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PubMed1995

An anatomical and embryological study of the clavicle in cats (Felis domestus) and sheep (Ovis aries) during the prenatal period.

The prenatal development of the clavicular area was studied in two species: the domesticated sheep, which lacks a clavicle, and the cat, with a nonfunctional, rudimentary clavicle. A morphological and computerized morphometric study of the clavicle was performed in 18 cat embryos between 25 and 48 days of gestation, and in 12 sheep embryos of 37-45 days. One group of embryos was processed with double staining in toto according to Hanken and Wassersug in 1981. The other group was examined by histological techniques: hematoxylineosin-Alcian blue and picrosirius. In both species, clavicular ossification is delayed (27% of gestation time elapsed in sheep and 53% in cats) compared to 16% in humans. Histological and morphological differences in shape and length of the clavicle were observed in both species. The clavicle is transient in sheep, whereas in the cat it persists with little change. In neither species does secondary cartilage develop. In cats, the periosteum is well developed with active osteoblasts, whereas in sheep the clavicle is surrounded by a single layer of epitheloid cells and the periosteum is less developed and contains osteoclasts. These results suggest that the morphogenetic pattern for the clavicle is altered at about day 34 in cats and day 40 in sheep, and is subsequently partly inhibited in the former and blocked in the latter.

Animals↗

PubMed1992

Brief communication: histological age estimation using rib and clavicle.

Histological methods for estimating age at death using osteon population densities for the rib, clavicle, and rib and clavicle combined are presented. Predicting formulas were generated from a sample of 40 individuals of known age, sex, and race. Independent samples of 12 ribs and 7 clavicles were used to test the formulas. Mean differences between known and predicted ages were 1.1 years, 2.6 years, and 3.4 years for the clavicle, rib and clavicle combined, and rib formulas respectively. An analysis of variance found no significant differences among the means for predicted and known ages. Since the formula based upon rib and clavicle combined has the higher standard error and r2, and includes data from different bones, it should provide better overall accuracy and reliability, and is recommended whenever both bones are available.

Adolescent↗

PubMed2006

Clavicle, a neglected bone: morphology and relation to arm movements and shoulder architecture in primates.

In spite of its importance for movements of the upper limbs, the clavicle is an infrequently studied shoulder bone. The present study compares clavicular morphology among different extant primates. Methods have included the assessment of clavicular curvatures projected on two perpendicular planes that can be assessed overall as cranial and dorsal primary curvatures. Results showed that in cranial view, three morphologies can be defined. One group exhibited an external curvature considerably more pronounced than the internal one (Gorilla, Papio); a second group was characterized by an internal curvature much more pronounced than the external one (Hylobates, Ateles); and a third group contained those with the two curvatures equally pronounced (Pan, Homo, Pongo, Procolobus, Colobus). Clavicle curvatures projected on the dorsal plane could be placed into four groups. The first group is characterized by two curvatures, an inferior and a superior (Apes, Spider monkeys). The second included monkeys, whose clavicles have an inferior curvature much more pronounced than the superior one. The third group includes only Hylobates, whose clavicles possess only the superior curvature. The last group includes only modern humans, whose clavicles show only the inferior curvature, which is less pronounced than that which exists in monkeys. Curvatures in cranial view relate information regarding the parameters of arm elevation while those in dorsal view offer insights into the position of the scapula related to the thorax. The use of clavicular curvature analysis offers a new dimension in assessment of the functional morphology of the clavicle and its relationship to the shoulder complex.

Animals↗

PubMed1999

Unusual fracture of distal third of the clavicle in a hockey player: case report and a new approach to treatment.

