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THE
FLOATING
CLAVICLE
DOLFI
AND
HERSCOVICI
JR,
NECK
G. T. W. FIENNES,
R#{228}tisches Kantons
mid-clavicular
IPSILATERAL
SCAPULAR
ALBERIC
From
In ipsilateral
SHOULDER:
and
FRACFURES
M. ALLG#{246}WER,
Regionalspital,
THOMAS
P. RUED!
Switzerland
and scapular-neck
fractures,
the mechanical
stability
of the suspensory
and the weight of the arm pull the glenoid fragment
distally
and
we recommend
internal
fixation of the fractured
clavicle
by a plate
patients
with this unusual
injury;
all achieved
an excellent
functional
result
structures
is disrupted
and muscle forces
anteromedially.
To prevent late deformity
and screws. We treated
without deformity.
seven
Fractures
constitute
of the scapula
are high-energy
1% of all fractures,
and
involving
the
shoulder
(Imatani
injuries
; they
of fractures
5%
1975;
McGahan,
berger
Simpson
1975;
and
treatment
in injuries
scapula,
is not
but
this
usually
of the
so when
produces
clavicle
both
MATERIALS
good
or
or of the
bones
Christ
1975;
Hardegger,
Rab
and Dublin
1980). Clavicle
fractures
are common,
usually
being caused
by a fall or a blow to the tip of the shoulder.
Conservative
excellent
results
Tscherne
and
Weber
1984).
are
AND
METHODS
We observed
1 1,004 trauma
patients
from January
1979
to April 1990; 145 (1 .3%) had clavicle
fractures
and 68
injured
simultaneously.
Table
I.
Definitions
and
ratings
of the
functional
examination
ANATOMY
The
glenohumeral
joint
Score
allows
the
arm
a wide
range
movement
tures must
movements.
in all directions,
and the surrounding
provide
stability
without
constraining
The capsule
and the glenohumeral,
clavicular,
acromioclavicular
ments
rotator
which
involving
the clavicle
When
there
help
muscles
the
is a fracture
the scapula
and
becomes
unstable
fragment
to maintain
and
the
(Fig.
acting
distally
on
and
liga-
pectoralis
and
and stabilising
stability
scapula.
of both
the surgical
humerus
pull
anteromedially
Subjective
Pain
None;
requires
no medication
Mild ; occurs with severe stress, rarely requires
medication,
i.e., less than twice a week
Moderate
; occurs
with prolonged
activity,
may have
changed
jobs or quit certain
sports,
requires
medication
two
to five times a week
Severe ; limits
all activities,
pain
at rest, requires
medication
more than five times a week
neck
(Ganz
of
fracture
arm and
the
glenoid
and
Noes-
Life-style
Occupation
and sport activity
level equal to pre-injury
Injury caused occupational
change
or limited
certain
Correspondence
Orthopaedic
33617-2011,
© 1992
should
Institute,
USA.
be
4175
sent
East
R#{228}tisches Kantons
British
Editorial
Society
ofBone
0301-620X/92/3323
$2.00
J Bone Joint Surg [Br]
1992; 74-B : 362-4.
362
state
sport
Can only perform
assistance
Total disability
Physical
examination
Range of abduction
activities
ofdaily
living
or needs
minimal
and
D. Herscovici
at
Avenue,
Tampa,
and
Joint
3
2
Surgery
RegionFlorida
Florida
4
3
4
3
2
Muscle
strength
Grade
5
Grade
4
Grade
3
Grade
2 or less
Functional
Excellent
Good
2
or flexion
120#{176}
90#{176}
to 120#{176}
45#{176}
to 90#{176}
<45#{176}
to Dr
Fowler
4
activities
>
D. Herscovici
Jr, DO, AO Fellow
A. G. T. W. Fiennes,
MS, FRCS
M. Allgower,
Trauma
Scholar
T. P. ROedi,
MD, FACS,
Professor
Department
of Trauma
and Surgery,
alspital,
Chur CH-7000,
Switzerland.
examination
in fractures
clavicle,
the
scapular
1) and the weight
of the
the
structhese
coraco-
coracohumeral
along with the deltoid,
trapezius,
cuff muscles
are the suspensory
structures
the
and
of
4
3
2
rating
13 to 16
9 to 12
5to8
4 or less
Fair
Poor
THE
JOURNAL
OF BONE
AND
JOINT
SURGERY
THE
FLOATING
Fig.
Figure
1a
- Unstable
Stable
fracture
-
:IPSILATERAL
SHOULDER
fracture
pattern
CLAVICLE
AND
SCAPULAR
NECK
la
FRACTURES
Fig.
of the scapular
neck with
with an ipsilateral
clavicle
an intact
fracture.
clavicle
and
363
lb
coracoclavicular
ligaments.
Figure
1b
were started
within
three to five days. Patients
treated
nonoperatively
also used a sling and started
active
exercises
as soon as their associated
injuries
allowed.
Review.
At review,
about
pain,
strength
and
were
the
were
and
muscle
as having
uninvolved
with
was
were
Anteroposterior
mid-shaft
clavicle
view of the
fractures.
(0.6%)
had scapular
(0. 15%) with fractures
of these
had
patients
Patients
taken
the
results
of the
deformities
the overall
or
were
using
clavicle
but the
functional
rating.
2
showing
fractures.
of both
ipsilateral
scapular
and
(Hardegger
have
Seven patients
had been treated
surgically
and all were
rated as excellent
at review.
