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PubMed1997

Management of clavicle fractures.

Fractures of the clavicle are among the most common fractures seen by family physicians. Common mechanisms of injury include a fall on an outstretched hand or direct trauma to the bone. Fractures of the middle third of the clavicle are the most common and usually heal without complication when managed with immobilization using a sling or figure-of-8 bandage. Fractures of the distal clavicle often are overlooked and may be difficult to distinguish from an acromioclavicular separation. These fractures are classified into three types. Types I and III fractures of the distal clavicle usually heal with symptomatic treatment. Type II fractures are displaced as a result of ligamentous disruption and usually require surgical repair. Fractures of the proximal third of the clavicle are uncommon. Nondisplaced proximal fractures are successfully treated with sling immobilization. Orthopedic referral is indicated for significant displacement or sternoclavicular dislocation. By following appropriate management guidelines, family physicians can successfully treat most clavicle fractures.

Clavicle↗

PubMed2001

Development of the clavicles in birds and mammals.

Clavicles (collar bones) are variably present in mammals. Furculae (wishbones)--which may or may not be homologous with clavicles--are variably present and/or fused in birds and present in theropod dinosaurs. In this overview the development of clavicles and furculae is discussed with special attention to modes of skeletogenesis (whether intramembranous or endochondral), numbers of centres of ossification (one in chick furculae; two in murine clavicles), presence of cartilage (primary in clavicles, secondary in furculae), evidence from experimental analysis and from mutations for dependence of both clavicular and furcular growth on mechanical stimulation, and syndromes and mutations affecting clavicular development leading to both under and over development. J. Exp. Zool. 289:153-161, 2001.

Animals↗

PubMed2006

Malunion of the clavicle causes significant glenoid malposition: a quantitative anatomic investigation.

OBJECTIVE: An experimental cadaver model was used to assess the effects of a malunited fracture of the middle third of the clavicle on the functional anatomy of the shoulder joint. METHOD: Anatomic samples were prepared with simulated shortening and axial malposition of the clavicle. From these, alterations in glenoid fossa position were measured and depicted graphically. RESULTS: Healing of clavicle fractures with bony shortening leads to a ventromedialcaudal shift in glenoid fossa position. The following malpositions of the clavicle lead to the respective glenoid fossa positional changes: caudal deviation leads to a mediocaudal shift, cranial deviation leads to a dorsolateral shift of the glenoid fossa, ventral deviation causes a ventrolateral shift, dorsal deviation leads to mediocaudal shift of the fossa, cranial rotation leads to ventrolateral shift in fossa position, and caudal rotation leads to a dorsomedial shift in glenoid fossa position. CONCLUSION: Clinical implication of these data is that bony shortening in combination with caudal displacement leads to distinct functional deficits in abduction, particularly overhead motion. Using the above data, a vector model was created to calculate position of the glenoid fossa dependent on clavicle position/malposition. The model is a valuable tool to be used for planning open reduction and fixation of clavicular fractures or malunions.

Clavicle↗

PubMed2004

[Posttraumatic nonunion of the clavicle in a child: case report].

A thirteen-year-old child underwent surgery for posttraumatic nonunion of the clavicle. This complication, which is uncommon in adults and exceptional in children, occurred after three fractures of the left clavicle. The diagnosis can be retained after ruling out congenital nonunion of the clavicle. Surgery can be proposed if functional impairment persists for at least one year. For children, the preferred technique is osteosynthesis with centromedullary pinning and bone graft. While surveillance may not be necessary for a unique fracture of the clavicle, prolonged surveillance appears to be necessary in patients who sustain repeated fractures of the clavicle.

Child, Preschool↗

PubMed2003

Long-term results of arthroscopic resection of the distal clavicle with concomitant subacromial decompression.

