University of Medicine and Pharmacy [627888]

University of Medicine and Pharmacy
“Iuliu Ha țieganu” Cluj-Napoca
Faculty of General Medicine
LICENSE THESIS
On the “topic” of
Displaced clavicle fractures treated with
pre-contoured
locking compression plates
Coordinator: MD PhD Adrian Todor,
Orthopedic & Traumatology Clinic “Alexandru Radulescu”,
Cluj-Napoca

Graduate: Isabella Geiger
2019

Table of Contents
General review ……………………………………………………………………………………….. 4
1. Abstract …………………………………………………………………………………………. 5
2. Embriology …………………………………………………………………………………….. 6
3. Anatomy & Biomechanics ………………………………………………………………… 6
4. Epidemiology of clavicular fractures ………………………………………………….. 8
5. Mechanism of injury ………………………………………………………………………… 9
6. Clinical Evaluation of clavicular fractures ………………………………………… 10
7. Classification of clavicular fractures ………………………………………………… 12
8. Treatment approaches in clavicular fractures …………………………………….. 16
8.1 Conservative treatment …………………………………………………………….. 16
8.2 Surgical treatment ……………………………………………………………………. 17
8.2.1 Closed reduction with intramedullary fixation ………………………. 17
8.2.2 ORIF with plates and screws ………………………………………………. 18
8.2.3 External fixation ……………………………………………………………….. 21
8.2.4 Experimental techniques ……………………………………………………. 22
8.3 Treatment in lateral and medial third fractures …………………………….. 22
9. Complications of clavicular fractures ……………………………………………….. 24
9.1 Complications of conservative treatment ……………………………………. 24
9.2 Early and late complications of surgical treatment in middle third
fractures ……………………………………………………………………………………….. 25
10. Aims and objectives of the study ……………………………………………………. 25
Special review ………………………………………………………………………………………. 27
1.Introduction ……………………………………………………………………………………. 28
2. Materials and Methods
……………………………………………………………………………………………………….. 28
3. Results ………………………………………………………………………………………….. 29
3.1. Age ………………………………………………………………………………………. 29
3.1.1. Absolute distribution ……………………………………………………….. 29
3.1.2. Mean, maximum & minimum ages …………………………………….. 30
3.1.3. Age peaks ……………………………………………………………………….. 30
3.1.4. Complications depending on the age
……………………………………………………………………………………………….. 30
3.2. Gender ………………………………………………………………………………….. 31
3.2.1. Distribution ……………………………………………………………………… 31
3.2.2. Predisposition to clavicle fractures …………………………………….. 31
3.2.3. Correlation between gender and post op-complications ………… 32
3.3. Season
……………………………………………………………………………………………………. 32
3.4. Type of accident ……………………………………………………………………… 33
2

3.3.1. Types of accidents and their absolute prevalence ……………………… 33
3.3.2. Correlation between type of accident and the fracture types …..33
3.4. Time passed after accident ……………………………………………………….. 35
3.4.1. Absolute number of patients ………………………………………………. 35
3.4.2. Correlation between Post operative complications and time of
presentation ……………………………………………………………………………… 35
3.5. Type of fracture and their absolute prevalence ……………………………. 36
3.6. Associated injuries ………………………………………………………………….. 37
3.6.1. Prevalence of poly or single trauma ……………………………………. 37
3.6.2. Correlation between poly trauma and post surgery complications
……………………………………………………………………………………………….. 37
3.7. Fracture side …………………………………………………………………………… 38
3.8. Plate type & Complications ……………………………………………………… 38
3.8.1. Plate distribution …………………………………………………………………. 38
3.8.2. Complication distribution (1) …………………………………………….. 39
3.8.3. Complication distribution (2) …………………………………………….. 40
3.8.4. Plate choices and the number of complications after surgery ….40
3.8.5. The correlation between fracture type and the plate which was
used…………………………………………………………………………………………. 41
3.8.6. The correlation between plate type and after surgery
complications …………………………………………………………………………… 42
3.9. Screws …………………………………………………………………………………… 42
3.9.1. Distribution of total screws used among the patients ……………. 42
3.9.3. Distribution of Locking Screws among the patients treated with
LCPs ……………………………………………………………………………………….. 43
3.9.4. Correlation between the complicated fractures and the amount of
looking screws used ………………………………………………………………….. 43
3.10. Period between operation and readmission ………………………………. 44
4. Discussion …………………………………………………………………………………….. 45
5. Conclusion ……………………………………………………………………………………. 54
Acknowledgment …………………………………………………………………………………… 55
3

General review
4

1. Abstract
“…if thou examinest a man having a break in his collar-bone and thou shouldst
find his collar-bone short and separated from its fellow….. thou shouldst place
him prostrate on his back, with something folded between his two shoulder-
blades; thou shouldst spread out with his two shoulders in order to stretch
apart his collar-bone until that break falls into its place, thou shouldst make for
him two splints of linen, and thou shouldst apply one of them both on the inside
of his upper arm, thou shouldst bind it with yarn, and treat it afterward with
honey every day, until he recovers …” (1)
Case 35 of the Edwin Smith Papyrus, on how a displaced clavicle fracture was
treated in the seventeenth century B.C..
Even today, in the 21st century, clavicular fractures are still treated by splinting,
though the follow-up treatment with honey is no longer applied. Traditionally
clavicle fractures are treated nonoperatively, using a sling or figure-of-eight
bandage. The majority of adults treated nonoperatively for midshaft clavicle
fractures will make a complete recovery. However, more recent studies have
shown that the number of complications arising after traditional treatment
maybe higher than previously reported. Recent evidence demonstrates that
operative treatment of middle third clavicle fractures can result in better func –
tional results and patient satisfaction than nonoperative treatment. The method
for treatment I will present in my thesis is the pre-contoured locking compres –
sion plate. It is an anatomically fitted plate for surgical stabilization of displaced
clavicle fractures. I will concentrate the focus on middle third fractures due to
their prevalence.
5

