falls (32%), followed by sports accidents (21%) and bicycle or motorcycle accidents (20%). Other traffic accidents in 10% and the use of force in 5% were less common causes. The dominant arm was affected slightly more often at 54%.

Symptoms

The first symptom of a broken collarbone is a visible and palpable swelling or step formation in the course of the bone , an apparent elongation of the arm and changes in the position of the head. In addition, the person concerned feels pressure and movement pain . The patient automatically puts on the upper arm in a relieving position , whereby the shoulder leans forward significantly.

Rarely does an open injury result from a skin piercing. Likewise, deeper large vessels or nerves can rarely be injured.

diagnosis

The diagnosis is often already made during the clinical examination through local swelling, tenderness, palpable bone ends under the skin or bone rubbing ( crepitation ). The diagnosis is confirmed by an X-ray examination .

Treatment in adults

development

In an ancient Egyptian papyrus, the stretching of the shoulder in the supine position with the shoulder blades underneath is described as a therapy for a clavicle fracture. Hippocrates described what is now called "conservative" treatment, immobilization.

Just Lucas-Championnière described the predecessor of today's backpack association, with a controversial effect according to recent studies, around 1860.

With the appearance of plaster casts , the broken collarbones were also immobilized with complex bandages.

Surgical treatment has spread since the 1960s and, with the advent of angle-stable plates from 2008, is the first choice for adults.

New with Locking Compression Plates

Locking Compression Plates revolutionized operative technology.

Two screws with different pitch (a standard and a head locking screw) are inserted through individual (oval) holes in the plate, one of which (the head locking screw) also has a thread in the head of the screw, for which the plate hole on the edge also has a corresponding thread so that the LC plate can be attached to the bone at a stable angle without the plate exerting pressure on the bone and periosteum as is the case with conventional compression plates.

The German designation angle stable plate is a description.

therapy

For a long time, therapy was the domain of conservative therapy with immobilization in an arm sling. Recent studies show that osteosynthesis (surgical treatment) can achieve a significantly better functional result. This is due to the fact that, from 2008, the surgeons will have locking compression plates (LCP) at their disposal, with which the ends of the fractures can be precisely adjusted and kept in this position during the healing process.

What is more controversial is the type of surgical treatment.

It depends on the patient and the complication of the fracture when and whether half a year, one or two years after the osteosynthesis the implant is removed again ("the metal removal") or left permanently in the bone.

Conservative treatment by immobilization with a sling

In the case of a simple fracture without significant dislocation of the bone fragments, it is sufficient in most cases to immobilize the affected shoulder for four to six weeks (three to four weeks in children).

The rucksack bandage was still widely used until 2014, but on the one hand it should be tightened regularly and if it is set tight it leads to signs of constriction in the arms. on the other hand, it can be set loosely or can no longer work properly when the shoulders are tilted forward when sleeping on the back. There is also the risk of possible nerve lesions due to pressure from the bandage in the armpit.

Regardless of whether the immobilization is done with a sling or with a backpack bandage, weekly radiological follow-up - using x-rays - is often recommended for the entire duration of treatment of 6 weeks, since significant displacements of the bone fragments can occur, especially with clavicle fractures of the middle third can then be treated surgically.

Risks

The problem with conservative treatment is that the lateral head of the sternocleidomastoid muscle constantly exerts tension on the middle third of the clavicle towards the neck and the pectoralis major muscle constantly exerts tension towards the chest, so that the bone fragments are displaced during the entire healing process can.

About 90% of clavicle fractures heal without problems under conservative therapy, but often in a shortened position and with a lowering of the affected shoulder, which significantly reduces the functionality of the arm and shoulder. In addition, there is a loss of strength of 20% (Hill 1997, McKee 2006).

Between 5 and 20% of the conservatively treated shaft fractures (i.e. fractures of the middle third of the clavicle) do not grow together or grow together in a severe misalignment and form a pseudarthrosis .

Pseudarthroses are even more common in lateral fractures. 22-33% of the conservatively treated lateral clavicle fractures develop pseudarthroses. In 45-47% of conservatively treated cases, it takes 3 months to heal until pain is free, while almost 100% of all surgically treated lateral fractures heal within 6-10 weeks.