PURPOSE: The goal of the study was to evaluate the long-term outcome of combined arthroscopic distal clavicle excision and subacromial decompression. TYPE OF STUDY: Retrospective, long-term cohort evaluation. METHODS: Twenty patients with an average follow-up of 6 years (range, 3.9 to 9 years) were reviewed. All patients had ipsilateral impingement syndrome and acromioclavicular joint disease at the time of surgery and underwent arthroscopic subacromial decompression combined with arthroscopic distal clavicle excision. All patients returned for evaluation in person, in addition to filling out a questionnaire incorporating the University of California, Los Angeles (UCLA), and Constant scoring systems. Preoperative and postoperative radiographs were available for all patients. RESULTS: Postoperatively, all patients had pain relief and were satisfied with the result. The average postoperative UCLA Shoulder score was 29.8 +/- 0.6, compared with 17.5 +/- 3.0 before surgery (P =.001). The Constant Shoulder score averaged 98.5 +/- 2.1 postoperatively, compared with 70.5 +/- 11.2 preoperatively (P =.001). There was 100% good to excellent results using both scoring systems. Individual components of the UCLA scoring system (pain, function, and power) all showed significant postoperative improvement (P =.001). Constant categories of pain, activities of daily living, range of motion, and power also improved. Follow-up radiographs showed maintenance of the resected distal clavicle in 19 patients. Five patients (25%) had radiographic evidence of calcific density distal to the resected clavicle but were asymptomatic. CONCLUSIONS: The long-term results of arthroscopic resection of the distal clavicle with concomitant subacromial decompression are uniformly good or excellent. Impingement and acromioclavicular joint disease frequently coexist and should be identified and treated concurrently.

Acromioclavicular Joint↗

PubMed1994

Fractured clavicle in the neonate: a retrospective three-year review.

A hospital-based case-controlled study was undertaken to determine maternal and neonatal characteristics associated with fractured clavicle. A total of 11,604 consecutive vaginal deliveries of liveborn infants in vertex presentation at the Mount Sinai Hospital from 1988 to 1990 were reviewed. Maternal and neonatal characteristics were compared for the neonates with and without a diagnosis of a fractured clavicle. Compared to controls, mothers of neonates with a fractured clavicle were more likely to be nulliparas or primiparas, to have had an operative vaginal delivery, and to have been delivered by an attending as opposed to a resident physician. The fractured clavicle group also had a longer gestational age, greater birthweight, and higher frequency of macrosomic infants. After controlling for maternal parity, type of delivery and infant birthweight, experience of the delivering physician, and gestational age at delivery were not significantly different. Fracture of the clavicle in the neonate is related to maternal parity, mode of delivery, and infant birthweight but not to the level of experience of the delivering physician.

Adult↗

PubMed2001

Posttraumatic osteolysis of the distal clavicle: analysis of 7 cases and a review of the literature.

OBJECTIVE: To discuss the clinical manifestation, radiographic features, and treatment of 7 cases of posttraumatic osteolysis of the distal clavicle. Also, to furnish evidence indicating that the current terminology for this disorder is ambiguous and to propose a new classification system. CLINICAL FEATURES: Three cases resulted from acute trauma, and 4 cases were caused by sports-related repetitive microtrauma. All the cases involved young male patients who had similar clinical presentations that included shoulder pain with decreased shoulder range of motion. Radiographic findings ranged from small erosive changes to aggressive osteolysis of the distal clavicle. INTERVENTION AND OUTCOME: All the patients were treated with conservative care consisting of sling immobilization, ice, various physiotherapeutic modalities, and mobilization exercises. The patients that followed through with care showed clinical improvement within 3 months. Follow-up radiographic examinations, when performed, demonstrated reconstitution of the distal clavicle of various degrees, although lagging behind clinical evidence of improvement. CONCLUSION: Traumatic osteolysis of the distal clavicle may result from acute trauma or repetitive microtrauma. Radiographic changes are varied, including irregularity of the distal clavicle, cystic erosions, and blatant osteolysis. Positive outcomes may be achieved with conservative care; however, patient compliance plays a fundamental role in the overall prognosis.

Adult↗

PubMed2006

Hook-plate fixation of unstable lateral clavicle fractures: a report on 63 patients.

BACKGROUND: Hook-plate fixation of unstable lateral clavicle fractures has given promising results in previous reports, but numbers of patients have been small. We assessed the results of this technique in 63 patients. PATIENTS AND METHODS: 63 patients with unstable lateral clavicle fractures were operated on at Oulu University Hospital during 1997-2004, using a clavicle hook-plate. Fracture union and complications were assessed retrospectively from case records and radiographs. The subjective part of the Constant score, Oxford shoulder questionnaire data and subjective shoulder value (SSV) were assessed after an average of 3.6 years in 58 patients. 31 patients were reviewed at the outpatient clinic, using complete Constant scores and radiographs of both acromioclavicular joints. RESULTS: 59 fractures united uneventfully. There was 1 case of delayed union and 3 nonunions, but only 1 of these required surgery. Additional complications involved 1 case of infection, 1 frozen shoulder and 3 cases of late fracture medial to the plate. The mean Oxford score was 15, the mean for the subjective part of the Constant score was 32, and the SSV was 86%. INTERPRETATION: Clavicle hook-plate fixation of unstable lateral clavicle fractures results in a good union rate and good shoulder function.

