Clavicle Fractures

Suture Fixation for Distal Clavicle Fractures

Introduction:

Suture Fixation for Distal Clavicle Fractures

Distal clavicle fractures comprise 15% of all clavicle fracture. Neer classified these fractures into 3 groups, based on the coraco-clavicular ligaments and the acromio-clavicular joint. The type 2 Neer fractures exhibit significant displacement. Conservative management has a high rate of delayed and non-union.

Operative management is therefore recommended. Various surgical procedures are available which include trans acromial wires, coraco-clavicular screws, (hook)plates and more recently the tight rope.

Technique of Suture Fixation:

The patient is placed in the beach chair position. An image intensifier is positioned to allow adequate imaging of the fracture. A small longitudinal skin incision (usually about 3 cm) is made over the fracture site. The delto-trapezial fascia is incised horizontally to expose the fracture. The fracture ends are refreshed. A 2 mm drill hole is made in the distal fragment. A PDS loop is passed through the drill hole from anterior to posterior and used to shuttle a PDS cord through. A second drill hole is made in the proximal fragment. The posterior limb of the PDS cord is passed over the fracture site and brought anteriorly. This is then passed through the proximal drill hole from anterior to posterior using the PDS loop. The fracture is then reduced by elevating the arm and the PDS cord is tied over the top in a figure of eight.

The patients are then placed in a polysling with a body belt for 6 weeks before mobilising the shoulder.

Fig 1 : Diagramatic representation of Technique

Fig 2: Introperative image showing Fig of 8 loop in situ

This technique is simple with good clinical outcome. It avoids the need for extensive exposure, especially around the coracoid, and provides good cosmesis.

Fig 3a: Pre op Radiograph

Fig 3a: Post op Radiograph

References:

Simple, minimally invasive surgical technique for treatment of type 2 fractures of the distal clavicle. Ofer Levy, MD, MCh(Orth), Reading Shoulder Unit, Berkshire, United Kingdom.

J Shoulder Elbow Surg, January/February 2003; 12 (1); 24-28.