CASE REPORT CiSE Clinics in Shoulder and Elbow Clinics in Shoulder and Elbow Vol. 18, No. 3, September, 2015 http://dx.doi.org/10.5397/cise.2015.18.3.162

Treatment of Medial End Fracture Using Double-plate Fixation

Seang Jang, Youngsoo Byun, Hyun Seung Yoo, Chul Jung, Dongju Shin

Department of Orthopaedic Surgery, Daegu Fatima Hospital, Daegu, Korea

Clavicle medial end fracture is rare, and it has not been studied extensively. Although there is debate regarding its treatment methods, because of the complications of conservative treatment, surgical treatment has been considered more than conservative treatment. This study describes a surgical method using double-plate fixation for treatment of clavicle medial end fractures in which plates were used on each anterior and superior border according to the anatomical structure of the clavicle. In addition, we report operative results of three patients treated by double-plate fixation. (Clin Shoulder Elbow 2015;18(3):162-166)

Key Words: Clavicle; Medial end fracture; Double plate

Although clavicle fracture accounts for 2.6% to 5.0% of the all performed using a reduction forcep. After fixation by K-wire, the fracture, clavicle medial end fracture has rarely been reported, reduction status was confirmed by c-. First, the plate and and only accounts for 2% to 9% of clavicle fractures.1,2) As a were fixed by placing the plate at the anterior aspect. In result, this research area has not received attention and has not the procedure, the elevator was placed at the opposite site of been studied intensively, resulting in controversy regarding surgi- cortical bone where a drill bit went through to avoid damage to cal indication and surgical methods. important structure behind the medial end of the clavicle. Then, This study reports on the surgical techniques and clinical the superior aspect was fixed with a plate. When making screw experience using double plates for the substantial fixation of holes in a downward position, the possibility of damage to other clavicle medial end fracture. structures in case of lateral fragment was low because of the first rib placed below it. However, the possibility of damage to the Case Report medial fragment was higher because the drill is directed toward the thoracic cage and sternoclavicular joint. To lower the risk, A patient was positioned on a beach chair. A transverse skin drilling should be stopped once the cortical bone on the op- incision was made from the center of the fracture. After expo- posite side was touched, and caution should be used in order to sure to the fracture site by incision of platysma, a transverse avoid perforating it. The plate was selected among 2.4 mm, 2.7 incision was made at the periosteum between pectoralis major mm, and 3.5 mm the locking compression plate (LCP) accord- positioned at the anterior aspect of the clavicle and sternocleido- ing to the size and location of , and a T-shaped metal plate mastoid muscle positioned at the superior aspect of the clavicle which could fix more screws on the proximal part was also used. to fix the plate. The anterior and superior aspect of the clavicle Finally, in reduction state, location of the plate and depth of were exposed by retracting the pectoralis major downward and the screws were confirmed through the c-arm. Pectoralis major, sternocleidomastoid muscle upward beneath the periosteum, sternocleidomastoid muscle were sutured, and irrigation was respectively, and then hematoma and soft tissues were removed. performed on the incision part. As a result, the skin was closed. The bony fragment was identified and anatomical reduction was After the operation, an arm sling was applied and pendulum

Received April 12, 2015. Revised June 17, 2015. Accepted July 26, 2015. Correspondence to: Dongju Shin Department of Orthopaedic Surgery, Daegu Fatima Hospital, 99 Ayang-ro, Dong-gu, Daegu 41199, Korea Tel: +82-53-940-7324, Fax: +82-53-954-7417, E-mail: [email protected] Financial support: None. Conflict of interests: None.

Copyright © 2015 Korean Shoulder and Elbow Society. All Rights Reserved. pISSN 2383-8337 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. eISSN 2288-8721 Treatment of Clavicle Medial End Fracture Using Double-plate Fixation Seang Jang, et al. exercise was performed in the pain tolerable range after three Case 1 days. The first patient was a 65-year-old male injured by a fall on Three medial end clavicle fracture patients underwent sur- the ground. He was diagnosed as 15-A3 according to OTA clas- gery using double-plate fixation from July 2010 to March 2013. sification and received conservative treatment. However, the pa-

A B

Fig. 1. (A) A 65-year-old male patient, diag- nosed as non-union 3 months after injury, during surgery to check the fracture surface after transverse skin incision. (B) Try reduc- tion using a reduction forcep. (C) Fixed lock- ing compression plate (LCP) recon plate on the anterior aspect. (D) After bone grafting C D from the patient’s ilium, fixed the LCP 2.7 condylar plate on the superior aspect.

