Bilateral Clavicle Fractures

SAOJ Winter 2011:Orthopaedics Vol3 No4 5/9/11 11:47 AM Page 56

Page 56 / SA ORTHOPAEDIC JOURNAL Winter 2011 | Vol 10 • No 2 ARTICLE

A RTICLE

Bilateral clavicle fractures A case report and review of the literature HET van den Bout MBChB, LLB Senior Registrar, Department of Orthopaedics, University of Pretoria CH Snyckers MBChB,Dip.PEC(SA),MMed(Orth), FCSA(Orth) Consultant, Department of Orthopaedics, University of Pretoria

Reprint requests: Dr CH Snyckers Wilgers Hospital Suite 108 Wilgers Pretoria 0041 Tel: (012) 807-5696 Fax: (012) 807-5694

Abstract Bilateral clavicle fractures are rare and are seldom reported on. Based on the literature review the incidence of bilateral clavicle fractures is 0.43% of clavicle fractures with an overall incidence of between 0.011 and 0.017%. The common mechanism of injury is one of a compressive force across both shoulder girdles and is different from that causing unilateral clavicle fractures. Bilateral clavicle fractures are usually associated with high-energy impact injuries and are commonly associated with other severe injuries. These injuries are not always evident and should be actively sought for and excluded. Bilateral clavicle fractures are not commonly mentioned as an indication for operative intervention. It is suggested that bilateral clavicle fractures should be surgically managed to limit the duration of functional disability. Furthermore the use of low profile locking plates provides the ideal fixation method allowing for an earlier functional outcome.

Case report His shoulder movements on the right were more A 27-year-old male presented to our hospital on 22 October markedly decreased than on the left. He had no neu- 2010. He was involved in a motor vehicle accident after he rovascular injuries. X-rays revealed a left clavicle fracture, fell asleep behind the steering wheel and subsequently (Figure 2) rolled his vehicle. The incident occurred six days prior to which was 300% displaced, a right clavicle fracture consultation. Immediately after the accident he had pain with mild comminution and 200% displacement and a over both clavicles and his right shoulder. He was initially right scapula neck fracture, which was minimally dis- transported to a local hospital but due to a perceived delay placed. Both clavicle fractures were type 1C Allman in his definitive treatment he decided to seek treatment at fractures and type 2B1 Robinson fractures according to 1 our institution. the relevant classification systems. The right humeral On examination the patient was haemodynamically stable. head did not display any subluxation and the shoulder He had sustained a blunt injury to his left shoulder with a joint did not displace more than 5 mm. contusion and some superficial abrasions . He For mobilisation purposes and due to the displacement of (Figure 1) also presented with pain, tenderness, bruising and bony the individual fractures the patient subsequently underwent instability bilaterally over his clavicles. The clinical diagno- open reduction internal fixation (ORIF) of both clavicles. sis was made of bilateral clavicle fractures. Both surgeries were performed through the classic superior Although the patient had marked bruising and abrasions incision and the fragments were fixed with interfragmentary screws and held with anatomical locking plates . over the left shoulder, he presented with increased pain over (Figure 3) the lateral aspect of the right shoulder and was tender on The operation was uneventful and the patient was dis- palpation along the right scapular spine. charged on the second postoperative day. SAOJ Winter 2011:Orthopaedics Vol3 No4 5/9/11 11:49 AM Page 57

ARTICLE SA ORTHOPAEDIC JOURNAL Winter 2011 | Vol 10 • No 2 / Page 57

Figure 1. Clinical appearance of young male with bilateral clavicle fractures. Some tenting of the skin can be seen over the right clavicle and superficial abrasions over the left shoulder

Figure 2. Pre-operative X-ray appearance of bilateral clavicle fractures. Both clavicle fractures have some comminution and are displaced. A scapula neck fracture is also visible on the right