Adolescent↗

PubMed2002

Determination of sex from the clavicle and scapula in a Guatemalan contemporary rural indigenous population.

The clavicle has been described as a useful bone for the metric determination of sex of human skeletal remains in a contemporary, predominantly white, North American forensic sample. In this article, measurements of clavicle and scapula are provided for a contemporary Guatemalan rural indigenous sample of forensic origin. Maximum length and circumference at midshaft of the clavicle, and height and width of the glenoid fossa of the scapula, were measured in 35 female and 62 male clavicles, and in 38 female and 65 male scapulae. Discriminant function analysis was used to study sexual dimorphism in this population with a classification purpose. Leave-one-out method (jackknife) matrices produced classification success rates ranging from 85.6% to 94.8%. A comparison with the North American forensic sample showed low percentages of correctly sexed Guatemalan male clavicles, ranging from 29.4% to 54.9%. The choice of an appropriate standard for the metric determination of sex is a crucial step in forensic anthropology.

Anthropometry↗

PubMed2000

Distal clavicle osteolysis unrelated to trauma, overuse, or metabolic disease.

Osteolysis of the distal clavicle has been reported to occur from traumatic, atraumatic (overuse), or systemic causes. Three patients with bilateral osteolysis of the distal clavicles whose osteolysis did not fit these etiologic categories were evaluated. Clinical, imaging, and laboratory evaluations were nonspecific, and histologic sections of the distal clavicle showed evidence of chronic inflammation with reactive change of the articular surface. Patients either had complete resolution or marked improvement of their symptoms after bilateral distal clavicle resection at mean followup of 5 years 3 months. These cases of osteolysis of the distal clavicle represent a category of this disorder not previously described.

Adult↗

PubMed1989

Nonunion of the clavicle and thoracic outlet syndrome.

Fifteen adult patients with clavicular nonunions were evaluated over a 10-year period. Fourteen of these patients were treated initially with a "figure-of-eight" clavicle strap. Seven presented with narrowing of the costoclavicular space, and symptoms of intermittent brachial plexus impingement or thoracic outlet syndrome. Two of these resulted from resection of the mid-portion of the clavicle with subsequent impingement from hypertrophy of the lateral stump. Most commonly, hypertrophic nonunion of the clavicle caused the thoracic outlet syndrome, frequently many months after the initial injury. This delayed onset led to diagnostic confusion with other causes of radiating upper extremity pain, including cervical disc disease. Treatment of the adult clavicle fracture is different from that of the child with potential for greater functional impairment. The "figure-of-eight" harness frequently does not provide pain relief or adequate reduction of the fracture. If an acutely displaced fracture in an adult cannot be reduced and held by closed casting technique, open reduction and internal fixation may occasionally be indicated. We have found transcortical fixation by locking Knowles pins to be effective for treating hypertrophic nonunions, as well as for unreducible acute fractures. Atrophic nonunions require plate fixation and autologous grafting. Nonunion of the clavicle has been among the most responsive of nonunions in our experience, since all fractures treated by adequate reduction and fixation healed promptly.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMedDate not supplied

Solitary osteochondroma of the clavicle.

There are no clinicopathologic reports of solitary osteochondroma of the clavicle other than listings in tumor registries. Two boys had solitary asymptomatic osteochondroma, in one at the medial and in the other at the lateral aspect of the clavicle. One underwent excision to correct cosmetic deformity. Several histologic and experimental studies have shown that osteochondromas originate from cells of the growth plate. During development of the clavicle, cartilage appears on both the medial and lateral aspects. Histologic studies have suggested that this cartilage is similar to a physeal growth plate. Experimental studies, however, have shown it to be a randomly organized secondary cartilage that develops in membranous bones once ossification has begun. The occurrence of an osteochondroma at the ends of the clavicle lends support to the theory that the cartilage at the ends of the developing clavicle functions as a growth plate.

Bone Neoplasms↗

PubMed1989

Growth of the clavicle and development of clavicular secondary cartilage in the embryonic mouse.