Clavicle fractures represent 5% of all skeletal injuries, and the distal third of the clavicle is involved in approximately 10%-15% of all these fractures. The incidence of delayed union or non-union in Neer type II fractures of the distal third of the clavicle is high. The ideal treatment for Neer type II fractures of the distal third of the clavicle is still open to controversy. Several treatments have been proposed, but there is no consensus about the treatment of choice. The case reported here presents a unique type of fracture of the lateral end of the clavicle that, since a medial fragment is involved, is a Neer type II fracture, but because of the nature of the fracture line the coracoclavicular ligaments remained intact. Trans-bony suture between the two fracture fragments was performed as the only treatment. This treatment has not been previously described and, although it has just been used in a single case, it appears to be an effective, efficient and simple alternative for the treatment of Neer type II fractures of the distal third of the clavicle.

Adult↗

PubMed1999

Post-traumatic and stress-induced osteolysis of the distal clavicle: MR imaging findings in 17 patients.

OBJECTIVE: To describe the MR imaging findings in patients with osteolysis of the distal clavicle and to compare the MR imaging appearance of clavicular osteolysis following acute injury with that related to chronic stress. DESIGN AND PATIENTS: MR imaging examinations were reviewed in 17 patients (14 men, 3 women; ages 16-55 years) with the diagnosis of post-traumatic or stress-induced osteolysis of the clavicle. A history of a single direct injury was present in seven patients and a history of weight-lifting, participation in sports, or repetitive microtrauma was present in 10 patients. RESULTS: MR imaging showed edema in the distal clavicle in 17 patients and, of these, eight also had edema in the acromion. The edema was most evident in STIR and fat-suppressed T2-weighted pulse sequences. Other findings about the acromioclavicular (AC) joint were prominence of the joint capsule in 14, joint fluid in eight, cortical irregularity in 12, and bone fragmentation in six patients. No differences in the MR imaging features of post-traumatic and stress-induced osteolysis of the distal clavicle were observed. CONCLUSION: Post-traumatic and stress-induced osteolysis of the distal clavicle have similar appearances on MR imaging, the most common and conspicuous MR imaging feature being increased T2 signal intensity in the distal clavicle.

Acromioclavicular Joint↗

PubMedDate not supplied

Geometric properties and the predicted mechanical behavior of adult human clavicles.

An image processing system was used to examine histomorphometric properties of 15 adult male and female human clavicles. Variations in porosity, cross-sectional area, anatomic and principal moments of inertia were assessed at 2.5-5.0% increments along the length of the clavicles. The clavicle's biomechanical behavior (axial, flexural, and torsional rigidities and the critical force for buckling) was modeled from these data using beam theory. Over threefold variations in porosity and moments of inertia were found along the length of the s-shaped clavicle--the greatest porosity and moments of inertia were located in the variably shaped sternal and acromial thirds of the bone in contrast to the denser and smaller, more circulatory shaped central third of the bone. Clavicle orientation, as indicated by the direction of greatest resistance to bending (maximum principal moment of inertia), was found to rotate from a primarily cranio-caudal orientation at the sternum to a primarily anterior-posterior orientation at the acromion. Based on cross-sectional geometry, section moduli, and estimates of flexural and torsional rigidity, the clavicle was found to be weakest in the central third of its length. These data concur with the fracture location most commonly reported clinically. Analysis of Euler buckling predicted a minimum critical force for buckling during axial loading of approximately two to three body weights for an average adult. Thus, buckling, or a combination of axial loading and bending or torsional loading, must be considered as possible failure mechanisms for this commonly injured bone.

Acromion↗

PubMed2006

Resection of the medial end of the clavicle: an anatomic study.

The biomechanical importance of the costoclavicular ligament is well known; however, an extensive debate still exists regarding the amount of the medial clavicle that can be removed without injuring the ligament. The goal of this anatomic study in fresh cadavers is to measure the distance between the inferior articular surface of the medial clavicle and the most medial clavicular insertion of the costoclavicular ligament, as well as to verify whether there is a relationship between this measurement and the length of the clavicle. Dissection of 100 shoulders from 50 fresh cadavers was performed. All specimens were from male cadavers ranging in age from 17 to 65 years (mean, 37 years). Variation in clavicular length did not alter the distance between the inferior articular surface of the medial clavicle and the most medial clavicular insertion of the costoclavicular ligament, which in our study measured 1.26 cm. The costoclavicular ligament can extend as far as the inferior articular surface of the medial clavicle. We recommend identification of this ligament during surgeries for resection of the clavicle's proximal extremity.

