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Fractured clavicle External 1/3: What attitude?
Interest minimally invasive arthroscopic techniques
The clavicle fractures affects about 2% to 5% of all fractures in adults and 10% to 15% of the child. They follow a bimodal distribution in function of age. Young men under 30 years and those aged over 70 seem to be the most vulnerable age groups.
In adults, more than two thirds of these fractures occur in the middle third of the clavicle with a larger displacement potential for fractures of the medial and lateral 1/3.
Since its first description by Neer in 1963, the ideal management of the fracture of distal third of the clavicle remains a matter of debate. Traditionally, conservative treatment is the rule. Functional results of the surgically treated group were comparable to those treated functionally, which has led many authors to advocate a non-surgical approach to this initial fracture. But this type of treatment does not bring good results. Recent data suggest that some patients may be at high risk of consolidation, have a dysfunction of the shoulder girdle on malunion, or have chronic pain. However, despite sometimes higher nonunion rates of 22-44%, less than 15% of the patients required surgical treatment for the treatment of a nonunion. In theory, surgery might minimize long-term complications.
Even before these high rates of non consolidation and the difficulties of the secondary management of these fractures, other authors recommend early surgery. Edwards et al reported a series of 43 patients with Neer type II fractures of which 23 were treated surgically. Consolidation has occurred in all patients treated surgically, while the treated group presented a functionally rate of non consolidation of 30% and a rate of 45% of delayed. Therefore, the specific treatment of clavicle fractures should not be used widely but must be individualized according to the characteristics of the fracture and patient expectations.
If one focuses specifically fractures of distal third of the clavicle, they are less common than shaft fractures but can lead to poor functional results. Neer classified them into three types depending on the location of coracoclavicular ligaments compared to the fracture line.
Type I fractures are stable with coracoclavicular ligaments intact, attached to the medial fragment. Type II fractures are compared to medial ligaments. Craig and Rockwood added two subtypes in the initial classification: type IIA, where coroco-clavicular ligaments are attached to the lateral fragment, and IIB, with detachment of the conoid ligament lateral fragment. Type III fractures are stable intra-articular fractures.
These fractures, treatment for type IIB remains controversial. While other fractures can be treated conservatively, those type IIB are known to be unstable at risk of consolidation and malunion in cases of non-surgical treatment (> 20%), thus requiring often surgical treatment for optimal functional outcome.
Several surgical techniques with different fastening systems have been described. However, for most of the techniques have been reported complications such as rupture, relaxation or migration of the implant, infection, not consolidation, erosion of the clavicle or acromioclavicular osteoarthritis. Recent arthroscopic techniques using synthetic grafts showed a decrease surgical morbidity and reduced complication rate.
Conservative treatment is to immobilize the upper limb trauma with a summing device most often a simple scarf or sash / scarf against the patient is very painful. Conventional clavicular rings are poorly tolerated because based directly on the fracture most often. Downtime varies depending on the type of fracture and age of the patient. If stable fracture, 3 to 4 weeks of immobilization serious enough usually followed by a relative immobilization, consisting primarily of a use restriction of the injured limb (no heavy load port, no untimely mobilization ...) . In case of unstable fracture, if surgery is not possible, strict immobilization of six weeks is required with regular monitoring of the fracture.
The goal of treatment is to achieve bone healing while minimizing shoulder dysfunction, morbidity immobilization and aesthetic deformity. Because the majority of fractures of the lateral third of the clavicle are not moved or moved little and extra-articular, conservative treatment is usually the treatment of choice. Thereafter, rehabilitation for a satisfactory result for most patients. To protect the collarbone, it is recommended to avoid contact sports for at least 4 to 5 months. A special feature for children and adolescents. The physis of the lateral portion of the clavicle merges at the age of 25 years. Therefore, most lesions of the lateral end of the clavicle resulting from separation of the physis rather than a fracture because the acromioclavicular ligaments and coracoclavicular are biomechanically stronger than the snail. Due to the physeal injury, there is a great potential for healing and remodeling. The majority of these fractures can be treated by simple immobilization. Surgical indications are rare, if the fracture is displaced, if there is interposition of soft tissues through skin opening, or soft tissue pain in adolescents.