2. Embriology
The clavicle is formed during the fifth week of fetal life, thus being the first bone
to ossify in the human body. (2) It is also the only bone which ossifies exclu –
sively intramembranous. The shaft ossifies from two primary centers which
fuse within four to five days after birth. Cartilage develops at both ends of the
clavicle but the medial cartilage contributes more to the growth and length of
the clavicle. In the late teens, a secondary ossification center develops at the
sternal end and sometimes at the acromial end. By the age of 23 years, both
epiphyseal plates have fused in both sexes. (3)
3. Anatomy & Biomechanics
The clavicle lies in a horizontal position at the root of the neck. (3) It is part of
the pectoral girdle and connects the skeleton of the upper limb to the axial
skeleton. This way it can transmit traumatic impacts to the trunk to avoid se –
vere injuries of the upper limb. (4) A small study with 12 fresh cadaveric clavi –
cles showed that it can sustain up to 1526,19 Newton. (5)
The shape of the clavicle is an elongated capital S. The dual-curved form pro –
vides stability and increases the range of motion of the arms. Its medial end ar –
ticulates at the sternoclavicular joint with the manubrium of the sternum. The
clavicle is connected laterally to the acromion via the acromioclavicular joint.
Posteromedial to the clavicle passes the neurovascular bundle. It is composed
of the roots of the brachial plexus, the subclavian vein and artery. The clavicles
function is to protect that bundle from direct injury. The anterior surface of the
clavicle lies deep to the skin and can easily be palpated. The inferior surface
connects the clavicle to the 1st rib via the costoclavicular ligament. The inser –
6

tion point of the ligament leaves an impression on the inferior surface. The
other ligaments inserting on the clavicle are called coracoclavicular ligaments.
The conoid ligament inserts on the conoid tubercle and the trapezoid ligament
on the trapezoid line. (4) Both insertion points are located at the lateral two-
fifths of the clavicle. (3) Their farther end is attached to the coracoid process
(Figure 1). The fixed position of the clavicle facilitates the rising of the ribs for
deep inspiration. The muscles attached to the clavicle on the superior surface
are the trapezius, deltoid, sternocleidomastoid and pectoralis major. On the in –
ferior surface the subclavian, the deltoid, the pectoralis major and the sternohy –
oid muscles (Figure 2). The muscles and ligaments give the displacement
forces when the clavicle fractures. (4),(6)
7
Figure 1-Ligaments

4. Epidemiology of clavicular fractures
Generally speaking, clavicle fractures are injuries that tend to occur frequently.
Reasons for this include its location in the human body, its structure and its ar –
ticulations. Its location is superficial, beneath the skin and a thin platysma mus –
cle. Therefore, it is one of the bones least protected by muscle or fat tissue.
Fractures of the clavicle are most commonly caused by trauma but can also be
due to metastatic or metabolic diseases. They represent 44-66% of all shoul –
der fractures and as in many traumas the prevalence is highest among the
young population, in children about 10-15%. The mean age is 29.3 years and
males are affected more often than females (67.9% vs 32.1%). (2)
A mid-shaft fractures is, at 85%, the most typical location for afracture on the
clavicle. (7) A reason for this is the contour change at that level from tubular
medially to flat laterally. (2) The midshaft is also the thinnest part (with a mean
8
Figure 2-Muscles

cortical thickness of only 2,05mm) and has less bony medulla. It is not as stabi –
lized by muscles and ligaments as the other two parts. Lateral and medial frac –
tures are rare because the two extremities of the clavicle are supported by
muscles, ligaments and the joint capsules. (8) Lateral fractures are similar to
acromioclavicular joint separation injuries and medial fractures may lead to life-
threatening mediastinal injuries which is the reason why they should be investi –
gated by a CT scan. (7)
5. Mechanism of injury
Clavicle fractures can be caused by direct or indirect trauma which is most of –
ten seen when the shoulder takes the full impact of the fall with the arm posi –
tioned down the side of the body. Such a fall emits extremely high compressive
force on the clavicle. Sports injuries are responsible for up to 45% of clavicle
fractures and they are especially common in direct contact sports such as
American football rugby and soccer. Clavicle fractures less commonly occur in
other nonsports injuries such as car accidents .(9) Another frequently described
traumatic cause of a midshaft clavicle fracture is the falling onto an out –
stretched hand (FOOSH injury). This type of fracture is common in cyclists. (10)
There are other causes of midshaft clavicle fractures, although these are much
less common. They can be split into congenital causes, pathologic causes, and
miscellaneous causes.
The most important congenital cause is osteogenesis imperfecta, which is a
disorder characterized by the defective formation of collagen and hence the os –
teoid matrix. (9)
Cancerous causes are also one of the less common kind of pathological clavi –
cle farctures. In a study by Smith et al.more than 30 malignant neoplasms were
seen to cause pathological fractures, of which plasmacytomas, osteosarco –
mas, and Ewing’s sarcomas were the most common. (11) Malignant metas –
9

tases can also deposit in the clavicle, this has been particularly noticed in pa –
tients with renal cell carcinomas and prostatic carcinomas. An additional non-
neoplastic cause of pathologic fractures are the effects of radiation therapy.
Radiation can cause demineralization of the bone which leads to loss of tra –
beculae, increasing the risk of fractures.
Miscellaneous causes of clavicle fractures are seen in obstetrics and occur as
a complication of breech deliveries. (9)
6. Clinical Evaluation of clavicular
fractures
Clavicular fractures should be assessed using the Advanced Trauma Life Sup –
port (ATLS) principles to avoid missing the diagnosis of severe injuries. The
ATLS was developed by the American College of Surgeons and its Committee
on Trauma. It is a systematical and evidence-based approach for the immedi –
ate management of severely injured patients. (12)
Initially, a clavicle fracture assessment should include a detailed history and a
physical examination. Important data are time and mechanism of injury, past
medical history, hand dominance, occupational status, and smoking history. (9)
The patient usually complains about pain across the affected side which wors –
ens during palpation. He or she may hold his injured arm with the healthy one.
Swelling and echymosis at the site of the injury can be seen. The skin should
be inspected for integrity and tenting in order to exclude the possibility of an
open fracture. Should the fracture be displaced deformities may be observed.
The affected shoulder may appear shorter than the other one. In a midshaft
fracture, the distal fragment displaces inferiorly, the proximal fragment superi –
orly. Furthermore, abnormal movements can be seen and crepitus may be felt.
10

An important aspect of the clinical examination is the assessment of the vascu –
lar status and neurologic function of the arm (the major part of the ATLS) to de –
fine potential brachial plexus, subclavian artery and vein injuries. In the case of
respiratory distress, a severe mediastinal injury should be suspected and in –
vestigated with a CT.
Radiographic assessment is primarily done by an upright anteroposterior clavi –
cle view (Figure 3). For lateral fractures a Zanca view (30-degree cephalic tilt)
(Figure 4) and for medial fractures, a Serendipity view is indicated (Figure 5) .
(2)
11
Figure 3-AP view