A B

C D E

Fig. 2. (A) A 65-year-old male patient, injured by a fall on the ground. Cephalic tilt view. (B) Non-union in computed tomography (CT) axial view after 3 months. (C) Operation using locking compression plate (LCP) on the anterior aspect, LCP 2.7 condylar plate on the superior aspect was done 3 months after in- jury. (D, E) Bone union was checked in CT axial and coronal view 4 months after the operation.

www.cisejournal.org 163 Clinics in Shoulder and Elbow Vol. 18, No. 3, September, 2015 tient continued to complain of discomfort due to persistent false Case 3 motion and pain for 3 months after injury. Therefore, computed The third patient was an 81-year-old male injured in a pe- tomography was performed, which detected displacement destrian traffic accident. Clavicle fracture was confirmed by CT on the fracture site, which was not clearly seen on X-ray. The and it was diagnosed as 15-A3 according to OTA classification. patient was diagnosed with nonunion and surgical treatment At one week after injuries, his general condition had recovered, was performed. Autogenous bone graft from iliac bone was per- and surgical treatment was performed. At 4 months after surgery, formed for non-union. Follow-up computed tomography (CT) 4 the fracture site was united. At the final follow-up, 7 months months after the operation showed bone union, and functional after the operation, the patient was satisfied with the outcome recovery was confirmed. At the final follow-up, 12 months after without any complication (Fig. 4). the operation, no complication was observed (Fig. 1, 2). Discussion Case 2 The second patient was a 48-year-old male who was injured Among clavicle fractures in adults, clavicle medial end frac- in a pedestrian traffic accident. He had fractures of the right ture is the most uncommon, thus information on such fractures clavicle medial end and scapular spine on the ipsilateral side. is insufficient. Clavicle medial end fracture with open wound, The clavicle fracture was 15-A1 according to OTA classification. neurovascular injury and threatened overlying skin are gener- We decided to perform an operation because it appeared to be ally treated operatively. Even though there is a displacement, unstable due to the accompanying scapular spine fracture. One non-operational treatment is preferred because of the high risk week after injuries, his general condition had recovered and the of complications due to anatomic location and failure of opera- surgical treatment was performed with the treatment of scapular tion.3) body fracture at the same time. Bone union was achieved dur- However, recent studies have suggested that outcome of ing the follow-up. The last follow-up was performed 17 months conservative treatment of clavicle medial end fracture is unde- later and satisfactory functional recovery was confirmed without sirable. Throckmorton and Kuhn2) reported that 57 cases in 55 complication (Fig. 3). patients among 615 cases in 595 patients with clavicle fractures

A C

D E F G H

Fig. 3. (A) A 48-year-old male patient, injured in a pedestrian traffic accident, with an ipsilateral fracture. Preoperation chest X-ray. (B) Clavicle medial end fracture and scapula spine fracture on 3-dimensional computed tomography axial view. (C) Surgical treatment by locking compression plate (LCP) 2.7 on the anterior surface, LCP 2.7 condylar plate on the superior surface. (D-H) One year 5 months after surgery, shoulder range of motion.

164 www.cisejournal.org Treatment of Clavicle Medial End Fracture Using Double-plate Fixation Seang Jang, et al.