Adolescent↗

PubMedDate not supplied

Arthroscopic distal clavicle resection from a bursal approach.

We retrospectively reviewed 117 consecutive patients who underwent arthroscopic acromioclavicular joint (ACJ) arthroplasties. Only patients who underwent ACJ arthroplasties from a bursal approach in conjunction with subacromial decompression were included. Patients with isolated ACJ arthrosis treated with resection of the distal clavicle from a superior approach, isolated impingement with only undersurface distal clavicle debridement, prior surgery, or other shoulder pathology were excluded. Twenty-four patients met these rigid criteria for inclusion in the study. After an arthroscopic subacromial decompression, the distal clavicle was visualized and resected through a standard bursal approach. In addition, an anterosuperior portal was used in 50% of the patients to confirm adequate clavicle resection. Postoperative follow-up averaged 32.5 months (range, 24 to 70 months). Preoperative and postoperative pain were rated subjectively on a 5-point scale (1, incapacitating pain; 5, no pain). Operative reports and postoperative radiographs were reviewed to determine technical factors that may have influenced outcome. Seventeen patients had excellent results (71%), 4 good (16.5%), and there were 3 failures (12.5%). Average preoperative pain rating was 1.8 and was improved to 4.3 postoperatively. The average amount of clavicle resection was only 5.4 mm. Given smooth, even, and complete bone removal, the amount of bone resected did not correlate with outcome. Arthroscopic distal clavicle resection performed in conjunction with subacromial decompression gave excellent results, comparable to isolated ACJ procedures. In this series, additional use of an anterosuperior portal for more direct shaver placement and complete ACJ viewing allowed consistent bone resection and excellent results in a high percentage of patients.

Acromioclavicular Joint↗

PubMedDate not supplied

A safe zone for resection of the medial end of the clavicle.

Medial clavicle resection is indicated when symptoms of sternoclavicular instability or degeneration remain disabling despite nonoperative management. Preservation or reconstruction of the costoclavicular ligament (rhomboid ligament) is essential to prevent subsequent instability of the remainder of the medial clavicle. Eighty-six cadaveric sternoclavicular joints were dissected to determine the distance (safe resection length [SRL]) from the inferior articular surface of the medial end of the clavicle to the most medial insertion of the costoclavicular ligament (rhomboid ligament). The mean SRL was 1.2 +/- 0.3 cm in men and 1.0 +/- 0.2 cm in women. Resection of 1.0 cm of the medial clavicle would result in no or minimal disruption of the costoclavicular ligament in 84% of men, and resection of 0.9 cm of the medial clavicle would result in no or minimal disruption of the costoclavicular ligament in 89% of women. We recommend that these amounts be used as a guide to safe resection of the medial clavicle but that the costoclavicular ligament be exposed to allow certainty of preservation.

Aged↗

PubMedDate not supplied

Proximal clavicle excision: an analysis of results.

Medial clavicle excision has been reported by several authors, but few cases are documented, and long-term follow-up information is lacking. The purpose of this study was to examine the long-term results of medial clavicle excision in regard to function, pain, cosmesis, and complications. Fifteen patients ranging in age from 18 to 64 years (average 43 years) were evaluated an average of 4.6 years (range 1 to 14 years) after proximal clavicle excision. The indications for excision were unstable anterior subluxation/dislocation of the sternoclavicular joint (four cases), unstable posterior dislocation (one case), sternoclavicular osteoarthritis (nine cases), and proximal clavicle osteomyelitis (one case). An average of 2.9 cm of the medial clavicle was excised (range 1 to 4 cm). Fourteen of the 15 patients received significant relief of pain. On a strict grading scale four patients had an excellent result, five a good result, four a fair result, and two a poor result. Regeneration of the clavicle appeared to contribute to a poor result. No operative complications occurred. These findings aid our understanding of surgical options and outcome in the treatment of sternoclavicular joint disease.