12
Figure 4-Zanca view
Figure 5-Serendipity view

7. Classification of clavicular fractures
Up until today, several classification systems have been introduced for clavicle
fractures. In 1967 Allman described the first classification of clavicular fractures
which is based on the location of the fracture on the three parts of the clavicle
(Groups I – III).
Allman's classification was not accurate enough for clinical practice so Neer in –
troduced his classification (Figure 6). This also uses the three different groups
of fractures but takes special account of distal third fractures. Furthermore, he
classified them initially into two groups and then later, in 1968, into three
groups. Type I fractures are not displaced due to the intact ligaments and re –
quire little treatment. Type II fractures may not be visualized on routine upright
anterior-posterior view and need erect oblique viewings (Zanca view). They are
displaced because the coracoclavicular ligaments are detached from the proxi –
mal fragment. Neer also states that there are four displacing forces which act
to retard union of the clavicle. The trapezius muscle, the weight of the arm, the
trunk muscles attaching the humerus and the scapula and the rotary displace –
ment by the scapular ligaments. Type III fractures are of the articular surface
and frequently lead to symptomatic arthritic changes.
Jäger and Breitner expanded Neer's classification of lateral clavicle fractures.
In the case of a concomitant acromioclavicular joint separation injury, the Rock –
wood classification has to also be applied.
In 1990 Craig introduced a more detailed classification of clavicular fractures
based on Allman's three types. He stressed the importance of the conoid liga –
ment and devoted a separate classification for pediatric clavicle fractures and
intra-articular fractures. (2),(13)
The Edinburgh classification by Robinson (Figure 7) has, according to a study
published in 2011, the greatest prognostic value for middle third fractures and it
also offers highly improved chances of choosing the correct therapy. This is the
13

classification which is most often used in today's clinical research.
Robinson describes three different areas of fractures: the diaphysis and the
medial and lateral ends. Furthermore, he divides the clavicle into fifths. In Type
1 fractures the medial fifth of the bone is involved. It is demarcated by a vertical
line drawn upwards from the center of the first rib. Type 2 fractures affect the
intermediate three-fifths of the diaphysis and are separated from the lateral fifth
by the conoid tuberosity. Type 3 fractures involve the lateral fifth of the clavicle.
Fractures are also subdivided into Groups A and B depending on their dis –
placement (more or less than 100% translation). Types 1A and 1B are further
subdivided into extra- or intraarticular fractures. The subgroups of Type 2A
fractures depend on the presence of angulation. All three types presented until
now have residual bony contact. In type 2B fractures there is no remaining
bone contact which leads to shortening of the clavicle. Simple or wedge com –
minuted fractures (type 2B1) are the most common type of clavicle fractures
(28,9% of the type 2B1 are wedge comminuted and the remaining ones are
simple). Type 2B2 are isolated segmental or segmentally comminuted frac –
tures.
Type 3 fractures are also subdivided according to articular involvement. In type
3B injuries the displacement showed a characteristic pattern of elevation and
posterior displacement of the fragment. The fragment was either configurated
in a simple oblique way or an inferior bone fragment had avulsed. (13)
14

15
Figure 6-Neer classification

16
Figure 7-Robinson classification

8. Treatment approaches in clavicular
fractures
Typically clavicular fractures are treated non-operatively. Radiological criteria
and patient factors play a role in offering possibilities for the correct treatment.
Indications for nonoperative treatment of clavicle fractures are closed fractures
which are nondisplaced. Alternatively, indications for surgery are open frac –
tures, fractures associated with vascular or neurologic injuries, associated
scapula fractures (floating shoulder), the severe displacement of the fracture
fragments, comminuted fractures, fractures with significant shortening, vertical
fragments and fractures that had complications after conservative treatment.
Contraindications to be taken into consideration are the patient's age (should
not be over 65 years), major co-morbidities, non-compliance, severe skin con –
ditions and stroke patients with little extremity usage. (7),(9)
Other factors that may affect decisions with regard to the treatment are previ –
ous fractures on the same shoulder and the state of the patient's hand domi –
nance. (2) Middle third and medial clavicular fractures are rarely treated surgi –
cally whereas lateral third fractures usually need surgical treatment. (6)
8.1 Conservative treatment
Initial nonoperative treatment protocol for clavicle fractures involves immobiliz –
ing the involved shoulder with a sling or a figure-of-eight brace to maintain
alignment during healing. Furthermore, antalgic therapy can be prescribed.
The figure-of-eight brace has more recently fallen out of favor because it was
found to cause patients discomfort and pain and showed no difference in the
rate or time of union. The figure-of-eight braces were also associated with tem –
poral brachial plexus palsies if applied incorrectly.
To prevent shoulder stiffness the patient may remove the sling and perform
pendulum exercises. After 2 weeks a wean off sling is applied and arange of
17

motion exercises should be performed. The patient should only commence
muscle strengthening exercises after 6 weeks. (7) It is recommended that no
contact sports be played until at least three months after the commencement of
treatment. The fracture should be monitored radiographically and through
physical examination on a regular basis until satisfactory progress has been
made. (9)
8.2 Surgical treatment
Recent studies have resulted in controversy with regard to the non-operative
treatment of clavicle fractures. A meta-analysis from 2005 revealed higher
nonunion rates for displaced fractures treated conservatively (15%) than oper –
atively (2,2%). (14)
Another minor study indicated that patients who underwent surgical treatment
were able to return to their pre-injury activities earlier (12w.) than those who
underwent conservative treatment (16w.). (15)
In a midshaft clavicular fracture (Group 1 Fracture) that requires surgery, there
are three possible techniques.
8.2.1 Closed reduction with intramedullary fixation
The first procedure involves closed reduction with intramedullary fixation (Fig-
ure 8) . It is a minimally invasive technique. Equipment options are cannulated
screws, specialized screw systems (e.g. Dual Trak), titanium elastic nails or
Hagle pins. Two options for the procedure can be found in the literature: either
a beach chair or supine approach with a posterolateral incision along Langer's
line, which causes less soft tissue dissection. The procedure involves drilling a
hole into the medullary canal and inserting a pin. The pin will transverse the
fracture. The pin will be removed 2 to 6 months postoperatively after healing is
confirmed. Contraindications for this approach are segmental fractures or se –
vere comminution. Advantages of this technique are a smaller incision which
results in less soft-tissue damage and the protection of the supraclavicular
18

nerves commonly injured during plating. Disadvantages are the necessity to re –
move the devices and the higher complication rate which includes hardware
migration. (9),(16) However, a meta-analysis in 2011 reported fewer sympto –
matic hardware events with intramedullary fixation compared with plating and a
2012 systematic review found no difference between plate and intra-medullary
fixation for displaced midclavicular fractures. (17),(18)
8.2.2 ORIF with plates and screws
The second technique is open reduction and internal fixation with titanium
plates and Alta screws. It is considered the gold standard and is also the oldest
surgical option. It is technically less demanding than an intramedullary fixation.
The displaced parts of the clavicle are reduced with the help of clamps, sutures
and Kirschner wires to regain the anatomy of the clavicle. The next step is the
placement of the plate onto the surface of the clavicle. The plate must be
aligned with the clavicle and is then fixated with screws. (9) The biomechanical
method using a conventional plate is compression this means that the actual
19
Figure 8-Intramedullary fixation