The patient was given a Barford-Jones-type arm sling for At 12 weeks postoperatively the X-rays (Figure 5) the right upper limb and a broad arm sling for the left upper revealed maintenance of initial reduction and advanced limb. He was instructed to keep his right shoulder immo- union. The patient was satisfied with the result and he was bilised for 6 weeks due to the associated scapula fracture, discharged. and to use his left hand for activities of daily living. The patient was reviewed 2 weeks, 6 weeks and 12 weeks postoperatively. On review of the patient at 6 weeks he was doing well. For mobilisation purposes and due to the He had full, pain-free range of motion of both shoulders displacement of the individual fractures the patient . The X-rays showed good alignment of the subsequently underwent ORIF of both clavicles (Figure 4) fractures with early signs of union. SAOJ Winter 2011:Orthopaedics Vol3 No4 5/9/11 11:49 AM Page 58

Page 58 / SA ORTHOPAEDIC JOURNAL Winter 2011 | Vol 10 • No 2 ARTICLE

Figure 3. Immediate postoperative X-ray showing good reduction and fixation with interfragmentary screws and low profile locking plates on both clavicles

Figure 4a & b. Postoperative images showing full recovery of abduction and forward flexion of both arms SAOJ Winter 2011:Orthopaedics Vol3 No4 5/9/11 11:50 AM Page 59

ARTICLE SA ORTHOPAEDIC JOURNAL Winter 2011 | Vol 10 • No 2 / Page 59

Figure 5. Postoperative X-ray at twelve weeks showing advanced union and maintenance of initial reduction

Literature review There are however several case reports in the literature. Clavicle fractures are common injuries. Isolated clavicle These case reports vary from bilateral non-traumatic clavi- 9 8-25 fractures have a reported incidence of 2.6%2 to 4%3 of all cle fractures, to bilateral traumatic clavicle fractures, and 29,32,40 fractures. The overall reported annual incidence ranges bilateral clavicle fracture non-unions. 18 from 29/100 0001 to 64/100 0003 with the highest inci- Marya reports on five bilateral clavicle fractures seen in dence (up to 150/100 000) found in young males.3,4 a time span of 3 months and they suspect that this injury Although clavicle fractures are often seen, bilateral clav- might be more common than previously reported. icle fractures are rare and are seldom reported on. The first few cases of bilateral clavicle fractures found are An electronic search of the English literature from 1887- documented and summarised in three articles in 8,23,24 The Lancet 2010 was completed. Inclusion criteria were articles that of July 1890. In these three articles reference is made to report on patients with bilateral clavicle fractures as well 41 cases of bilateral clavicle fractures with Gurlt having as articles that investigated bilateral clavicle non-union seen 18 of them. and epidemiological studies on clavicles. Including the two cases presented, there was a total of 29 Several series of clavicle fractures have been published males and 11 females with bilateral clavicle fractures, and 65 patients in which the gender was unknown . and the incidence of bilateral clavicle fractures is as fol- (Graph I) lows: The different age groups of patients with bilateral clavicle 3 fractures reviewed are illustrated in . In 74 cases the • Nordqvist reported no bilateral cases in 2 035 clavi- Graph II cle fractures. age is not stated. • Nowak4 had two bilateral cases in 185 patients. Regarding the mechanism of injury in unilateral clavicle • Throckmorton5 found 16 bilateral clavicle fractures fractures, it has been shown that several mechanisms can 26 in 593 patients. cause a unilateral clavicle fracture including a fall on an • Daab6 found four cases out of 1 348 clavicular frac- outstretched hand, a fall onto the shoulder, a direct blow on tures. the point of the shoulder and a direct blow on the clavicle. It • Rowe7 found a 1% incidence in 690 fractures. was previously thought that the most common cause of a • Malgaigne8 found only one case in over 2 000 cases. unilateral clavicle fracture is a fall on an outstretched hand • Robinson1 had no bilateral cases in 1 000 cases but he but subsequent studies have shown that a fall or a blow on excluded patients who had other shoulder girdle the point of the shoulder is the more common mecha- 26,27 injuries. nism, causing clavicle fractures in up to 94%. • Postacchini2 reported on two bilateral fractures in 533 Mechanisms for causing bilateral clavicle fractures patients but his study only looked at patients with iso- include a compressive force across both shoulder gir- 14,17,19,23,28 8,12,14,22 lated clavicle fractures, which means that polytrauma dles, direct trauma to both clavicles, direct patients were excluded, and most patients with bilat- trauma on one side and indirect violence in a subsequent fall 22 eral clavicle fractures have multiple injuries. on the other and two sequential episodes of direct trauma 20,21 Based on above studies, excluding those by Robinson and to the shoulder. Only one case is reported where indirect Postacchini, the incidence appears to be around 0.43% of violence (fall on outstretched arms) caused bilateral clavicle 8 clavicle fractures. fractures. SAOJ Winter 2011:Orthopaedics Vol3 No4 5/9/11 11:50 AM Page 60