Five had no pain and two
There
were
17 patients
bones,
but only 11 (0.10%)
clavicular
fracture
of these
as
RESULTS
a mid-shaft
scapular-neck
Two
scapula
Muscle
abduction
of motion
fair or poor
and the scapula
to identify
residual
radiological
findings
did not affect
Fig.
range
recorded.
good,
criteria
in Table
I.
Follow-up
radiographs
and
shoulder
the lowest
strength
excellent,
by questionnaire
life-style.
in flexion
the
function
weakest
asked
present
ofmovement
using
The
rated
the
range
recorded,
control.
patients
medication
and
an
et a! 1984)
since
died.
We
have
had
pain
pain
ipsilateral
(Fig.
2).
only
control
previous
on exertion.
and
None
only
two
medication
failed
to return
for
to their
life-style.
Of the two patients
reviewed
required
had
treated
conservatively
one had a
the remaining
nine patients,
one by telephone
interview
only.
There
were five men and four women
with a mean
good and one a poor result.
Both,
however,
had suffered
severe
associated
injuries
which
was
the reason
for
nonoperative
treatment.
One
had an ipsilateral
hemi-
age of 29.6 years (17 to 58). Six patients
had
the left side. All the fractures
were closed.
plegia
follow-up
was
had
caused
been
Treatment.
surgically,
either
48.5
months
by traffic
(2 to 132).
3.5 mm
AO
arm
was
placed
VOL.
74-B,
No.
AO
3, MAY
in a sling
1992
who
had
been
of the clavicle
dynamic
reconstruction
of the injuries
accidents.
In those
patients
primary
stabilisation
a 3.5 mm
Most
the injury on
The average
compression
plate.
for comfort
treated
was by
plate
or a
Postoperatively,
and
active
the
exercises
and
a sequel
his
the other
breathing,
his
activities.
All the
fractures
tively
treated
showed
(Fig.
3).
but
strength.
greater
had
pain,
not
to lung and thoracic-wall
All
ability
to sleep
united.
one
in his shoulder,
injuries,
The
and
two
‘drooping’
oftheir
patient
obtained
which
his
but
as
affected
recreational
patients
injured
grade-S
conservashoulders
muscle
Seven patients
achieved
a range of movement
than
1350 in both abduction
and flexion,
as
364
D. HERSCOVICI
compared
with
160#{176}
on the
uninjured
side.
chest-wall
injuries
limited
movement
and abduction
in one patient
and
attributed
to his recent
There
were
w.
A. G. T.
JR,
FIENNES,
M. ALLG#{246}WER,
T. P. RUEDI
Associated
to l250
in another
in flexion
to 1 iSO,
surgery.
no surgicalcomplications
in the operated
group.
Four patients
complained
of minor
discomfort
when carrying
knapsacks
or skis but this was always
relieved
when the load was adjusted.
All the surgically
treated
patients
were pleased
with the appearance
of the
injured shoulder.
DISCUSSION
Although
uncommon,
fractures
of the scapula
are usually
caused by higher energy injuries than those ofthe clavicle.
Both, however,
heal well with conservative
care. Surgery
Drooping
fixation
is traditionally
surgeons
fixation
both
reserved
the
clavicle
clavicular
for
and
fracture
may
Johnston
injuries
involving
However,
be clinically
fracture
may be missed
Khan
and Lucas
1978;
and
certain
scapula.
obvious
only
the
; the scapular
et al 1984;
Aulicino
et a!
1986; Jupiter
and Leffert
1987; R#{252}ediand Chapman
1988). This may result
in unnecessary
disability
due to
distal and anteromedial
displacement
of the fracture
of
the scapular
neck.
There
have
been
few
descriptions
of this
several
reasons.
First,
the diagnosis
secondly,
a failure
to understand
anatomy
may
lead
to
injury
for
may be missed;
the pathological
undertreatment
; thirdly
not
of
injuries
culoskeletal
neck
divert
the
clavicle
If the
internal
as soon
conservatively,
without
with
the technique
of
; and lastly
the severity
may
recommend
of the
views.
then
treated
attention
from
internal
of the
the
mus-
damage.
We
graphs
of a patient
clavicle.
are familiar
these
bones
associated
(Rowe
1968 ; Imatani
1975 ; Ali
McGahan
et al 1980; Wilkins
1983 ; Hardegger
left shoulder
of the fractured
injury
of anteroposterior
scapula,
pattern
fixation
as possible
use
and
and
described
here
of the clavicle
to prevent
radio-
trans-scapular
should
malunion
is present,
be performed
of the
scapular-
fracture.
We wish
to thank
all
article.
No benefits
from a commercial
this article.
Ms Anne
Palmer
for her help
in the preparation
of
this
in any
party
form
have
been
related
directly
received
or will be received
or indirectly
to the subject
of
REFERENCES
All Khan MA, Lucas
HK.
clavicle.
Injury 1978;
AUIICInO PL,
articular
fixation.
Ganz
R, Noesberger
Simpson
fractures.
RJ.
Fractures
Jupiter
JB,
Leffert
1987
LA,
Weber
J Bone
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ofthe
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JP,
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A. Fractures
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J Trauma
1980; 20 :880-3.
Williamson
by open
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1975 ; 126:59-62.
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[Am]
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Hardegger
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der
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1984;
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I
THE
JOURNAL
OF BONE
AND
JOINT
SURGERY