stability results from the friction between the bone and the plate. In case of
conventional plating there has to be a wide exposure of the bone for access
and visibility of the fracture and pre-contouring of the plate is necessary.
To avoid damage to the bone's surface and allow a bridge for multifragmentary
fractures, locked internal fixators were developed. (19)
In 2003, Acumed designed the first anatomic clavicle plate and soon after –
wards, the Locking Clavicle Plate System (Figure 9 & 10) became available for
intraoperative use. Bio-mechanical studies have shown beneficial clinical out –
comes and decreased postoperative complications with pre-contoured plates
compared to traditional plating. (20) The Locking Compression Plates with com –
bination holes can be used as a compression plate and a locked internal fixa –
tor. This combines the two techniques and provides a greater variability of
treatment with only one plate. (19) Locking plates provide greater angular sta –
bility and rigid constructions this is why they are especially indicated in patients
with comminuted fractures or osteoporotic bone whereas nonlocking plates are
more commonly used and are more suited in cases where good bony apposi –
tion can be obtained. Locking plates have a tapered end to preserve tissue via –
bility and allow early mobilization. (20)
Preoperative planning is via radiographic assessment. With the help of the x-
ray pictures, the length of the plate and the position of the screws can be deter –
mined. (9) The approach variants are by means of beach chair (Figure 11) or
supine positioning with a direct superior or anterior incision. (16) A recent study
stated that the decision whether to place the plate superiorly or anteroinferiorly
has remained controversial. Both variants have an identical union rate of 95%
and are safe treatment methods for displaced clavicle fractures. Disadvantages
of superior plating are that it leads to more patient reported implant prominence
which increases the requests for removal of the plate and neurovascular in –
juries due to penetrating screw trajectories. (16), (21) This is why anteroinferior
plate placement has become more popular. (9)
During the operation, it is extremely important that in the case of comminuted
20

fractures the bony fragments are not detached from the periosteum in order to
allow for proper healing underneath the locking plate. The next step is the de –
termination of the plate length and its anatomical adaption using bending irons
in case the pre-contoured form is not suitable for the patient. The plate then
has to be positioned onto the bone and fixed temporarily until an x-ray has
been taken. The first screws to be inserted are the cortex screws which fasten
the bone onto the plate after that the locking screws can be placed. In case of
severe fractures or osteoporotic bone synthetic and allogenic bone replace –
ment materials can be used to allow for improved stability. (22)
In general, plating results in a rigid fixation, an excellent cortical compression
and rotational control over the fracture. (9)
21
Figure 9-LCP
Figure 10-LCP in an x-ray

8.2.3 External fixation
The third variant of surgical treatment in midshaft clavicle fractures is the exter –
nal fixation. This method is more effective in open fractures and in patients
where union cannot be achieved. The procedure involves drilling into unfrac –
tured parts of the clavicle and screwing wires or bolts through the holes. There
is a lower chance of clavicle devascularization with this technique because the
periosteum remains intact. Although this variant results in fast healing and in –
creased stability the risk of infection is high due to the wires puncturing the
skin. This is why proper skin care must be performed next to the puncture site.
(9)
Following surgical treatment postoperative rehabilitation is recommended.
Early rehabilitation is with the use of a sling for 7-10 days which is then fol –
lowed by active motion. At 6 weeks, after evidence of union and pain free mo –
tion, strengthening exercises can be started. Full activity can only be restarted
after 3 months. (16)
22
Figure 11-beach chair approach

8.2.4 Experimental techniques
There are also experimental plating techniques and materials. Polymeric and
carbon fibers have an elasticity very similar to that of bone structure, but they
have the disadvantage that they cannot be molded during surgery and tend to
be brittle. Other efforts are directed towards the development of resorbable
plates and screws to allow for a gradual increase in physiological transmission
of stresses. All of these experimental plates and screws have not, as yet been
introduced into clinical practice. (23)
8.3 Treatment in lateral and medial third fractures
According to Neer fractures of the distal third account for approximately half of
all clavicular nonunions, therefore, there is a high controversy about the appro –
priate management of them. (6),(24) In general the treatment depends on the
type of the fracture. In type 1 fractures the coracoclavicular ligaments are intact
and the fracture is not displaced. In type 3 fractures the acromioclavicular joint
is involved which may only lead to minimal displacement. Both types are usu –
ally treated conservatively. Type 2 fractures, on the other hand, tend to have
significant displacement. Treatment of this fractures requires a vertical surgical
incision to visualize the fracture site properly. The fracture will be then reduced
and the coracoclavicular ligaments are stabilized. A possible repair technique
for type 2B fractures is the fixation of the fracture with a Kirschner wire (Figure
12) and the repair of the torn ligament with a Mersilene tape (Figure 13). An-
other possibility is the use of a Wolter plate.
Medial fractures (Group 3) are treated nonoperatively, surgery is only indicated
in severe displacement or intrathoracic injuries. (16)
23

24
Figure 12-K wire
Figure 13-Mersilene tape

9. Complications of clavicular fractures
Even though clavicle fractures usually heal without complications, they are still
possible and can be very severe. They can be subdivided into early and late
complications and depend on the treatment option.
9.1 Complications of conservative treatment
The complications of conservative treatment can be subdivided into nonunion
(1-5%) and malunion (67%). Malunion is defined as shortening of over 3cm,
angulation of more than 30 degrees and a translation of more than 1cm. In
case of malunion patients may complain of difficulties while wearing backpacks
(pain) or performing overhead activities (decreased range of motion). Also, the
cosmetic aspect of the malunion could lead to patients dissatisfaction. A more
severe problem caused by malunion is the thoracic outlet syndrome a neu –
rovascular compression of the subclavian bundle. Treatment in case of symp –
tomatic malunion is a clavicle osteotomy with bone grafting.
Nonunion is defined as an arrest in the fracture repair process which leads to
large segmental defects. It has to be differentiated from a delayed union which
is a fracture that takes longer than expected to heal (>6 months post-injury).
Both complications are commonly due to inadequate fracture stabilization and
poor blood supply (hypertrophic nonunion or atrophic nonunion) but also infec –
tions (septic nonunion) the location (near the joint – pseudoarthrosis) and the
pattern of the fracture (fragment displacement – oligotrophic nonunion) can
play a role. Other etiologies are female gender, advanced age and smoking. If
symptomatic nonunion should be treated with open reduction and internal fixa –
tion with plate and bone grafts. (16),(25)
25