Page 60 / SA ORTHOPAEDIC JOURNAL Winter 2011 | Vol 10 • No 2 ARTICLE

70 36% of patients with unilateral clavicle fracture with 14.4% having a superficial wound on the upper extremity or head, 60 1.8% having another extremity fracture, 7.2% having one or more rib fractures, 5.4% cerebral concussion and 7.2% hav- 50 ing two or more associated injuries. 40 In contrast, bilateral clavicle fractures are usually described in the setting of polytrauma. 30 Associated injuries reported8,10-14,16-21,29,31-33 includes severe 20 head injuries, severe chest injuries (multiple rib fractures, flail chest, sternal fractures, haemopneumothoraces, pneu- 10 mopericardium, lung contusion, aortic dissection), brachial 0 plexus injury, associated scapula fractures (as in our pre- Male Female Unknown sented case), humerus fracture, intra-abdominal injuries (ruptured spleen), spinal fractures, pelvic fractures and Graph I: Gender distribution of patients lower extremity fractures. Bilateral fractures of the medial with bilateral clavicle fractures reviewed third of the clavicle are most commonly associated with in this article multisystem trauma and have a high associated mortality rate. In Throckmorton’s study5 both patients with bilateral medial clavicle fractures passed away. Bilateral clavicle fractures are usually caused by a high Similar to unilateral clavicle fractures the treatment of energy impact incident such as a motor vehicle acci- bilateral clavicle fractures has evolved over the years from dents,10,11,16-20,29,30 motorcycle accidents,12,28 pedestrian-vehicle conservative measures to operative measures. In the first accidents,21,25,31 pedestrian-cycle accident,22 crush type of few cases described, the patients were instructed to rest in injury,8,14,15,18,20,23-25,28 trampling by an animal,13,22 fall from a bed, in an unsupported supine position.8,23 Other conserva- height8,32 and railway accident.8 tive treatment methods employed in the reviewed articles All 18 cases seen by Gurlt8 were caused by great violence. include bed rest with the arms bandaged across the chest,24 Associated injuries are seen much more frequently with handkerchiefs wrapped around each shoulder and tied at the bilateral clavicle fractures than with unilateral fractures and back according to the method of Syme,8 figure-of-eight the associated injuries are often more severe. Robinson1 bandage,20,31 figure-of-eight plaster of Paris bandage,22 fig- reports associated injuries with unilateral clavicle fractures ure-of-eight bandage and slings,21 collar-and-cuff slings,20 in 9.6% of patients. Nowak4 reported associated injuries in broad arm slings18,29 and others.

0 0 -10 11 - 20 21 - 30 31 - 40 41 - 50 51 - 60 61 - 70 71 - 80

Graph II: Age group distribution of patients with bilateral clavicle fractures reviewed in this article. In 74 cases the age is not stated SAOJ Winter 2011:Orthopaedics Vol3 No4 5/9/11 11:51 AM Page 61