If the symptoms persist, a secondary operation is then necessary, often with the use of a bone chip to fill the gap in the defect.

There are also clearly visible callus formations and breaks that heal in a malposition.

In a Scottish retrospective case series with 941 displaced shaft fractures of the collarbone in adults, three independent and significant risk factors for non-growing together (in 13%) could be identified in a multivariate analysis :

  • Smoking increases the risk with a odds ratio (OR) of 3.76, pseudarthrosis occurred in 7.2% of non-smokers and 33.3% of smokers.
  • Comminuted fractures have a ratio of 1.75, pseudarthrosis was found in 8.5% of the fractures without a debris zone and 21.3% of the debris fractures
  • a displacement of the fragments increases the risk with an odds ratio of 1.17 per millimeter of displacement. With a displacement of less than 15 mm, pseudarthroses were found in 2.1%, above that in 27%.

Healing in a shortening deformity can be regarded as the cause of the poor results of the displaced fractures under conservative treatment.

Since the results are less favorable than with direct surgical treatment, there is an increasing number of operations on collarbone fractures, when the collarbone is displaced by the width of a shaft, as well as almost always with fragmentary fractures .

Operative treatment

Plate fixation right clavicle

An operation is essential for complicated fractures and is recommended for fractures with displaced fracture ends.

A reduction of the fracture ends in conservative therapy is not indicated, as no bandage has the potential to keep a reduction result permanently.

There is a risk that the fragments will not grow together well, shortened or not at all or that sharp-edged fragments will spear through the skin . Surgery is also indicated for vascular or nerve injuries. Surgery also follows unsuccessful conservative treatment.

There is a tendency for collarbone fractures to be operated on more and more frequently, although modern implants also present risks and a pseudarthrosis can also arise through implant fracture or loosening.

During the operation, an osteosynthesis is carried out, i.e. the bone is stabilized by an implant that is later removed. The operation, the so-called metal removal, is carried out under general anesthesia . Metal removal is the rule for uncomplicated healing processes and for younger patients.

In the case of a pseudarthrosis in the middle and especially in the lateral third of the clavicle, the implant is usually no longer removed.

plates

In the frequently used surgical method of plate osteosynthesis, the fracture is stabilized with a plate and screws, as well as two lag screws anchored in an interfragmentary manner. Due to the high risk of refraction, the plate is removed after one and a half to two years at the earliest.

If the bone fracture is healed radiologically, the plate is usually removed again together with the (tension) screws - this is referred to as metal removal - especially since they often protrude through the skin and can cause local pain or allergies. If they don't bother you, they can also be left in the body.

As a further development of the conventional plates, special flat ( low profile ) and angle-stable plates (Locking Compression Plates, LCP for short) are now used, with which the anatomical position of the collarbone is precisely adjusted during the operation (osteosynthesis) and throughout the operation Healing time can be maintained.

In addition to oval holes, angle-stable plates contain individual holes with an additional thread in order to anchor the screws in an angle-stable manner. The oval-shaped holes in the plate allow the screws to be anchored slightly tilted in the bone. Overall, in contrast to conventional plates, the plate is stable in the bone without the periosteum being destroyed by the pressure of the plate.

In the case of lateral fractures in particular, a hook plate is occasionally used , the medial part of which is a screwed plate, while the lateral part is a hook that is placed under the corner of the shoulder (acromion). With mostly good results, the complication rate of up to 40% is very high, which is why it is used increasingly less. Problems can primarily be impingement through the hook in the space under the acromion (subacromial), but also osteolysis on the acrmion and stress fractures of the collarbone at the medial end of the plate.

Wires and nails

In addition to the plate fixation, wires and more stable nails are also often used, which are pushed into the medullary canal from the side and stabilize the break from the inside. This results in a smaller scar and a better cosmetic result, but the wires and the plates can break, loosen or emerge through the skin.

As an alternative to wires, elastic nails have also been used in Germany since 2003, which are also known as Prévot nails. In English this procedure is often called "ESIN", for elastic-stable intramedullary nailing , or "TEN" (English: titanic elastic nail ). Other known and used nails are e.g. B. Hagie, Rockwood nails or Steinmann nails.