9.2 Early and late complications of surgical treatment in
middle third fractures
During the procedure, immediate damage can be done to the vessels around
the clavicle, the nerves and the pleura. Some of the complications are immedi –
ately seen due to particular signs like distal ischemia after an artery occlusion
or hemorrhage due to a vessel tear but other complications are occult and can
later result in life-threatening emergencies. An example for this is an asympto –
matic aneurysmal dilatation.
Late complications of surgical treatment in clavicle fractures are non-union,
malunion, excessive callus formation, hardware prominences and infections.
Non-union can result in increased mobility of the fragments which can damage
the neurovascular structures leading to severe pain or paresthesias and insta –
bility which ends in decreased mobility of the affected side. Malunion, exces –
sive callus formation and hardware prominences usually only lead to poor cos –
metic results and patient's dissatisfaction but can also compress neurovascular
structures because of costoclavicular space narrowing. Overlying supraclavicu –
lar cutaneous nerves can be trapped which leads to troublesome pain in the
pectoral region and paresthesias. (26)
10. Aims and objectives of the study
1.To study the role of locking plates in clavicle fracture management
2.To study the advantages of the locking plate over the normal
conventional plating in severely displaced midshaft-clavicle-fractures
3.To follow up the patients until radiological union and study the
complications of the locking plate system.
26

Special review
27

1.Introduction
The clavicle, as part of the pectoral girdle, is an important bone for the move –
ment of the arms and for the protection of the neurovascular bundle lying be –
neath it. Mid-shaft clavicle fractures are frequent and can be serious, so that
the only option for treatment is surgery. The goal of fracture fixation is to achie –
ve bone healing and to restore the function of the injured limb in the shortest
possible time while avoiding complications. The correct choice of plating tech –
nique can influence the result of the surgery. The main purpose of this study is
to report the complications that arose after surgery in a comparison of conven –
tional plates with locking compression plates.
2. Materials and Methods
Data of all patients admitted in the orthopedic hospital Alexandru Radulescu for
clavicle-shaft-fracture surgery with plates and screws from 1.1.2015 until
31.12.2018 were collected electronically for this retrospective study. A total
number of 60 patients underwent surgery from which 19 were treated with
Locking Compression Plates. The following facts were obtained from their files:
•Age
•Gender
•Season
•Type of accident
•Time passed after accident
•Type of fracture
•Associated injuries / poly-trauma
•Fracture side
•Type of plate & complications
28

•Screws
•Period between operation and readmission for complications
We included in this study all 60 operated patients (15 females, 45 males; mean
age: 40, age range 18-88 years). Outcomes and Complications were evaluated
by means of x-ray images. Comparing pre- and postoperative images as well
as images taken at readmission.
The statistical review in this article is made with SPSS. The Pearson Chi-Squa –
re Test of Independence was chosen to evaluate the statistical significance and
a p-value of less than 0,05 was considered statistically significant. The Null Hy –
pothesis (H0) is, that there is no statistical significant relationship between the
two compared variables. The alternative Hypothesis (Ha) is, that there is a sta –
tistical significant relationship between them.
3. Results
3.1. Age
3.1.1. Absolute distribution
290-30 30-40 40-50 50-60 60-70 70-80 80-90024681012141618201817
910
8
01Number of patients

3.1.2. Mean, maximum & minimum ages
Overall mean age: 40 years and 8 months
Mean age for males/ females: 38 years and 5 months/ 47 years and 10 months
Minimum age:18
Maximum age:88
3.1.3. Age peaks
Majority of patients age: The frequency function of the ages has two peaks,
one at 25 and one at 31 years as seen below.
3.1.4. Complications depending on the age
Age bins Percentage of
the population Observed
complicationsExpected
complications
Less than 30 30% 5 5,4
30 to 40 28.(3)% 6 50,94
40 to 50 15% 4 2,7
50 to 60 16.(6)% 2 29,88
60 to 70 13.(3)% 1 23,94
70 to 80 0% 0 0
More than 80 1.(6)% 0 2,88
Chi square value 2.244 with 5 degrees of freedom. P value 0.814 the correlati –
on is not statistically relevant. So post op complications appear at approximate –
ly the same rate regardless of age.
30

3.2. Gender
3.2.1. Distribution
3.2.2. Predisposition to clavicle fractures
Observed Expected
Females 15 30
Males 45 30
We calculate the Chi-Square test for patients in general. The Chi-Square value
is 15, with one degree of freedom. We consider the standard significance level
α =0.05, and the p value is 0,000108. The result is statistically relevant i.e. we
can say that males are far more predisposed to this type of fracture than fema –
les.
314515Gender distribution
Males
Females

3.2.3. Correlation between gender and post op-complications
Observed post op
complications Expected post op
compliations
Females 4 9
Males 14 9
We calculate the Chi-Square Test of Independence for the appearance of
complications and their relationship to the patient's gender.
Chi-Square test is 5.55 with 1 degree of freedom. We consider the standard
significance level α =0.05, and the p value is 0,095, therefore the result is not
statistically relevant and we refute the alternative Hypothesis (Ha).
3.3. Season
Observed fractures Expected fractures
Winter 14 16,5
Spring 17 16.5
Summer 21 16.5
Fall 14 16.5
Chi square value s 2 with 3 degrees of freedom. P value is 0.57. The correlati –
on is not statistically relevant so people get fractures at about the same rate in
every season .
32

3.4. Type of accident
3.3.1. Types of accidents and their absolute prevalence
3.3.2. Correlation between type of accident and the fracture types
1.Open fracture
Bike Car Horse Heights Motor
cycleFall Sky Training Work
Open
fracture
observed2 0 0 0 1 0 0 0 0
Open
fracture
expected 0.33 0.33 0.33 0.33 0.33 0.33 0.33 0.33 0.33
Chi square test is 12.1215 with 8 degrees of freedom. we consider the stan –
dard significance level α =0.05, and the p value is 0,14588. This correlation is
not statistically relevant.
33Circumstances of the injury0510152025303540
11
3
1 1534
212Bike
Car
Horse cart
Hights
Motorcycle
Fall
Sky
Training
At work

2.Comminuted fracture
Bike Car Horse Heights Motor
cycleFall Sky Train
ingWork
Comminuted
– observed2 0 0 0 2 6 1 0 1
Comminuted
– expected1.33 1.33 1.33 1.33 1.33 1.33 1.33 1.33 1.33
Chi square test is 22.55 with 8 degrees of freedom. we consider the standard
significance level α =0.05, and the p value is 0.003993, the result is statistically
relevant. The difference in the number of comminuted fractures can be attribu –
ted to the type of accident.
3.Intermediary fragment
Bike Car Horse Height
sMotorc
ycleFall Sky Trainin
gWork
Intermediary
fragment
observed4 1 1 0 1 6 1 0 1
Intermediary
fragment
expected1.66 1.66 1.66 1.66 1.66 1.66 1.66 1.66 1.66
Chi square test is 19.277 with 8 degrees of freedom. we consider the standard
significance level α =0.05, and the p value is 0.0134, the result is statistically
relevant. The difference in the number of fractures with intermediary fragments
can be attributed to the type of accident.
34