ARTICLE SA ORTHOPAEDIC JOURNAL Winter 2011 | Vol 10 • No 2 / Page 61

Operative measures used for bilateral clavicle fractures These early studies however did not look specifically at include external fixators10 used in a case of suspected the non-union rate for displaced midshaft clavicle frac- underlying infection, ORIF with reconstruction plates,13,17 tures in the adult. There are however recent studies show- ORIF with angle stable locking T-plates,12 ORIF with ing that non-union rates for clavicle fractures treated con- dynamic compression plates34,35 and ORIF with servatively are much higher than initially reported. intramedullary devices.15,28,33,36 A systematic review by Zlowodzki of 2 144 clavicle In our case described we used interfragmentary screws fractures found a non-union rate of 15.1% for non-opera- with low profile locking plates (see discussion). tively treated displaced fractures of the middle third of the Indications for ORIF specific to bilateral clavicle frac- clavicle.38 According to this review a relative risk reduc- tures are to improve ventilatory function30 especially in tion of 57% for non-union can be achieved when using a associated, severe chest injuries13 and to reduce the dura- plate compared with non-operative treatment for acute tion of functional disability associated with conservative midshaft clavicle fractures (86% for displaced fractures). treatment.10 In the studies reviewed in this article there were no non- Non-union rates of clavicle fractures depend on several unions reported where ORIF was used to treat bilateral factors including age, gender, fracture comminution and clavicle fractures. There are however several examples displacement of the fracture.37,38 where non-operative treatment has led to non- Early studies reported low non-union rates for conserv- union.8,29,31,32,40 Of the 18 cases seen by Gurlt, eight ended atively treated clavicle fractures. Neer39 found a non- up with non-union. It is however not clear from the liter- union rate of 0.13% of those treated conservatively, com- ature review how many of these fractures were displaced pared with 4.6% in patients treated operatively. midshaft clavicle fractures.

Literature analysis

Number Type of Study Age Gender Mechanism Type Associated injury Treatment Outcome of cases injury

Motor vehicle 27 M ? Mid Scapula fracture ORIF locking plate Union accident (MVA) Van den Bout 2 Severe head injuries Scheduled for ORIF 20 M MVA ? Mid Orbital fracture ? locking plates Right first rib fracture

MVA Lateral Pelvic fracture Bonnevialle10 1 58 F collision and ? Mid External fixator Union Bilateral lung contusions multiple rollovers

Severe head injuries Aortic dissection Severe chest injuries Rodriguez- MVA high 1 27 M ? Mid Retroperitoneal ? ? Martin11 velocity haematoma Fracture dislocation right hip

Motorcycle Direct trauma Haemopneumothorax ORIF with angle stable Brunner12 1 21 M accident on shoulder Med Ruptured spleen Union lock T-plates (MCA) girdles Lower limb fractures

? Crush Fractures of all 24 ribs Trampling by ORIF with AO 3.5 mm Puranik13 1 45 F ? Bilateral Mid Bilateral haemo- Union cows recon plates direct trauma pneumothoraces

Bilateral Crushed by Agrawal14 1 47 M direct ? Multiple rib fractures ? ? stones trauma SAOJ Winter 2011:Orthopaedics Vol3 No4 5/9/11 11:51 AM Page 62

Page 62 / SA ORTHOPAEDIC JOURNAL Winter 2011 | Vol 10 • No 2 ARTICLE

Number Type of Study Age Gender Mechanism Type Associated injury Treatment Outcome of cases injury

Crushed Compressive between force across ORIF intramedullary Dahners15 1 18 M Mid ? ? vehicle and both shoulder nail ground girdles

Concussion Haemopneumothorax Multiple rib fractures Lee16 1 24 M MVA ? Mid ? ? Multiple T-spine fractures Brachial plexus injury

Bilateral floating Hart17 1 24 F MVA ? Mid shoulders ORIF recon plates Union Rib fracture

Crushed Compressive between force across 35 M Mid Concussion Broad arm slings Union tractor and both shoulder wall girdles

MVA high Multiple rib fractures 28 M ? ? Broad arm sling Union velocity Haemothorax

Marya18 5 MVA high Broad arm slings and 38 M ? ? Severe head injury Union velocity a clavicular brace

Bilateral clavicular MVA high 7 F ? Mid Severe head injury brace with shoulder Union velocity slings

MVA high 40 M ? ? Flail chest Conservative Union velocity

Pneumopericardium Bilateral haemo- MVA high Gould19 1 31 M ? ? pneumothoraces ? ? velocity Multiple rib fractures Sternal fracture Crushed Compressive between force across 18 M Lat Right first rib fracture Collar-and-cuff slings Union vehicle and both shoulder ground girdles Sutherland20 2 Sequential direct trauma Figure-of-eight 71 F MVA ? Rib fractures Union to tip of bandage shoulders

Pedestrian Sequential vehicle direct trauma Figure-of-eight Tennent21 1 49 M Mid ? Lung contusion Union accident to tip of bandage and slings (PVA) shoulders