These procedures are all mainly used for shaft fractures and are not applicable for lateral acromial or sternal fractures, as they cannot sufficiently stabilize the lateral fragment.

Metal removal

Metal removal, the removal of the implants used in osteosynthesis, such as the plate and all screws used for fixation, is not without complications such as refracture, only partial metal removal (when screws break), a nerve lesion, an infection.

Removal of metal from the clavicle is indicated if the implants cause local interference.

The osteosynthesis material is removed from nails 3 to 6 months after the osteosynthesis, from a plate 18 to 24 months.

Complications and risks

Problems arise when the wrong implant choice is made, due to insufficient reduction or screw anchoring. Modern implants can also break or loosen. Sometimes the fastening screws break when removing the plate, so that metal removal is incomplete.

Pseudarthrosis occurs less frequently with surgical treatment - in 1–3% of cases - than with conservative therapy, in which this occurs in 15–20% of cases.

Tendency of therapy

The treatment of clavicular fractures has long been the domain of conservative therapy. Recent studies show that osteosynthesis can achieve a better functional result. The therapy decision also depends on how far the bone fragments are displaced. The operation and metal removal are demanding.

Treatment in children

In children, broken collarbones generally heal with conservative treatment and have a high rate of spontaneous correction, so that malpositions almost always grow out completely after healing. Pseudarthroses are extremely rare; not a single pseudarthrosis was found in a case series of 184 child shaft fractures. This is why the American standard work on child traumatology of Mercier rank says:

"When the two fractured ends of the collarbone are in the same space, they will heal together and adequately remodel."

Therefore, no position correction is necessary, and immobilization z. B. in a triangular cloth or in a backpack bandage is only used for temporary pain relief and can usually be removed after ten days at the latest. After three to four weeks, the child's fracture is usually safely healed. Exercise should only be resumed when shoulder mobility is as free as on the opposite side. The remodeling can take up to six months.

Surgical therapy is only recommended for adolescents with a shoulder (lateral) or near the sternum (medial) fracture, as well as for children and adolescents with severe soft tissue injuries over the fracture site and open fractures.