The indication of surgical treatment of the third lateral clavicle is based on the stability of clavicular segments compared to coracoclavicular ligaments (CC), the displacement of the fracture and the patient's age. The integrity of the CC ligaments plays a key role in ensuring the stability of the medial fragment. The displacement of the medial part of the cl
avicule is observed when the CC ligaments are damaged. It is established that this fracture configuration leads to rates of non consolidation of up to 28%. Some authors have confirmed that the risk of non consolidation increased with age and displacement. The presence of cutaneous suffering, polytrauma, and the floating shoulder are also surgical indications.
Many surgical techniques have been proposed to stabilize these fractures. These include the fixing transacromial by pins or the technique of pin-rigging, the coracoclavicular screws, locked or unlocked plates, hook plates, direct suture techniques or other synthetic grafts systems coraco clavicular which are also used during the reconstruction of the acromioclavicular joint. These techniques can be combined to enhance the main fixation. Some fixing means, in particular the plates and the pins are generally removed after 8-12 weeks when the fracture is consolidated radiographically and clinically cured patient. This avoids the acromial osteolysis or other complications caused by the hardware, pin migration, the stiffness of the shoulder girdle met in coracoclavicular fixings screws. No fastening techniques described has been recognized as a "gold standard", and each has its advantages and disadvantages. Some techniques have a high rate of complications, such as the pin migration rates that can reach up to 50%. The failure of this way of fixing has led several authors to recommend that it not be used as a fixation technique in first intention.
The choice of a fastening system may also depend on the characteristics of the fracture can be very distal or comminuted for example. This commits to master several techniques to suit the type of fracture met.
Conservative treatment of fractures of the lateral third of the clavicle provides good results in over 98% of cases for little or no displaced fractures. The rate of non consolidation is much higher for displaced fractures, Neer Type II and up to 33% if treatment is non-surgical.
The delay of surgery for fractures of the lateral third seems more important for the prognosis of patients compared with fractures of the middle third. The complication rate is higher when surgical treatment is delayed (7% vs 36%).
Fractures of the lateral third of the clavicle with intra-articular extension at increased risk of osteoarthritis of the acromioclavicular joint. If acromioclavicular arthritis occurs, the patient may require a modeling arthroplasty acromioclavicular joint secondarily.
Open surgical techniques
Consolidation rates reported in the literature of 94%. Although the setting seems improved, this technique is associated with complications, including fractures around the equipment (5%), the acromial wear and no consolidation (5%). In addition to these complications, it was recommended that the equipment be removed after the consolidation because of the acromial it causes abrasion, thus requiring the patient to undergo a second surgery.
Some series have reported the results of the top locking plates for unstable fractures of the distal third of the clavicle. This technique provides good results but complications have been described as non-consolidation, fracture around the implant, infection or iatrogenic acromioclavicular dislocation. Some teams combine this extra coracoclaviculaire plate mounting system to prevent lateral withdrawal of screws. This plate may require further intervention to effect its removal.
Arthroscopic surgical techniques
Recently, arthroscopic techniques have been used for surgical treatment of acromioclavicular dysjonctions but also in the treatment of these fractures of the lateral third of the clavicle. This technique uses synthetic grafts which are stretched between the clavicle and the coracoid process, and allow the fracture reduction and consolidation is open.Very encouraging results were published with these minimally invasive procedures. It is recognized by many authors that this technique reduces surgical morbidity and reduced the rate of complications. It is performed during a shoulder arthroscopy with 2 arthroscopic approaches, posterior to the anterior optic and an instrumental. A third approach is performed on the clavicle to introduce the fastening system. Some rare complications are described as transitional retractile capsulitis, secondary symptomatic acromioclavicular osteoarthritis and implant failure leading to non consolidation.
Some surgical techniques require a second surgery to remove the implant which is not the casesutures or synthetic grafts posed by the arthroscopic technique. On plates or intramedullary fixations, some authors recommended the removal of the implant systematically when bone healing was achieved.
The treatment of fractures of the lateral third of the clavicle is based on the precise analysis of the fracture line that defines the stability of the fracture. The indication is also based on the importance of initial displacement. In case of flat or slightly displaced fracture, conservative treatment provides excellent functional results, even in cases of nonunion often very well tolerated. Surgical treatment is recommended in case of unstable or displaced fracture andmust use a technique with low risk of complications with a high degree of consolidation. Minimally invasive arthroscopic techniques develop and become a preferred option in the treatment of fractures of the distal clavicle 1/3.
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