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 Clavicle 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-arm. First, the plate and and only accounts for 2% to 9% of clavicle fractures.1,2) As a bone 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 bones, 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 scapula 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.