3.4. Time passed after accident
3.4.1. Absolute number of patients
90% of patients presented themselves to the hospital the same day
3.4.2. Correlation between Post operative complications and time of
presentation
Post op
complicationsPost op
complications
Early 17 1
Late 9 9
Chi square score is 14.22, with one degree of freedom. We consider the stan –
dard significance level α =0.05, and the p value is less than 0.000163. The dif –
ference is statistically relevant.
35Number of patients010203040506054
6Presented immediately
Presented later

3.5. Type of fracture and their absolute prevalence
We consider comminuted fractures, intermediary fragment fractures and open
fractures as complicated fractures in the following pages. And no complications
means that there is only displacement.
36Number of patients05101520253035
3161529
Open fracture
Comminuted fracture
Intermediary fragment
fracture
No complications fracture

3.6. Associated injuries
3.6.1. Prevalence of poly or single trauma
•20% of the patients have a single trauma
•80% are poly-trauma patients
3.6.2. Correlation between poly trauma and post surgery complications
After surgery
complications
observedAfter Surgery
complications
expected
Poly trauma 16 9
Single trauma 2 9
3712
48Single trauma
Poly trauma

Chi square score is 10.888, with one degree of freedom. We consider the stan –
dard significance level α =0.05, and the p value is 0.000968. The difference is
statistically relevant.
3.7. Fracture side
3.8. Plate type & Complications
3.8.1. Plate distribution
3831281
Left side
Right side
Both sides

3.8.2. Complication distribution (1)
394119
Conventional plate
Locking compression
plate
Number of patints051015202530354045
1842
Post op complications
No post op
complications

3.8.3. Complication distribution (2)
3.8.4. Plate choices and the number of complications after surgery
We conclude that 31,27% of patients treated with LCP’s and 29,26% of pati –
ents treated with conventional plates had complications after surgery.
40Number of complications after surgery02468101214
12
6Conventional plates
Locking compression
platesNumber of patients012345678910
39
3 3Migration of the plate
Mechanical complication
deterioration of the
osteosynthesis material
inflammation at the
operation side

3.8.5. The correlation between fracture type and the plate which was
used
1. Conventional plates
Open
fractureComminuted
fractureIntermediary
fragment
fractureNo
complications
Conventional
plates
observed3 9 11 21
Conventional
plates
expected1.5 8 7.5 14
Chi square score is 6.75, with 3 degrees of freedom. We consider the standard
significance level α =0.05, and the p value is 0.080. The difference is not stati –
stically relevant meaning that the choice of putting a conventional plate was not
influenced by the type of fracture in a statistically significant degree.
2. LCP’s
Open
fractureComminuted
fractureIntermediary
fragment
fractureNo
complications
Compression
locking
plates
observed0 7 4 8
Compression
locking
plates
expected1.5 8 7.5 14.5
Chi square score is 5.82, with 3 degrees of freedom. We consider the standard
significance level α =0.05, and the p value is 0.120. The difference is not stati –
stically relevant indicating that the choice of putting a compression locking
41

plate was not influenced by the type of fracture in a statistically significant de –
gree.
3.8.6. The correlation between plate type and after surgery complications
Conventional plate LCP
Observed after
surgery
complications12 6
Expected after
surgery
complications9 9
Chi square score is 2, with 1 degree of freedom. We consider the standard
significance level α =0.05, and the p value is 0.157. The difference is not stati –
stically relevant indicating that the rate of post op complications was not influ –
enced by the type of plate used.
3.9. Screws
3.9.1. Distribution of total screws used among the patients
42Number of patients0246810121416
115
14
12
9
7
24 screws
6 screws
7 screws
8 screws
9 screws
10 screws
11 screws

3.9.3. Distribution of Locking Screws among the patients treated with
LCPs
3.9.4. Correlation between the complicated fractures and the amount of
looking screws used
4 screws 6 screws 7 screws 8 screws 9 screws 10 screws 11 screws
Complicat
ions in
general
observed1 2 4 2 2 1 0
Complicat
ions in
general
expected1.71 1.71 1.71 1.71 1.71 1.71 1.71
Chi square score is 5.51, with 6 degrees of freedom. We consider the standard
significance level α =0.05, and the p value is 0.48. The difference is not statisti –
cally relevant.
43Number of patientswith LCP024681012141618
117
12-5 Screws
6-9 screws
10-11 screws

3.10. Period between operation and readmission
Average time: 280 days i.e. about 9 months. There are equal number of pati –
ents readmitted in the 8-12 month intervals and the 12-16 months interval. The
maximum time between operation and readmission is 17 months and the mini –
mum is 14 days.
44Number of patients0123456
4
35 5
1Less than 4 months
4-8 months
8-12 months
12-16 months
More than 16 months

4. Discussion
A person who experiences immobility for an extensive period of time could face
severe economical distress . The conservative means of treating most of the
fractures including clavicle fractures have become inadequate. Moreover, there
have been a few studies which have reported poor results and higher rates of
non-union of the fractures where conservative methods have been employed.
Patients seek a more rapid, improved functional outcome and are willing to risk
surgery. With the advent of improved surgical techniques, sterile maintenance
and post operative protocols the results of surgical management are far superi –
or when compared to conservative methods .(27)
The patients included in our study had an average age of 40 years. The youn –
gest patient included was 18 years old, the oldest 88. As we can see in graph
2, most of the patients underwent an operation at the age of 25 and 31 years.
And the most probable age cohort was between 18-30 years with a distribution
of 30%. These results conform with data found in the literature as the preva –
lence of midshaft-clavicle-fractures was found to decrease progressively with
age.(28) As the prognosis of any injury or disease should be the most import –
ant declerative statement and therefore deserves extreme consideration we
also assessed the relationship between age and the occurence of post operati –
ve complications with Chi square test (table1). The conclusion was that post
operative complications appear at approximately the same rate regardless of
the age, so the correlation was statistically insignificant.
The data of our study illustrated in graph 3 assessed that from 60 patients 45
were male. This lead to the question whether males are more predisposed to
mid-clavicle fractures than females. In table 2 we evaluated this hypothesis
with Chi-Square tests and came to the result that there is a statistically relevant
45