Trampling by Direct trauma ?? ?? ?? a horse to clavicles

Direct trauma Wilson22 2 Pedestrian to one clavicle Figure-of- eight POP 7M cycle and indirect Mid Union ? bandage accident trauma to other SAOJ Winter 2011:Orthopaedics Vol3 No4 5/9/11 11:52 AM Page 63

ARTICLE SA ORTHOPAEDIC JOURNAL Winter 2011 | Vol 10 • No 2 / Page 63

Number of Type of Study Age Gender Mechanism Type Associated injury Treatment Outcome cases injury

Conservative - bedrest without a Indirect pillow, violence handkerchiefs Fell down Owen8 1 50 F (fall on Mid ? wrapped around Union stairs outstretched each shoulder and arms) tied at the back according to the method of Syme Great 8 Gurlt8 1 18 ? ? ? Conservative violence ? non-union

Hamilton8 2 ? M ? ? ? ? Conservative ?

Fall from a Malgaigne8 1 ? ? ? ? ? ?Conservative ? height Crushed by a Bilateral direct Pick8 1 ? M ? ? ?Conservative ? heavy object trauma Railway Erichsen8 1 20 M ? ? Multiple rib fractures ?Conservative ? accident ? F ? ? ? Rib fractures ?Conservative ? Hulke8 2 47 M ? ? ? ? ?Conservative Non-union

Polaillon8 8 ? ? ? ? ? ? ?Conservative ?

Ringwood8 1 ? ? ? ? ? ? ?Conservative ?

Union of Thrown from Burr8 1 50 M ? ? ? ?Conservative only a cart one side Compressive Crush injury Conservative- force across Page23 1 ? M between 2 Mid – bedrest without a Union both shoulder wagons pillow girdles

Bedrest with the Crushed by a Boger24 1 45 M ? Mid ? arms bandaged ? horse across the chest

? M ? ? ? ? ?Conservative Union Bennett25 2 6 F PVA ? ? ? ?Conservative ?

Crushed by a Flinn25 1 ? M ? Lat + med ? ?Conservative Union heavy object

Malgaigne25 4 ? ? ? ? ? ? ?Conservative ?

Right haemothorax Fall from Bilateral pneumo- Kloen32 1 30 F ? Mid Conservative Non-union elephant thoraces Multiple rib fractures

Multiple rib fractures MVA high Haemothorax Bilateral triangular Mullet29 1 51 F ? Mid Non-union velocity Right brachial splints plexus injury Figure-of-eight Hargan31 1 39 F PVA ? Mid Head injury Non-union bandage O’Conner40 1 ? ? ? ? ? ? Conservative Non-union Khan30 1 61 M MVA ? Mid ? ORIF plating Union SAOJ Winter 2011:Orthopaedics Vol3 No4 5/9/11 11:53 AM Page 64

Page 64 / SA ORTHOPAEDIC JOURNAL Winter 2011 | Vol 10 • No 2 ARTICLE

Number of Type of Study Age Gender Mechanism Type Associated injury Treatment Outcome cases injury

? ? MCA ? Mid ? ORIF nail Union

28 ? Crush/ Jubel 3 Squeezed Compressive between ? ? force across Mid ORIF nail Union ramp and ? both shoulder trailer girdles Shahid34 1 20 M 20 20 Lat ? ORIF DCP Union

Schwarz35 1 ? ? ? ? Mid ? RIF DCP unilaterally ?

ORIF Ahmad36 1 ? ? ? ? ? ? Union Rockwood pin

Lengua33 1 ? ? ? ? Mid Humerus fracture ORIF closed pinning Union

Postacchini2 2 ? M ? ? ? ? ? ?

Nowak4 2 ? ? ? ? ? ? ? ? 10 mid Throckmorton5 16 ? ? ? 4 lat ? ? ? 2 med Rowe7 ? ? ? ? ? ? ? ? ?