Adult↗

PubMed1980

[Studies on the biomechanics of the human clavicle (author's transl)].

64 non preserved and 35 preserved clavicles were fractured in three defined positions in a bending test by a tension testing machine with electronic measurement of force. 30 non preserved bones were fractured in an axial infraction test. Force-deflection-diagrams were registered, and the values of maximum load, breaking load, ultimate deflection and energy were correlated to cross section and thickness of compacta. The significantly greater non preserved male clavicles are loadable at a higher level (medium breaking load about 1200 N) than female bones (medium breaking load abut 800 N). The breaking energy of the more flexible female clavicles is about 30% lower than those of males whereas elastic modulus of female clavicles is significant greater. Preservation has a significant influence on biomechanical properties of bones: ultimate deflection decreases; breaking energy, ultimate stress and elastic modulus increase. Breaking load is greatest in the middle portion of the clavicle, while deflection is greatest in the sternal portion. Removal of periosteum causes lower breaking load, deflection, ultimate stress and elastic modulus as well. With axial load clavicle fractures occur most frequently between middle and sternal third.

Age Factors↗

PubMedDate not supplied

Atraumatic osteolysis of the distal clavicle: MR findings.

OBJECTIVE: The purpose of this study was to describe the MRI appearance in atraumatic osteolysis of the distal clavicle (AODC). MATERIALS AND METHODS: We retrospectively evaluated MRI, medical records, ancillary diagnostic imaging studies and clinical course in five men and two women (mean age, 39 years) in whom the final clinical diagnosis of AODC was established. None of the patients had significant shoulder injury, but all participated in activities involving repetitive strain of the acromioclavicular (AC) joint. In three of these patients, we performed follow-up MRI (ranging from 5 1/2 to 15 months after the initial MRI). RESULTS: In all seven patients, signal intensity changes within the intramedullary portion of the distal clavicle on MRI were consistent with diffuse bone marrow edema. Marrow edema was most conspicuous on STIR imaging and occasionally could be misinterpreted as normal marrow signal patterns on spin-echo imaging. Cortical thinning or irregularity of the distal clavicle was seen in six cases and tiny subchondral cysts were seen in three, corresponding to subtle cystic changes on shoulder radiography. Limited bone scans obtained in two patients showed markedly increased uptake of radiotracer at the distal clavicle and AC joint. Histologic examination in one case showed disruption of articular cartilage, subchondral cysts, and metaplastic bone formation with increased osteoclastic activity. Follow-up MRI in three patients who were asymptomatic following conservative therapy showed normalization of marrow signal intensity. CONCLUSION: Atraumatic osteolysis of the distal clavicle is a relatively uncommon but important cause of shoulder pain. Particularly when the clinical history is suggestive of repetitive AC joint stress, MRI of the distal clavicle should be examined closely for marrow edema, cortical irregularity, and cystic changes. Such abnormalities may be especially conspicuous when STIR imaging techniques are used.

Acromioclavicular Joint↗

PubMed2005

The treatment of distal clavicle fractures with coracoclavicular ligament disruption: a report of 10 cases.

OBJECTIVE: Fractures of the distal third of the clavicle with coracoclavicular ligament disruption have been associated with delayed union or nonunion. A combined surgical technique for the fracture fixation and ligament repair for acute fractures was developed. The technique includes K-wire fixation and suture anchor placement with Ethibond suture to the coracoid process. The results of this combined technique were evaluated. DESIGN: Prospective, consecutive case series. SETTING: Surgical treatment was performed at the Department of Orthopedics and Traumatology. PATIENTS: Ten patients with acute fractures of the distal third of the clavicle were enrolled with a mean follow-up period of 24.1 (range, 12-36) months. INTERVENTION: A single suture anchor was placed on the coracoid process in a vertical position. The Ethibond suture attached to the anchor was used to depress the elevated proximal part of the clavicle by pulling it down to the coracoid process where the anchor was placed. The suture was pulled over the proximal clavicle and tied. The distal fragment was fixed to the proximal clavicle by an intramedullary K-wire. The torn coracoclavicular ligaments were approximated using absorbable suture. MAIN OUTCOME MEASUREMENTS: The patients were evaluated by the Constant scores and Modified Shoulder Rating Scale. RESULTS: The mean Constant score was 96.6 points in the last follow-up. Nine patients had excellent results, and 1 patient had a good result, using the Modified Shoulder Rating Scale. CONCLUSIONS: This is a reliable technique with encouraging results for treating displaced distal third clavicle fractures with coracoclavicular ligament disruption.