predisposition of males to this type of fractures as opposed to females. Also
other studies have also stated the statistically significant high number of fractu –
res in males. (29) This might be due to the increased willingness of men to take
risks.
Apart from the age, also the gender of the patients may also play a role as a
risk factor for post operative complications. However, we could not determine
any statistically relevant correlation between the gender and post operative
complications (table 3).
With regard to seasonal occurrence a Swedish study in 2017 stated that clavi –
cular fractures were a more common occurence at weekends and in the sum –
mer months (May to August). This is possibly due to an increase in outdoor
activities during the Swedish summer. (30) We also made the correlation bet –
ween fracture occurrence and seasons. Although there was a slight increase in
the number of fractures in summer it was not statistically significant. This could,
however, be based on the relatively small number of patients included in our
study.
Same-level falls have been reported as the most common cause of clavicle
fractures not only in this study but also in previous studies. (31) An Italian study
reported the most common cause of fractures to be accidental falls in the el –
derly but also traffic accidents in young adults (28), which deviate very little
from the results of this study.
The finding that bicycle accidents were the second most common cause of
clavicle fractures coincides with a Swedish epidemiological study, which
demonstrates that bicycle accidents caused 45% of the clavicle fractures in
females and 26% in males aged from 15 years upwards (32). It is however in
contrast with the findings of a Scotland-based epidemiological study (33),
where only 11% of clavicle fractures were sustained through bicycle accidents.
In tables 5,6 and 7 we tested the correlation between the type of accident and
the fracture types (here: open fracture, comminuted fracture and fracture with
46

intermediary fragment) with Chi square test. For comminuted fractures and
fractures with intermediary fragment the tests were statistically significant in
indicating that the fractures can be attributed to the type of accident (both
falling from the same height). The test result for open fractures was
insignificant due to a lack of patients with this type of fracture.
We also dicovered that 90% of the patients presented themselves to the
hospital on the day of the accident resulting in the question as to whether the
early presentation prevented them from suffering severe post operative
complications. We made the correlation between post operative complications
and the time of presentation with Chi square test and found the test to be
statistically significant. All of the patients who presented themselves late to the
hospital had experienced post operative complications.
In graph 6 we can see the type of fractures and their absolute prevalence. 48%
of the patients had only displaced fractures (stated as non complication
fracture in the graph) and the second most frequent fractures were
comminuted ones with 27%. Most of the patients had more than one trauma
(poly trauma 80%, n=48) the rest had only the clavicle fracture. As in previous
studies left sided fractures (in our study n=31) were slightly more common than
right sided fractures (in our study n=28) whereas bilateral fractures were
uncommon (in our study n=1) as shown in graph 8 (30),(32). This means that
the hand preference (not actually studied in this instance, but generally the
right side is more common) does not influence the side of fracture. In table 9
we made the correlation between polytrauma and post surgery complications
with Chi square test and dicovered a statistically relevant difference meaning
that polytrauma patients experienced more after surgery complications than
single trauma patients. This was also stated in a very recent study were
patients with isolated shaft fractures experienced a more favorable outcome in
comparison to combined fractures or polytrauma patients (34).
47

The improvement of the Locking Compression Plate (LCP) has only been
made possible due to the know-how gained with the PC-Fix (point contact fixa –
tor) and LISS (less invasive stabilization system). With account to the mechani –
cal, biomechanical and clinical results, the new AO LCP with combination holes
can be applied as a locked internal fixator, a compression plate or as an inter –
nal fixation system combining both techniques. The LCP with combination ho –
les can also be used in either a conventional technique (compression
principle), bridging technique (internal fixator principle), or a combination tech –
nique (compression and bridging principles). The connection of both screws of –
fers the possibility to gain a union of both internal fixation types. Where the
LCP is applied as a compression plate, the operative technique is similar to the
conventional technique. This means that existing instruments and screws can
be used. The internal fixator method can be applied through an open but less
invasive or an MIPO (minimally invasive plate osteosynthesis) access. An indi –
rect closed reduction is useful when operating with the LCP in the internal fixa –
tor method to cover the fracture zone. A combination of both plating techniques
is possible, depending on the indication (19). When LCPs are used to treat mid-
clavicle fractures, the risks of injury to the brachial plexus or subclavicular arte –
ry can be minimized because fixation can be achieved without the screw rea –
ching the opposite bone cortex and periosteal stripping can be reduced (35). In
our study we had 41 patients were treated with conventional plates and 19 with
LCPs (graph 9). We made the correlation between fracture type and plate se –
lection, but found no statistical significance. This indicates that the plate selec –
tion was not influenced by the type of fracture in our study group (graphs 10 &
11). The distribution of screws used among the patients is depicted in graph
13. Most of the patients were treated with 6 screws (n=15, 25%). In case of
Locking compression plates (graph 14) 6-9 screws were used most often
(n=17, 90%). To find out whether the number of locking screws was influenced
by the fracture complications (open fracture, comminuted fracture or fracture
with intermediary fragment) we made the Chi Square test of correlation but
48

found no statistical significance (table 13). We also analyzed the number of pa –
tients with complications (n=18) and the distribution of the types of post opera –
tive complications. Half of the patients had unspecified mechanical complicati –
ons with the plate the other patients had migrations of the plate (17%), deterio –
ration of the material (17%) and inflammation on the operated side (17%) as
complications (graph 11). In our study 31,27% of the patients treated with
LCPs and 29,26% of the patients treated with conventional plates had post
operative complications (graph 12). So as opposed to other studies (35), and
according to our study LCPs lead to slightly more complications in our study.
Although there are more complications due to LCPs the correlation between
plate type and after surgery complications made with Chi square test was stati –
stically insignificant.
In graph 15 we depicted the period between operation and readmission for
complication treatment. The average time was 280 days i.e. about 9 months.
There are equal numbers of patients readmitted in the 8-12 months interval
and 12-16 months interval. The minimal time between operation and readmis –
sion was 14 days and the maximal time was 17 months.
49

50
Female patient, 38 years old admitted 15.07.2016, pre-
OP x-ray, AP view of the left shoulder
Female patient, 38 years old admitted 15.07.2016, post-OP x-ray, AP
view of the left shoulder, conventional plating, no post-OP complications

51
Female patient, 31 years old admitted 12.01.2017, pre-OP x-ray, AP
view of the left shoulder
Female patient, 31 years old admitted 12.01.2017, post-OP
x-ray, AP view of the left shoulder, conventional platting,
post-OP complication = migration of the plate

52
Female patient, 19 years old admitted 08.05.2018, pre-OP x-
ray, AP view of the right shoulder
Female patient, 19 years old admitted 08.05.2018, post-OP x-ray, AP view of
the right shoulder, LCP , no post-OP complication

53
Male Patient, 44 years old admitted 21.07.2016, pre-OP x-ray, AP
view of the left shoulder
Male Patient, 44 years old admitted 21.07.2016, post-OP x-ray, AP view of the
left shoulder, LCP , post operative complication = migration of the plate

