A variant of a type V lateral clavicle fracture involving a posteriorly displaced medial segment. A case report
© Goss and Li; licensee BioMed Central Ltd. 2012
Received: 30 January 2012
Accepted: 5 December 2012
Published: 12 December 2012
The clavicle connects the shoulder girdle to the axial skeleton, providing support and mobility for optimal upper extremity function. Fractures of the clavicle account for up to 4% of all fractures and comprise up to 44% of all injuries to the shoulder girdle. We present a 63-year-old female patient who suffered what appeared to be a minimally displaced Type V lateral clavicle fracture after a fall as evidenced by an anteroposterior shoulder radiograph. However, an axillary projection demonstrated the proximal segment to be posteriorly displaced and buttonholed through the trapezius musculature with tenting of the skin. The patient underwent an open reduction and Kirschner wire fixation of the fracture with complete healing, subsequent removal of the hardware and return to her previous level of function six months following surgery. After an extensive literature search, we believe this is the first case report documenting a variant of a Type V lateral clavicle fracture, specifically with significant posterior displacement of the proximal segment, mimicking a Type IV AC separation. This fracture pattern is unstable and represents a double disruption of the superior shoulder suspensory complex. Surgical management was successful in returning our patient back to her previous activity of daily living.
The clavicle connects the shoulder girdle to the axial skeleton, providing support and mobility for optimal upper extremity function. Fractures of the clavicle account for up to 4% of all fractures and comprise up to 44% of all injuries to the shoulder girdle [1–3]. These fractures can be separated into three varieties according to anatomic location (Allman’s classification) . The majority occur in the middle third of the clavicle with about 17% involving the lateral third and less than 3% involving the medial third . Fractures of the lateral third of the clavicle can be subdivided into five types. The first three types were originally described by Dr. Neer and types IV and V were added later. Type I injuries are nondisplaced with the coracoclavicular (CC) ligament attached to the medial segment. Type II injuries are separated into IIA and IIB. In the type IIA injury, the CC ligament is not torn and attached to the lateral segment while the medial segment is displaced superiorly. Type IIB fracture consists of a torn conoid ligament while the trapezoid ligament is attached to the lateral fragment, thus the medial segment is displaced. Type III injuries involve the articular surface of the lateral clavicle. Type IV injuries are pediatric periosteal sleeve fractures. Type V are comminuted lateral clavicle fractures with the CC ligament intact but attached to one of the fracture fragments which is detached from the proximal or medial segment [5–7].
We present a 63-year-old female patient who appeared to suffer a minimally displaced Type V lateral clavicle fracture. However, an axillary projection demonstrated the proximal segment to be posteriorly displaced, possibly protruded through the trapezius muscle. In this study, we describe the first report of a case documenting a variation of a type V lateral clavicle fracture, specifically with significant posterior displacement of the proximal segment, mimicking a type IV acromioclavicular (AC) joint separation. This fracture pattern also represents a double disruption of the superior shoulder suspensory complex . The clinical presentation, radiographs, and surgical management are presented. The patient was informed that the data, clinical, and intraoperative pictures concerning her case would be submitted for publication and she has consented. This case report was exempt from the IRB.
Fractures of the clavicle are common injuries [1–3]. Most involve males, about 80% involve the middle third and adults are more likely to have a displaced fracture than children . There are two peaks in the incidence of clavicle fractures: the first is in males less than thirty years of age and the second is in females over the age of eighty years [3, 9, 10]. Most fractures of the middle third are acceptably displaced, whereas fractures involving the medial and lateral thirds tend to be non-displaced . As noted earlier, five types of lateral clavicle fractures have been described in the orthopaedic literature [5–7]. In the Type V variety; the lateral clavicle fracture is comminuted, however the CC ligament (conoid and trapezoid) is intact but attached to an intermediate inferior clavicular fragment, resulting in its functional detachment from the proximal segment .
The superior shoulder suspensory complex (SSSC) is comprised of the glenoid, coracoid, and acromial processes, the CC ligament, the lateral clavicle, and the AC joint. The SSSC is therefore a bone and soft tissue structure, which provides considerable stability and some mobility to the shoulder girdle. A disruption of two of the components of the SSSC results in a potentially unstable anatomic situation that can have adverse healing and long term functional consequences [8, 11]. Both Type II and V lateral clavicle fractures represent a double disruption of the superior shoulder suspensory complex (two disruptions of the clavicular-scapular linkage), characterized by a lateral clavicle fracture and a detachment of the coracoclavicular ligament from the proximal segment. Consequently, a strong case can be made for simplifying the classification scheme by eliminating the Type V variety and considering such injuries as a Type II variant. As a double disruption of the SSSC, a potentially unstable anatomic situation is present -- the scapular/distal clavicular segment can displace inferiorly and to a lesser degree the proximal clavicular segment can displace superiorly. If displacement is significant, there is the potential for a nonunion occurring at the clavicular fracture site and a surgical ORIF must be considered. In our patient, however, displacement of the proximal segment was posterior with buttonholing through the trapezius muscle (a situation reminiscent of a Type IV AC joint separation). The mechanism of injury most likely included either an anterior to posterior directed force applied to the proximal segment or a posterior to anterior directed force applied to the distal segment or a combination of both [6, 11–14]. Many different surgical techniques have been described in the literature for the treatment of significantly displaced lateral clavicle fractures [5, 9, 15–18].
There are two case reports in the literature describing a posteriorly displaced proximal clavicular segment entrapped within the trapezius muscle associated with a lateral clavicle fracture. Both involved pediatric patients. Itokazu et al.  reported an 11-year-old child with this particular injury pattern after a fall from a bicycle who underwent open reduction with Kirschner wire fixation and returned to previous activity at the final follow up. A closed reduction under general anesthesia and non-operative management was also successful in a 13-year-old hockey player with this particular injury pattern. The authors concluded that patients with an open physis and a thick periosteum, a closed reduction could be successful in the treatment of a lateral clavicle fracture with posterior displacement of the medial segment . In our adult patient, however given the significant posterior displacement through the trapezius muscle with tenting of the skin by the proximal segment, a surgical open reduction and internal fixation was necessary to prevent a non-union and persistent discomfort/dysfunction from occurring. Kirschner wire fixation of lateral clavicle fractures has been associated with pin breakage and proximal migration . In our patient, the wires were bent, left beneath the skin and removed when callus was seen on follow-up radiographs. It is essential to bend the K-wire at the end to prevent migration. Another key component of our case is obtaining the axillary radiograph view to make this diagnosis. It is very important to get both the AP and axillary view on lateral clavicle fractures to make sure that the medial segment is not displaced posteriorly before considering treatment options.
To the best of our knowledge, this is the first report of an adult patient with a variant of the type V lateral clavicle fracture and the proximal clavicular segment displaced posteriorly and entrapped within the trapezius muscle. The patient did well and returned to her previous functional status six months following open reduction and Kirschner wire fixation. At the one-year follow-up, the patient continued to do well without any complications.
In patients sustaining a fracture of the lateral third of the clavicle, both anteroposterior and axillary radiographic views must be obtained given that the AP projection may look to be quite acceptable, while the axillary view may reveal the true nature of the injury. Our patient presented with a type V lateral clavicle injury with the proximal clavicular segment posteriorly displaced and buttonholed through the trapezius muscle. We believe type V lateral clavicle fractures should be considered a type II variant as both represent a double disruption of the superior shoulder suspensory complex (SSSC). Such double disruptions represent a potentially unstable anatomic situation, requiring a surgical open reduction and internal fixation if significant displacement is present as was the case with our patient.
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