Web links

Commons : Clavicle Fractures  - Collection of images, videos, and audio files

Individual evidence

  1. ↑ a b c d e Alexander Kristen, Reiner Wirbel: Clavicle fractures and dislocations. In: Ingo Marzi, Tim Pohlemann (Ed.): Special trauma surgery. Elsevier, Munich 2017, ISBN 978-3-437-23226-8 , pp. 12-17.
  2. ↑ FL Allman, Jr: Fractures and ligamentous injuries of the clavicle and its articulation. In: Journal of Bone and Joint Surgery American. Volume 49, 1967, pp. 774-784.
  3. ^ Thomas J. Vogl, Wolfgang Reith, Ernst J. Rummeny: Diagnostic and interventional radiology. Springer Medicine, Berlin et al. 2009, ISBN 978-3-540-87667-0 .
  4. ^ A b c d e Fritz Uwe Niethard, Joachim Pfeil, Peter Biberthaler: Orthopedics and trauma surgery. Thieme, Stuttgart 2014, ISBN 978-3-13-130817-7 .
  5. ↑ a b c I.R. Murray, CJ Foster, A. Eros, CM Robinson: Risk factors for nonunion after nonoperative treatment of displaced midshaft fractures . In: The Journal of Bone & Joint Surgery . tape 95 -Am, No. 13 , July 3, 2013, p. 1153-1158 , doi : 10.2106 / JBJS.K.01275 .
  6. ^ P. Blomstedt: Orthopedic surgery in ancient Egypt. In: Acta orthopedica. Volume 85, Number 6, December 2014, pp. 670-676. doi: 10.3109 / 17453674.2014.950468 . PMID 25140982 . PMC 4259025 (free full text).
  7. ^ On the Articulations By Hippocrates , Website of The Internet Classics Archive, Massachusetts Institute of Technology (MIT).
  8. ↑ a b c d e A. Prokop, G. Schiffer, A. Jubel, M. Chmielnicki: Treatment of clavicle fractures. In: Trauma and Occupational Disease. August 2014, Supplement 3, pp. 238–242. doi: 10.1007 / s10039-013-2034-6
  9. ↑ a b c Locking Compression Plate (LCP) ( Memento of the original from September 24, 2017 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. , Christoph Sommer, website of the AO Foundation ( working group for osteosynthesis issues ). @1@ 2Template: Webachiv / IABot / www.aovideo.ch
  10. ↑ a b c Schiele, Clara Sophie: The plate osteosynthesis for lateral clavicle fractures , dissertation, Eberhard-Karls-Universität zu Tübingen 2015.
  11. ↑ a b c ALLEX - Everything for the exam. Volume B: Clinical Subjects. Thieme, Stuttgart / New York 2014, ISBN 978-3-13-146952-6 , p. 234.
  12. ↑ a b c d e f Gereon Schiffer, Christoph Faymonville, Emmanouil Skouras, Jonas Andermahr, Axel Jubel: Clavicle shaft fracture: No harmless minor injury. New therapy concepts . In: Deutsches Ärzteblatt . Volume 107, No. 41 , October 15, 2010, p. 711–717 , doi : 10.3238 / arztebl.2010.0711 ( aerzteblatt.de [PDF]).
  13. ↑ P. Biberthaler, EC Schubert, C. Kirchhoff et al: Treatment after a collarbone fracture : The rucksack bandage is out. In: MMW - Advances in Medicine. 157, 2015, p. 50. doi: 10.1007 / s15006-015-2702-5 .
  14. ↑ B. Petracic: On the question of the efficiency of a backpack bandage in the treatment of clavicle fractures. In: Trauma Surgery. 9, Feb 1983, pp. 41-43.
  15. ↑ Prof. Dr. Peter Biberthaler, Medical Director of the Clinic for Trauma Surgery at the Klinikum rechts der Isar, Munich, said in an interview with Isabel Hertweck-Stücken on June 23, 2015: "If the backpack bandage is loosened to reduce the symptoms, it can no longer be used work properly. " Tucked tightly, however, the backpack bandage causes nerves and blood vessels to be squeezed off, which can result in swelling or temporary numbness of parts or the entire arm. "For this reason we actually no longer use the backpack bandage."
  16. ↑ a b Peter A. Cole, Aaron R. Jacobson In: James P. Stannard, Andrew H. Schmidt (Eds.): Surgical Treatment of Orthopedic Trauma. Thieme, New York / Stuttgart / Delhi / Rio de Janeiro 2016, ISBN 978-1-60406-762-0 , p. 319.
  17. ↑ A. Klonz et al: Clavicle fractures . In: The trauma surgeon . tape 104 , 2001, p. 70-81 , doi : 10.1007 / s001130050691 .
  18. ^ CM Robinson: Fractures of the clavicle in the adult. In: Journal of Bone and Joint Surgery British. Volume 80, 1998, pp. 476-484.
  19. ↑ Xuetao Xie, Yuqi Dong, Lei Wang, Zhiquan An, Wie Zhang, Congfeng Luo: Conservative Treatment for clavicular stress fractures following the clavicular hook plate fixation Acta Orthopædica Belgica 2019, Volume 85, Issue 3 of September 2019, pages 283-288
  20. ↑ Basic considerations on metal removal , Prof. Dr. Wolfgang Grechenig, AUVA Accident Hospital Graz.
  21. ^ Jacob Schulz, Molly Moor, Joanna Roocroft, Tracey P. Bastrom, Andrew T. Pennock: Functional and radiographic outcomes of nonoperative treatment of displaced adolescent clavicle fractures. In: The Journal of Bone & Joint Surgery. 2013, Volume 95-Am, Edition 13, July 3, 2013, pp. 1169–1165, doi: 10.2106 / JBJS.L.01390 .
  22. ^ Lutz von Laer: Fractures and dislocations in growing age. 3. Edition. Georg Thieme-Verlag, Stuttgart 1996, ISBN 3-13-674303-2 , p. 87 ff.