A B C

D E

Fig. 4. (A) An 81-year-old male patient, injured in a pedestrian traffic accident. Preoperation Clavicle anteroposterior view. (B) Preoperation clavicle oblique view. (C) Clavicle medial end fracture on 2-dimensional computed tomography axial view. (D, E) Operation using locking compression plate (LCP) on the ante- rior aspect, LCP 2.7 condylar plate on the superior aspect was done 3 months after injury. were clavicle medial end fractures and conservative treatment medial fragment is not large enough to be fixed by five locking was administered in 51 patients besides open fractures. Out of screws, its application will be limited. Since a screw inserted in 32 patients who were followed-up, 17 had consistent pain and the anterosuperior aspect is facing posteroinferiorly, it is usually 3 patients required surgery. Although this research suggests the directed into the thoracic cage. Therefore, there could be limita- necessity of surgery for treatment of a displaced clavicle medial tion in gaining firm fixation because the risk of perforation at the end fracture, anatomic risk resulting from the closeness of major opposite cortical bone is high. Double plate fixation is known as organs, nerves, and vessels and the fact that attaining sufficient a general treatment of distal fracture.10) Whereas a suf- fixation power is difficult because shortness of the fracture frag- ficient number of screws cannot be fixed with one plate, double ment makes selection of surgical treatment difficult. plates can provide strong resistance against rotational force and Various methods of internal fixation including K-wire, circular shear force. This concept can be applied to clavicle medial end wire fixation, plate with screw, and suture anchor have been fracture. tried.4-8) However, iatrogenic injury from the migration of internal Clavicle medial end is known as cylindrical. However, in fact, fixation and the limitation of internal fixation power still remain. in our experience, the anterior aspect is narrow and the poste- Recently, LCP, which has been broadly applied to osteoporosis rior aspect is wide like a trapezium. Therefore, fixation of each patients, has an advantage of increasing fixation power and de- plate at the superior and anterior aspect is possible and the size creasing the migration of internal fixation. of the plate can be selected according to the patients’ anatomic Siebenlist et al.9) reported satisfactory outcome of clavicle me- characteristics. It provides relatively firm fixation force compared dial end fracture using one pre-contoured locking compression with that of using not enough screws at the medial fracture frag- plate at the anterosuperior aspect of the clavicle. However the ment with one plate. medial fragment of the fracture was relatively large in his case, Cautions of this operation method are injury of nearby organs so that fixation of cortical lag screw and 5 locking screws at the such as heart, lung, subclavian vessels, trachea, and sterno-cla- medial fragment of the fracture was possible. If the size of the vicular joint. When fixing the plate at the anterior aspect of the

www.cisejournal.org 165 Clinics in Shoulder and Elbow Vol. 18, No. 3, September, 2015 clavicle, perforation of screws can be checked at the posterior fractures are common: a prospective study of 222 patients. aspect so that placement of a tool like an elevator can reduce in- Acta Orthop. 2005;76(4):496-502. jury from the drill. In addition, placement of a plate at the supe- 2. Throckmorton T, Kuhn JE. Fractures of the medial end of the rior aspect of the clavicle to perforate through the inferior aspect clavicle. J Shoulder Elbow Surg. 2007;16(1):49-54. is relatively safe because the first rib exists beneath the clavicle. 3. Robinson CM. Fractures of the clavicle in the adult. Epidemiol- However, if it is close to the sterno-clavicular joint, the drill faces ogy and classification. J Bone Joint Surg Br. 1998;80(3):476- toward the thoracic cage or sterno-clavicular joint. Therefore, 84. the far cortex should not be perforated if possible. When per- 4. Bartonícek J, Fric V, Pacovský V. Displaced fractures of the me- forating, it is preferable to progress slowly in order to feel the dial end of the clavicle: report of five cases. J Orthop Trauma. cortical bone at the opposite site. Perforating cortical bone at the 2010;24(4):e31-5. opposite site should be avoided by occasionally checking the C- 5. Brinker MR, Simon RG. Pseudo-dislocation of the sternocla- arm. vicular joint. J Orthop Trauma. 1999;13(3):222-5. This study indicates that surgical treatment of clavicle medial 6. Fowler AW. Migration of a wire from the sternoclavicular joint end fracture patients using double-plate fixation results in firm to the pericardial cavity. Injury. 1981;13(3):261-2. reductions and satisfactory outcomes without any specific com- 7. Kim KC, Shin HD, Cha SM. Surgical treatment of displaced plication during a short follow-up period. However, additional medial clavicle fractures using a small T-shaped plate and ten- research on biomechanical and anatomical stability regarding sion band sutures. Arch Orthop Trauma Surg. 2011;131(12): the fixation force is needed in order to demonstrate the effec- 1673-6. tiveness of using a double plate for clavicle medial end fracture. 8. McKenna M. Plating of a periarticular medial clavicle fracture. In addition, long term follow-up of a larger numbers of patients Orthopedics. 2009;32(5):366. and comparison between other operational methods are need- 9. Siebenlist S, Sandmann G, Kirchhoff C, Biberthaler P, Neuma- ed. ier M. Anatomically precontoured LCP for delayed union of a We propose that the operational method using a double medial third clavicle fracture. Case report with review of the plate is a relatively safe way to achieve a firm fixation at the literature. Acta Chir Orthop Traumatol Cech. 2013;80(6):407- clavicle medial end fracture. 10. 10. Self J, Viegas SF, Buford WL Jr, Patterson RM. A comparison References of double-plate fixation methods for complex distal humerus fractures. J Shoulder Elbow Surg. 1995;4:10-6. 1. Nowak J, Holgersson M, Larsson S. Sequelae from clavicular

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