Whether secondary cartilage develops in the mammalian clavicle has been a matter of controversy. This study documents, in the embryonic mouse: (a) the onset of clavicular osteogenesis at 14 days of gestation (Theiler stage 22); (b) the appearance of secondary cartilage at 16 days of gestation (Theiler stage 24) and its persistence as a prominent cartilage until 18 days of gestation; (c) that the relative growth rate of the clavicle is much higher (0.097 mg/g body weight/day) between 16 and 17 days of gestation than at later ages (mean of 0.005 mg/g/day between 17 days of gestation and 4 days postnatally), and (d) that secondary cartilage failed to form in clavicles from 15-day-old embryos maintained in vitro. We conclude that secondary cartilage is a feature of the developing mouse clavicle, that it arises when the relative growth rate of the clavicle is highest, and that the most likely stimulus for differentiation of this cartilage is mechanical, muscle-based and associated with rapid relative clavicular growth.

Animals↗

PubMed1996

The results of operative resection of the lateral end of the clavicle.

Seventy-three patients had operative resection of the lateral end of the clavicle for the treatment of a painful condition of the acromioclavicular joint. Thirty-two of the patients had had a traumatic separation of the acromioclavicular joint, eight had had a fracture of the lateral end of the clavicle, and thirty-three had primary acromioclavicular osteoarthrosis. An average of sixteen millimeters (range, fine to thirty-three had primary acromioclavicular osteoarthrosis. An average of sixteen millimeters (range, five to thirty-seven millimeters) was resected; the amount was similar in each of the three groups. The patients were evaluated an average of nine years (range, four to sixteen years) after the operation. The result was considered good in twenty-one patients, satisfactory in twenty-nine, and poor in twenty-three. A poor result was more common in the patients who had had a fracture of the lateral end of the clavicle (p<0.01). Forty-six patients reported pain with exertion, and thirteen noted pain at rest. Eighteen patients had a decrease in the strength of the involved upper extremity, and sixteen had some limitation of the mobility of the shoulder. Elevation of the lateral end of the remaining part of the clavicle as compared with the scapula was noted in eighteen patients and was more likely to be associated with pain (p<0.05). The extent of the resection was significantly associated with pain; patients who had had a smaller amount of resection (ten millimeters or less) had less pain than those who had had a larger amount (p<0.03). A good result was more common in the patients in whom less than ten millimeters had been resected and who had had a previous traumatic separation of the acromioclavicular joint or had primary acromioclavicular osteoarthrosis. We recommend that resection of the lateral end of the clavicle be considered with caution for patients who have severe post-traumatic or degenerative osteoarthrosis of the acromioclavicular joint. If resection is performed, it should not exceed ten millimeters.

Acromioclavicular Joint↗

PubMed1997

Shortening of clavicle after fracture. Incidence and clinical significance, a 5-year follow-up of 85 patients.

We evaluated the incidence and clinical significance of postfracture shortening of the clavicle in 85 patients. There were 71 mid-clavicular fractures and 14 of the lateral end of the clavicle. 46 fractures were primarily undisplaced and 39 displaced. All fractures were nonoperatively treated with sling immobilization. All patients were reexamined 5 years after the fracture. 35 clavicles had healed with at least 5 mm shortening. Clavicles with originally displaced fractures were shorter and radiologically more frequently malunited. Mobility, strength and the functional Constant score were similar in the injured and normal shoulders. Our findings suggest that permanent shortening of the clavicle is common after fracture, but has no clinical significance.

Activities of Daily Living↗

PubMed2001

The clavicle: a vulnerable bone in pediatric oncology.

The clavicle is frequently incorporated into the radiation field in the treatment of malignant tumors located in the head and neck. From 1954 to 1995, 499 pediatric patients were treated with moderate to high-dose radiation therapy to the head and neck at the University of Texas M.D. Anderson Cancer Center. The medical records of 312 of these patients were available and were reviewed. The period of observation ranged from 5 to 30 years. Five late radiation-induced abnormalities of the clavicle were encountered: osteosarcoma; osteochondroma; malignant fibrous histiocytoma; radionecrosis and impaired healing following trauma and radionecrosis and lysis. The doses of radiation therapy which induced the abnormalities varied from 35 to 60.5 Gy (median 34.75 Gy). The interval from radiation therapy to discovery of the complications varied from 6 to 11 years. Two patients died: one from malignant fibrous histiocytoma and another from a radiation-induced meningioma of the brain (which accompanied radionecrosis of the clavicle). We conclude that the incidence of radiation-induced abnormalities of the clavicle in pediatric long-term survivors is low (1.5%). However, some of the late sequela are potentially fatal. The clavicle should be considered a vulnerable bone to radiation therapy and should be monitored in long-term survivors of childhood cancer. The experience is compared to radiation-induced abnormalities recorded in the literature.