Adult↗

PubMed2005

Treatment of acute midshaft clavicle fractures: systematic review of 2144 fractures: on behalf of the Evidence-Based Orthopaedic Trauma Working Group.

BACKGROUND: Fractures of the clavicle were reported to represent 2.6% of all fractures with an overall incidence of 64 per 100,000 per year (1987, Malmö, Sweden). Midshaft fractures account for approximately 69% to 81% of all clavicle fractures. Treatment options for acute midshaft clavicle fractures include nonoperative treatment (mostly sling or figure-of-eight bandage), open reduction and internal fixation with plates, and closed or open reduction and internal fixation with intramedullary pins, wires, or a nail. Most surgeons prefer nonoperative treatment of nondisplaced midshaft clavicle fractures. However, the optimal treatment option for isolated acute displaced midshaft clavicle fractures remains controversial. OBJECTIVES: This study was designed to systematically summarize and compare results of different treatment options (nonoperative, operative extramedullary fixation, and operative intramedullary fixation) in the management of midshaft clavicle fractures, specifically for displaced fractures.

Clavicle↗

PubMed2006

Surgical treatment for distal clavicle fracture associated with coracoclavicular ligament rupture using a cannulated screw fixation technique.

BACKGROUND: A clavicle fracture is a common traumatic injury. However, the high percentage of distal clavicle fractures associated with a rupture of the coracoclavicular (CC) ligament can result in delayed union or nonunion. There is no standard treatment for a clavicle fracture. This report introduces a method for treating distal clavicle fractures associated with a ruptured CC ligament using a cannulated screw. METHODS: Seventeen patients suffering from a clavicle fracture caused by a rupture of the CC ligament were treated with a closed reduction and a cannulated screw fixation technique. Twelve patients were male and five were female and the average age was 30.5 years (range, 8-64 years). The patients were assessed using a clinical and radiologic evaluation as well as by the University of California at Los Angeles (UCLA) shoulder rating scale for 12 to 16 months after surgery. RESULTS: After confirming the formation of a callus, the implants were routinely removed approximately 8 weeks after surgery in all patients except for one. In this patient, the implant was removed 16 weeks after surgery as a result of a loosened screw, which caused displacement at the fracture site. During the final follow-up, the fracture site displayed nonunion and a partially limited range of motion (ROM). The shoulder function of the other 16 patients was restored to the preinjury level after 4 approximately 6 months of treatment. In one patient, heterotopic ossification was observed along the CC ligament without any functional deficit. All but one patient showed good results according to the UCLA scale. CONCLUSIONS: The cannulated screw fixation technique can maintain the rigid fixation of fracture fragments and allow an early return to work and sport activities. Therefore, the cannulated screw fixation technique is expected to be a useful method for treating distal clavicle fractures associated with a coracoclavicular ligament rupture.

Adolescent↗

PubMed1993

Fractured clavicle of the newborn in a population with a high prevalence of grand-multiparity: analysis of 78 consecutive cases.