Discussion This point was well demonstrated with a subsequent Bilateral clavicle fractures are uncommon and seldom admission. A 20-year-old male was admitted to our reported on. The mechanism of sustaining bilateral clavi- institution on 13 January 2011 after he was involved in cle fractures is different from the mechanism for unilater- a motor vehicle accident. He sustained bilateral midshaft clavicle fractures . He had been al clavicle fracture. While a fall or a blow on the point of (Figure 6) the shoulder usually causes unilateral clavicle fractures, involved in a high-energy transfer incident and had also bilateral clavicle fractures are often caused by a compres- sustained an orbital fracture, severe diffuse axonal brain sive force across both shoulder girdles. Bilateral clavicle injury, a right first rib fracture and significant lung con- fractures are usually associated with high-energy transfer tusion. His clavicle fractures were type 1B fractures and therefore are associated with other concomitant according to the Allman classification and type 2B1 injuries. fractures according to the Robinson classification. The treating surgeons should thus have a high index of suspicion for associated injuries and actively exclude any such injury. This requires careful examination of the involved areas (i. e spine, thorax, scapula, plexus and others) as well as the necessary special investiga- tions. This becomes especially important in the poly- traumatised patient,18 as bilateral clavicle fractures are associated with a higher mortality rate.5 While a single clavicle fracture is usually a simple injury, bilateral clavicle fractures are much more seri- ous as they greatly incapacitate the patient, who can do little for himself. Furthermore the inspiratory capacity of the thorax is greatly limited and the patients are prone to develop respiratory complications.21 This was evident in the above-mentioned patient, as the intensive care staff experienced great difficulty with the patient’s Figure 6. X-ray demonstrating bilateral dis- ventilation. placed midshaft clavicle fractures SAOJ Winter 2011:Orthopaedics Vol3 No4 5/9/11 11:54 AM Page 65

