Page 54 - ISAKOS 2021 Newsletter Volume 1
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Management of Distal Clavicular Fractures
The earliest operative technique to treat Type-II and Type-V injuries was to place pins or Kwires laterally through the skin, the acromion, the distal fragment, and the clavicular shaft. While inexpensive and relatively easy to perform, this technique can be plagued by pin breakage and migration of the pins to various sites, including the cervical spine, trachea, lung, vascular structures, and even the abdomen2. The use of Knowles pins or additional tension band wiring with K-wires and intramedullary screw fixation may decrease the rate of complications associated with this technique. More rigid fixation can be obtained with use of interfragmentary fixation with locking plates (either one plate or two plates oriented 90° to each other). Unfortunately, fixation into the distal fragment can be tenuous and failure may occur, especially if the bone is soft3. Augmenting the plate with sutures around the coracoid and clavicle can help to prevent failure until the fracture heals. Hook plates have been reported to be effective for the treatment of distal clavicular fractures, but that technique requires removal of the plate; if the plate is not removed, erosion of the acromion and rotator cuff symptoms can occur3.
Other promising techniques involve reconstruction of the CC ligaments with devices that secure the clavicle down to the coracoid, essentially replacing the CC ligaments. The options in the literature have included the use of a CC screw alone, polydioxanone (PDS) sutures, Dacron graft, Mersilene tape, Ethibond sutures with a button, and suture anchors.
Results and Complications
The results of various techniques can be evaluated on the basis of patient-reported outcomes and return to work or sports. In terms of patient-reported outcomes, previous studies have demonstrated good to excellent results with no difference between K-wires, tension band wiring, hook plates, interfragmentary locking plates, and CC stabilization2,3. Another consideration when treating Type-II and Type-V distal clavicular fractures is the effect of the surgical technique on return to work, sports, and other activities. In one study, hook plates demonstrated a higher rate of return to work at 3 months (94% vs. 60%) and a higher rate of return to the preinjury level of activity at 6 months (81% vs. 40%) as compared with K-wires with tension band wiring2 (Table I). Zhang et al., in a systematic review of 22 studies, reported that locking plate fixation had a higher rate of return to work at 3 months postoperatively as compared with hook plates (94.4% vs. 73.3%)4.
One of the most common complications associated with any of these surgical techniques is failure of fixation and subsequent nonunion. The complication rates reported for operative treatment reveal that some techniques are preferable to others.
Oh et al.1, in a systematic review, found that the complication rate was 41% for hook plates, 20% for K-wires with tension band wiring, 6.3% for locking plates, 2.4% for transacromial intramedullary screws, and 4.8% for CC ligament reconstruction with various materials. The complication rate associated with nonoperative treatment has been reported to be as low as 6.7%, so this should be considered when the options are being discussed with the patient. The systematic review by Zhang et al., also indicated that locking plate fixation had lower rates of complication in comparison with hook plates (5.6% vs. 23.3%)4. Asadollahi and Bucknill, in a meta-analysis of 11 studies, reported that the rate of complications associated with hook plates was 3.2 times lower than that for K-wires with tension band wiring, 3.7 times higher than that for CC stabilization, and 5.2 times higher than that for interfragmentary locking plates3. In summary, the available literature seems to indicate that interfragmentary locking plate and CC stabilization may be preferred methods of distal clavicular fracture fixation because those methods are associated with lower complication rates.
Open vs. Arthroscopic Techniques
The published studies of arthroscopic techniques for the treatment of distal clavicular fractures have shown high union rates with few complications (Table I). Banerjee et al., in a review article, reported promising results in association with arthroscopic treatment of distal clavicular fractures with use of CC stabilization with a double-button device and sutures2. Flinkkilä et al., in a study in which arthroscopic CC stabilization with use of TightRope was compared with hook plate fixation, found similar patient-reported outcomes between the two groups5. However, arterial injury has been observed in association with arthroscopic treatment of this type of injury, so the proximity of the neurovascular bundle should be considered when performing surgery in this area.
In summary, the decision to treat Neer Type-II and Type-V distal clavicular fractures should be individualized after adequate counseling of the patient regarding the outcomes of nonoperative and operative treatment and complications related to various methods of fixation. Interfragmentary locking plate and CC stabilization may be preferred methods for the operative treatment of distal clavicular fractures because those methods are associated with lower rates of complications.
1. Oh JH, Kim SH, Lee JH, Shin SH, Gong HS. Treatment of distal clavicle fracture: a systematic review of treatment modalities in 425 fractures. Arch Orthop Trauma Surg. 2011 Apr;131(4):525-533. 2. Banerjee R, Waterman B, Padalecki J, Robertson W. Management of distal clavicle fractures. J Am Acad Orthop Surg. 2011;19(7):392- 401. 3. Asadollahi S, Bucknill A. Hook Plate Fixation for Acute Unstable Distal Clavicle Fracture: A Systematic Review and Meta-analysis. J Orthop Trauma. 2019 Aug;33(8):417-422. doi: 10.1097/BOT.0000000000001481. 4. Zhang C, Huang J, Luo Y, Sun H. Comparison of the efficacy of a distal clavicular locking plate versus a clavicular hook plate in the treatment of unstable distal clavicle fractures and a systematic literature review. Int Orthop. 2014 Jul;38(7):1461-1468. 5. Flinkkilä T, Heikkilä A, Sirniö K, Pakarinen H. Tight Rope versus clavicular hook plate fixation for unstable distal clavicular fractures. 2015 Apr;25(3):465-469.

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