OBJECTIVE: To perform a clinical analysis of newborn babies with a fractured clavicle and investigate the possible role of relative calcium deficiency in the aetiology. DESIGN: Prospective descriptive study (clinical aspects); case controlled study (calcium, phosphate, alkaline phosphatase). SETTING: The Nazareth Hospital, Israel. SUBJECTS: All babies with a fractured clavicle detected in the newborn period and their mothers delivered between 23 August 1987 and 22 June 1989. The majority of the population were Arab. INTERVENTIONS: Serum calcium, phosphate and alkaline phosphatase were measured on the third postpartum day in 42 affected babies (with uncomplicated deliveries), their mothers, and a matched group of babies and mothers as controls. MAIN OUTCOME MEASURES: Clinical associations of fractured clavicle of the newborn; statistical comparison of affected group with controls (calcium study). RESULTS: The incidence of fractured clavicle was 18.7 per 1000 singleton vaginal births; 38 in the posterior clavicle at delivery, 27 in the anterior, position unascertained in nine. Four (5.2%) occurred in instrumental deliveries, three (3.9%) in assisted breech delivery; shoulder dystocia was noted in 13. The male to female ratio of 51:26 was significantly different but not due to birth weight. Affected babies were significantly heavier than the unaffected population. The incidence was higher in parous mothers older than 25 years of age but there was no evidence of increased incidence with increasing parity. No significant results were obtained in the calcium study between affected babies and their mothers, when compared with controls. CONCLUSIONS: Fractured clavicle of the newborn is a benign form of birth trauma from which heavier babies are at greater risk. It occurs in 1 to 2% of deliveries, most of these being uncomplicated vaginal births, and is often undetected. There is no evidence for relative calcium deficiency.

Adolescent↗

PubMed2000

The rhomboid fossa of the clavicle as a sex and age estimator.

The costoclavicular (rhomboid) ligament connects the first rib to the clavicle, stabilizing the pectoral girdle. It produces skeletal traits that may be tubercles, roughened impressions, shallow groove-like fossae, deep fossae, or leave no trace. A pit or depression at this site is often called a "rhomboid fossa." While these markings may appear pathological, they are normal variants of the clavicle. Using a large contemporary sample (N = 344:113 females, 231 males), we evaluated the presence of a rhomboid fossa as a sex and age indicator for unidentified skeletal remains. Logistic regression found significant relationships between the presence of a rhomboid fossa and sex and between presence of a rhomboid fossa and age. Fossae were more common in males (36% left, 31% right) than in females (3% left, 8% right). Posterior probabilities suggest that a fossa on the right clavicle is indicative of a male with 81.7% probability; a fossa on the left is indicative of a male with 92.2% probability. Younger individuals more commonly exhibited rhomboid fossae than older individuals, and the largest fossae were most common in males 20-30 years of age. However, the age effect was not conclusive and must be corroborated by other methods. A test of the sex estimation method on an independent sample (26 males, 23 females) found nine males and only one female with fossae present on the left clavicle. When the costoclavicular attachment exhibits an impression, a tubercle, or leaves no trace, this method cannot be used for sex estimation. When a clavicle exhibits a rhomboid fossa, it is likely from a male. The greater difference in fossa expression between the sexes on the left clavicle makes use of the left bone preferable. This technique can corroborate other sex estimates or provide an estimate for unknown individuals in the absence of other skeletal indicators.

Adolescent↗

PubMed1989

Current concepts in the treatment of fractures of the clavicle.

Clavicle fracture is a common injury in all age groups. Injuries can be classified into groups. Group I includes fractures of the middle one third, the most frequent site. Group II fractures account for 10% of fractures of the clavicle and involve the clavicle lateral to the coracoclavicular ligament and are caused by direct violence. These injuries are divided into two subsets. Group II Type I fractures occur lateral to the coracoclavicular ligaments and are stable. Group II Type II fractures occur just medial to the coracoclavicular ligaments and are unstable. These latter injuries require stabilization. Group III fractures are uncommon and involve the medial end of the clavicle and are rarely caused by direct violence. Most fractures of the clavicle can be treated closed with excellent results. Open treatment is only occasionally indicated and then only under certain stringent conditions. Most complications occur with open treatment and include nonunion and infection. Neurovascular complications are uncommon but not unusual. Although reasonable shoulder function is compatible with surgical resection of the clavicle, it cannot be done with impunity.

Adolescent↗