Adolescent↗

PubMed2000

Unilateral absence of the clavicle with rapidly progressive scoliosis in an 8-year-old.

We report a possible association of unilateral absence of a clavicle with rapidly progressive scoliosis. Cleidocranial dysplasia (CCD) is an autosomal dominant disorder that is characterized by defective bone formation. The clavicle, pelvis, and skull are the most commonly affected bones. A review of the literature found two cases of CCD and scoliosis. Unilateral absence of the clavicle in association with rapidly progressing scoliosis has not been previously reported. Review of the patient's charts and radiographs from age 8 to 17 years, 5 years after treatment with posterior spinal instrumentation is presented, together with a review of the literature. Our patient initially presented without any spinal deformity until age 9, when she had a 10 degree curve between C-8 and L-T. Eighteen months later, the curve progressed to 52 degrees, Risser 1. Associated anomalies include posterior-element hypoplasia of the thoracic spine and posterior fusion of C4-6. She was treated with posterior spinal instrumentation from C-8 to L-4 without complications. Correction was maintained at 5-year follow-up. There may be an association between unilateral absence of the clavicle and rapid progression of scoliosis in immature children. We hypothesize that the asymmetrical influence of the unilateral absent clavicle may have played a causative role in her rapidly progressive scoliosis.

Cervical Vertebrae↗

PubMed2000

[Congenital pseudarthrosis of the clavicle: 25 childhood cases].

PURPOSE OF THE STUDY: Congenital pseudarthrosis of the clavicle is rare, only 200 cases having been reported. Based on 25 personal cases and an overview of the literature, we try to explain the etiology of this condition and the different kinds of treatment. MATERIAL AND METHODS: A retrospective analysis was performed on twenty-five children (16 females, 9 males, mean age at the end of the follow up - 11.5 yrs) from three different centers. We assessed the outcome of surgical and nonsurgical procedures, based on pain, functional ability, cosmetic results, and x-ray examination. RESULTS: A family background was noted in three children. The lesion always involved the right side. Twenty patients presented a bump over the middle third of the clavicle, thirteen a foreshortened shoulder girdle, three complained of discomfort. In two cases, palpation of the clavicular area was painful. No neurovascular compressive syndrome was reported. None of the patients complained of a decrease in the range of motion or in the strength of the upper limb. X-rays showed a middle third defect. In five cases we found abnormal first ribs. Seventeen patients underwent surgery, at a mean age of 6 years and 4 months. The procedure always included excision of the pseudarthrosis at both ends and internal fixation with a wire or a plate. In only eight cases a bone graft was used. Healing was achieved in fourteen patients. Three patients needed a second surgical procedure. In these 3 cases we had not used bone grafting. All patients had a normal range of shoulder motion, except a twelve year old girl who complained of discomfort of the right upper limb. The cosmetic result was good in eleven cases, one surgical wound was noted as hypertrophic, and one developed a keloid. An asymmetry of the trunk was still noted in seven cases. The x-rays showed symmetric clavicles in ten cases. Eight patients were treated conservatively. All of them had a normal range of motion of the shoulder, six had a good cosmetic result and two cases a poor one. DISCUSSION: According to Alldred, the anomaly results from the failed coalescence of the two primary ossification centers of the clavicle. The overview of the literature and our findings (in one case) confirm that the cartilage which covers both ends of the bone is made of growth cartilage. However, the true mechanism of the nonunion is still unknown. The three familial cases of our work suggest a possible genetic transmission of the disease. The diagnosis is based on the following criteria: right side lesion, found in infancy, without previous fracture, increasing size with growth, without major functional consequences, without neurofibromatosis or cleidocranial dysostosis symptom. X-rays or histologic examination will confirm the diagnosis showing the usual findings described above. Complications of the pseudarthrosis of the clavicle are rare and late. Conservative management appears to give good results as seen with our eight patients. However surgical treatment ensures symmetrical shoulder girdles and good function with few complications. Therefore, we recommend performing an excision of the cartilaginous caps, followed by an iliac bone graft and an internal fixation with wire. Surgical management will be preferred in symptomatic patients, in the case of major or increasing deformity, or on parental request.

Arm↗