FRACTURES OF THE CLAVICLE AND SCAPULA
Fractures of the distal third of the clavicle are classified as those involving the lateralmost portion of the clavicle. A type I fracture involves the clavicle distal to the corticoclavicular ligaments and is without significant displacement. Type II fractures involve the distal third of the clavicle in the region of the corticoclavicular ligaments. These fractures are often displaced based on the location of the fracture relevant to the corticoclavicular ligaments. Those fractures that are medial to the corticoclavicular ligaments have a stable lateral fracture fragment, whereas those that have involvement of the fracture lateral to the ligaments with disruption of the corticoclavicular ligaments result in a displaced clavicle segment. Type III fractures involve a contusion or compression fracture of the distal third of the fracture at its articular surface. Type I fractures are often treated by nonoperative measures. Type II fractures with minimal displacement can likewise be treated with nonoperative treatment, whereas those with significant displacement will often require fixation of the fracture and reconstruction of the corticoclavicular ligaments by either direct suture or ligament substitution. Type III fractures are often treated nonoperatively, but in many cases post-traumatic arthritis will result.
Midclavicular fractures involve the middle third segment. These are very common fractures in all age groups and one of the most common fractures throughout the body. In many cases, these fractures can be treated nonoperatively. Only when there is significant comminution and displacement of the middle third fractures is early surgical treatment indicated. In severely displaced fractures, significant malunion, nonunion, or compromise of the neurovascular structures can result. In cases in which nonoperative treatment is
appropriate, use of a figure-of-eight harness or sling is an effective means to decrease the use of the shoulder and to place the shoulder in a more favorable position. A figure-of-eight harness places the shoulder in a position of scapula retraction and helps to support the fracture and lengthen the clavicle to aid in reduction of the fracture fragments. Fracture healing with and without internal fixation will result in callus formation with a residual deformity in the area of the clavicle. Minor deformities often remodel over time, resulting in an acceptable appearance to the contour of the shoulder.
Fractures Of The Clavicle In Children
Fractures of the clavicle are among the most common fractures in children and can be caused by both direct trauma to the clavicle or indirect trauma from a fall onto an outstretched arm. The clavicle in the children has great healing potential, and even with comminution or deformity these fractures heal and remodel better than the same fracture type in adults. Most children without a closed clavicular fracture without neurovascular injury will be successfully treated with closed non-operative management. Use of a figure-of-eight brace maintains a comfortable position of the fracture and allows for healing. True fracture immobilization is not achieved with this type of fracture, and pain management is largely a matter of decreased activity level and analgesic medication. In the child, early fracture healing and decreased mobility of the fracture fragments occurs within 4 to 6 weeks after fracture. Solid fracture healing takes considerably longer, and these patients should avoid participation in any sports for 3 months and in any contact-type sport for 4 to 6 months.
Fractures Of The Scapula
Scapular fractures often result from high-velocity trauma to the chest wall. These fractures can often be associated with other visceral or thoracic trauma, including rib fractures. Glenoid rim fractures can occur as a result of traumatic dislocations of the shoulder. The anterior glenoid rim fractures often result from anterior dislocation, and posterior rim fractures occur from posterior dislocation of the shoulder. Early surgery should be performed for reduction of the fragment and internal fixation when larger in size and displaced. When these are isolated fragments, this can be done by arthroscopic surgery.
Acromial fractures often result from trauma to the superior aspect of the shoulder by direct trauma. Nonfused growth centers of the acromion can occur and appear to be fractures but are not related to trauma. This entity is more commonly associated with chronic rotator cuff problems and is called an os acromiale. These growth abnormalities are shown in Plate 1-39.
Fracture fragments can include multiple portions of the scapula body. Scapular body fractures or scapular neck fractures that are not displaced or only moderately displaced are most often treated by nonoperative measures. Those fracture fragments that involve the articular surface of the glenoid with displacement are often treated by surgical means, particularly those that are associated with anterior or posterior dislocation of the shoulder. These fracture fragments often will result in persistent instability of the shoulder. Displaced fractures of the glenoid fossa can also result in significant post-traumatic arthritis.