ARTICLE SA ORTHOPAEDIC JOURNAL Winter 2011 | Vol 10 • No 2 / Page 65

The clavicle fracture can also form part of a more complex References disruption of the shoulder girdle and stability of the shoul- 1. Robinson CM. Fractures of the clavicle in the adult. der complex can often be achieved by stabilisation of the Epidemiology and classification. 1998; :476- JBJS Br. 80-B clavicle.41 84. Open reduction and internal fixation should form the 2. Postacchini F, Gumina S, De Santis P, Albo F. Epidemiology of clavicle fractures. mainstay of treatment of bilateral clavicle fractures. In con- J Shoulder Elbow Surg 2002 Sep-Oct; (5):452-56. trast to unilateral injuries, where each fracture is assessed 11 3. Nordqvist A, Petersson C. The incidence of fractures of the individually for possible operative intervention, bilateral clavicle. 1994; :127-32. Clin Orthop 300 clavicle fractures are per se an indication for surgical stabil- 4. Nowak J, Mallmin H, Larsson S. The aetiology and epi- isation. demiology of clavicular fractures. A prospective study dur- Anatomic angle stable fixation devices are becoming pop- ing a two-year period in Uppsala, Sweden. Injury, Int. J. ular in the treatment of varying fractures, especially in 2000; :353-58. Care Injured 31 osteoporotic bone where the pull-out strength of conven- 5. Throckmorton T, Kuhn JE. Fractures of the medial end of 42,43 the clavicle. 2007; :49-54. tional systems is often overcome. Although clavicle frac- J Shoulder Elbow Surg 16 tures more commonly occur in normal bone in patients 6. Daab J, Król P, Sonecki LO. Mechanizmie rzadkich, obus- tronnych, jednoczasowych uszkodzN obojczyków. below the age of 50 years, the weight of the arm creates a Chir 1965; (5):497-500. Narzadow Ruchu Ortop Pol 30 cantilever force that increases screw pull-out, especially on 7. Rowe CR. An atlas of anatomy and treatment of midclavic- the lateral aspect. Therefore screw pull-out strength can be ular fractures. 1968; :29-42. 42,43 Clin Orthop Relat Res. 58 improved with the use of locking plates. 8. Owen E. St. Mary’s hospital: a case of simultaneous frac- Furthermore peri-articular fractures that require early ture of both clavicles; remarks. The Lancet 1890; (3488):19-20. mobilisation are also increasingly being stabilised with 136 angle-specific locking plates.44 A patient is severely inca- 9. Quinn RH, Drenga J. Case reports: concurrent bilateral nontraumatic fractures of the clavicle. pacitated following bilateral clavicle fractures and will often Clin Orthop Relat 2006 Jun; :252-55. need to use at least one of the injured limbs in activities of Res. 447 10. Bonnevialle N, Delannis Y, Mansat P, Peter O, Chemama B, daily living. Therefore the use of stable angle locking plates Bonnevialle P. Bilateral clavicle fracture external fixation. that improve the fixation biomechanics allows for early non- Orthopaedics & Traumatology: Surgery & Research weight bearing activities, as long as the general biomechan- 2010; :821-24. 96 ics of locking plates are followed. Current locking plates are 11. Rodriguez-Martin J, Pretell-Mazzini J, Porras-Moreno MA, anatomically contoured which reduces the need to bend the Hernanz-Gonzalez Y, Resines-Erasun C. A polytrauma plates and thus concurrently weaken the fixation device. patient with an unusual posterior fracture-dislocation of the femoral head: a case report. Strat Traum Limb Recon 2010; :47-51. 5 Key notes on bilateral 12. Brunner A, Wedi E, Hoffmann A, Babst R. Bilateral frac- clavicle fractures ture of the medial clavicles treated by open reduction and internal fixation using angle stable locking T-plates. • Rare injuries but might be more common than Injury 2008; (8):276-78. Extra 39 previously reported 13. Puranik G, Gillham N. Bilateral fractured clavicles with • Associated with high energy transfer multiple rib fractures. 2007 Sep; (9):675. Emerg Med J. 24 • Often caused by a compressive force across both 14. Agrawal A, Pratap A, Kumar A, Thapa A, Sinha A. Multiple shoulders fractures upper body fractures associated with extradural • More common in the polytrauma setting hematomas. 2007; (1):11-13. Pak J Neurol Sci 2 15. Dahners LE. Opinion: Antegrade clavicle nailing. • Actively exclude associated injuries of the head, J Orthop 2005; (7):501-503. thorax, spine, and shoulder girdle. Trauma. 19 • Bilateral medial clavicle fractures have a high 16. Lee Y, Park S, Hamm I. Cerebral fat embolism with multiple rib and thoracic spinal fractures. mortality J Korean Neurosurg 2004; :408-11. Soc 36 • Surgical stabilisation indicated: 17. Hart R, Janecek M, Bucek P, Chaker A. Bilateral clavicular • to improve ventilatory function of severe and scapular neck fractures. Scripta Medica (BRNO) associated chest injuries 2004; (1):3-10. 77 • to reduce the duration of functional disability 18. Marya KM, Yadav V, Kochar H. Bilateral clavicle fractures. 2002; (1):39- associated with conservative treatment Hong Kong Journal of Orthopaedic surgery 6 • Fixed angle fixation devices indicated 41. • Anatomic locking plates recommended 19. Gould JC, Schurr MA. Tension pneumopericardium after blunt chest trauma. 2001; :1728-30. Ann Thorac Surg 72 20. Sutherland AG, Knight DJ. Bilateral fractured clavicles – a pair of cases. 2000 Jun; (3):306-307. The content of this article is the sole work of the authors. Acta Orthop Belg. 66 21. Tennent W. Bilateral fractures of the clavicles. No benefits of any form have been or are to be received Br. J Radiol 1942; :211. from a commercial party related directly or indirectly to 15 22. Wilson MJ. Bilateral fracture of the clavicle: report of an the subject of the article. atypical case. 1931; :564-65. JBJS Am. 13 SAOJ Winter 2011:Orthopaedics Vol3 No4 5/9/11 11:54 AM Page 66

Page 66 / SA ORTHOPAEDIC JOURNAL Winter 2011 | Vol 10 • No 2 ARTICLE

23. Page HW. Simultaneous fracture of both clavicles. 35. Schwarz N, Hocker K. Osteosynthesis of irreducible frac- The 1890; (3489):72. tures of the clavicle with 2.7mm ASIF plates. Lancet 136 The Journal 24. Boger WH. Simultaneous fracture of both clavicles. 1992; (2):179-83. The of Trauma 33 1890; (3491):175-76. 36. Ahmad S, Jahraja H, Sunderamoorthy D, Barnes K, Sanz L, Lancet 136 25. 1887; :178. Waseem M. Rockwood pin fixation of clavicle fractures. The Lancet 1 26. Stanley D, Trowbridge EA, Norris SH. The mechanism of 2009; supp 1:10-11. JBJS Br. 91-B clavicular fracture. A clinical and biochemical analysis. 37. Robinson CM, Court-Brown CM, McQueen MM, 1988; :461-64. Wakefield AE. Estimating the risk of nonunion following JBJS Br. 70B 27. Sankarankutty M, Turner BW. Fractures of the clavicle. nonoperative treatment of a clavicular fracture. JBJS Am. 1975; :101-106. 2004; :1359-65. Injury 7 86 28. Jubel A, Andermahr J, Schiffer G, Tsironis K, Rehm KE. 38. Zlowodzki M, Zelle BA, Cole PA. Treatment of acute mid- Elastic stable intramedullary nailing of midclavicular frac- shaft clavicle fractures: systematic review of 2144 fractures with a titanium nail. tures. On behalf of the Evidence-Based Orthopaedic Clin Orthop Relat Res. 2003; :279-85. Trauma Working Group. 2005; (7):504- 408 J Orthop Trauma 19 29. Mullett H, Laing A, Curtin W. Successful operative treat- 507. ment of bilateral clavicle non-union. 39. Neer CS. Nonunion of the clavicle. 1972; :1006- Injury. Int. J. Care JAMA 1960 2001 Jan; (1):69-70. 11. Injured 32 30. Khan MA, Lucas HK. Plating of fractures of the middle 40. O’Conner D, Kutty S, McCabe JP. Long-term functional third of the clavicle. outcome assessment of plate fixation and autogenous bone Injury: British Journal of Accident 1978; :263-67. grafting for clavicular non-union. Surgery 9 Injury, Int. J. Care 31. Hargan B, Macafee AL. Bilateral pseudoarthrosis of the 2004; :575-79. Injured 35 clavicles. 1981; (4):316-18. 41. Goss TP. Double disruptions of the superior shoulder sus- Injury 12 32. Kloen P. Bilateral clavicle non-unions treated with pensory complex. Journal of Orthopaedic Trauma, anteroinferior locking compression plating (LCP): a case 1993; (2):99-106. 7 report. 2004 Dec; (6):609-11. 42. Egol KA, Kubiak EN, Fulkerson E, Kummer FJ, Koval KJ. Acta Orthop Belg. 70 33. Lengua F, Nuss J-M, Lechner R, Baruthio J, Veillon F. The Biomechanics of locked plates and screws. Journal of treatment of fractures of the clavicle by closed medio-later- September 2004; (8):488-93. Orthopaedic Trauma, 18 al pinning. 43. Perren SM. Evolution of the internal fixation of long bone The French Journal of Orthopaedic Surgery 1987; (3):279-82. fractures. The scientific basis of biological internal fixation: 1 34. Shahid R, Mushtaq A, Maqsood M. Plate fixation of clavi- choosing a new balance between stability and biology. JBJS cle fractures: a comparative study between reconstruction Br. 2002; :1093-110. 84-B plate and dynamic compression plate. 44. Smith WR, Ziran BH, Anglen JO, Stahel PF. Locking Acta Orthop. Belg 2007; :170-74. plates: tips and tricks. 2007; (10):2298-307. 73 JBJS Am. 89-A

• SAOJ Criteria for authorship and co-authorship of articles

The following are internationally acknowledged criteria for authors/co-authors. With the increase in faculty and in research projects, there is a potential for increased confusion and conflict regarding appropriate authorship credit on manuscripts and presentations. The following are some relatively standardised criteria that can be helpful. These may be overstrict when considering clinical studies in which surgeons often do the “hands on work” that create the study but may not perform major analysis and writing functions. However, all authors should read and contribute editing comments prior to submission.

Relman criteria for authorship In particular, to qualify as an author a person should fulfil at least three of the following five requirements: 1. Conception of idea and design of experiment 2. Actual execution of experiment; hands on lab work 3. Analysis and interpretation of data 4. Actual writing of manuscript 5. Be able to present to a learned gathering a lecture on the work; interpret it, defend it and take responsibility for it.

These are just guidelines. On the other hand it is probably far worse to leave someone off the list who feels they may have contributed than to include someone who did a bit less.

We should all be as inclusive as possible, offer our interested colleagues the opportunity to provide input, analysis and editing of our works to support each other and improve our papers.