5. Conclusion
This study had some limitations. The conclusions drawn from this analysis can –
not be generalized because of the small number of cases and that the study
design was retrospective. Therefore, the efficacy of a conventional plate and
reconstruction LCP for the treatment of midshaft clavicle fractures should be
tested in prospective studies involving a larger number of cases.
In conclusion we can state that clavicle fractures are more common in young
male patients and post operative complications were not dependent on the age
nor the gender. The most common accidents were falls from the same height
and bicycle accidents. Most of the patients presented themselves immediately
on the same day as the accident happened which prevented most of the pati –
ents from developing severe post operative complications. Most of the fractu –
res were on the left side and displaced without further complications. Poly trau –
ma patients were the most common, which leads to the conclusion that operati –
ve treatment of clavicle fractures is mostly undertaken in the case of a poly –
trauma. Furthermore polytrauma patients compared to single trauma patients
had a higher rate of after surgery complications leading to more than one ad –
mittance and operation. Most of the patients were readmitted within an 8-12
months and 12-16 months interval for a further operation which was either
removal of the plate or an other ORIF (open reduction and internal fixation).
We can also state that most of the patients had no post operative complicati –
ons and the plate choice did not significantly affect the complication rate after
surgery. As an end result bony union could be achieved in both the conventio –
nal plate and reconstruction LCP groups and the clinical outcomes were satis –
factory. Overall, both operative procedures using conventional plates or recon –
struction LCP, which can be shaped to match the contour of the clavicle, can
be effective in the treatment of clavicle midshaft fractures.
54

Acknowledgment
“The single greatest cause of happiness is gratitude.”- Auliq Ice
My sincere gratitude is directed towards all of my supporters who made it pos –
sible for me to finish this thesis and study for my dream to come true.
Therefore, big thanks go to:
My tutor Dr. Adrian Todor for giving me the opportunity to conduct this study
and for his spontaneous support at all times even during holidays!
The whole team at Orthopedic & Traumatology Clinic “Alexandru Radulescu”
for their help and assistance during data collection.
My friends who always motivated me and also showed me the fun sides of life.
Mrs. Talmon for proof-reading this thesis.
My boyfriend Sebastian who stayed by my side through 5 years and gave me
his endless support and time in difficult moments,
and my deepest gratitude belongs to my parents Anna and Franz for always
being the best role models in my life and making it possible for me to study
medicine.
55

Bibliography
1. Breasted JH. A Fracture of the Clavicle. 3rd ed. Chicago: The University of
Chicago Oriental Institute Publications; 1930. p. 350-3.
2. Paladini P, Pellegrini A, Merolla G, Campi F, Porcellini G. Treatment of
Clavicle Fractures[Internet]. Transl Med UniSa; 2012 [cited2018Mai7].
Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3728778/
3. Standring S, Anand Neel, Birch R, Collins P, Crossman AR, Gleeson M et
al.. Bones. 41st ed. London: Elsevier; 2016. p.799-801.
4. Moore KL, Dalley AF, Agur AMR. Moore – Clinically Oriented Anatomy.
7th ed. Philadelphia: Lippincott Williams & Wilkins; 2014. p. 673-713.
5. Harnroongroj T, Tantikul C, Keatkor S. The clavicular fracture: a
biomechanical study of the mechanism of clavicular fracture and modes of the
fracture[Internet]. J Med Assoc Thai; 2000 [cited2018Mai7]. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/10932494
6. Kleinhenz BP. Clavicle Fractures Treatment & Management[Internet].
Medscape; 2017 [cited2018Mai16]. Available from:
https://emedicine.medscape.com/article/92429-treatment
7. Dehghan N, Mckee MD. Evaluation and Management of Clavicle
Fractures: Midshaft, Lateral and Medial[Internet]. Cancer Therapy Advisor;
2017 [cited2018March24]. Available from:
http://www.cancertherapyadvisor.com/shoulder-and-elbow/evaluation-and-
management-of-clavicle-fractures-midshaft-lateral-and-medial/article/626611/
8. Pecci M, Kreher JB. Clavicle Fractures[Internet]. American Family
Physician; 2008 [cited2018June10]. Available from:
https://www.aafp.org/afp/2008/0101/p65.html
9. Burnham JM, Kim DC, Kamineni S. Midshaft clavicle Fractures: A Critical
review[Internet]. Sociedad Gallega de Cirurgia Ortopedica y Traumatologia;
2016 [cited2018Juli11]. Available from: https://sogacot.org/midshaft-clavicle-
fractures-a-critical-review/
10. Van Tassel D, Owens BD, Pointer L, Moriatis Wolf J. Incidence of
clavicle fractures in sports: analysis of the NEISS Database[Internet]. Int J
Sports Med; 2014 [cited2018Mai7]. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/23771828
11. Smith J, Yuppa F, Watson RC. Primary tumors and tumor-like lesions of
the clavicle[Internet]. Springer Verlag; 1988 [cited2018Juli11]. Available from:
https://link.springer.com/article/10.1007%2FBF00401804#citeas
12. Rotondo M. About Advanced Trauma Life Support[Internet]. American
College of Surgeons; 2018 [cited2018June10]. Available from:
https://www.facs.org/quality-programs/trauma/atls/about
56

13. O'Neill BJ, Hirpara KM, O'Briain D, McGarr C, Kaar TK. Clavicle
fractures: a comparison of five classification systems and their relationship to
treatment outcomes [Internet]. Int Orthop.; 2011 [cited2018Mai8]. Available
from: https://www.ncbi.nlm.nih.gov/pubmed/21088834/
14. Zlowodzki M, Zelle BA, Cole PA, Jeray K, McKee MD, Evidence-Based
Orthopaedic Trauma Working Group. Treatment of acute midshaft clavicle
fractures: systematic review of 2144 fractures: on behalf of the Evidence-Based
Orthopaedic Trauma Working Group[Internet]. J Orthop Trauma; 2005
[cited2018Mai15]. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/16056089
15. Naveen BM, Joshi GR, Harikrishnan. Management of mid-shaft clavicular
fractures: comparison between non-operative treatment and plate fixation in 60
patients[Internet]. Strategies Trauma Limb Reconstr.; 2017 [cited2018Mai15].
Available from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5360671/#CR10
16. Sheth U. Clavicle Shaft Fractures[Internet]. Orthobullets;
[cited2018Mai18]. Available from:
https://www.orthobullets.com/trauma/1011/clavicle-shaft-fractures
17. Duan X, Zhong G, Cen S, Huang F, Xiang Z. Plating versus
intramedullary pin or conservative treatment for midshaft fracture of clavicle: a
meta-analysis of randomized controlled trials.[Internet]. J Shoulder Elbow
Surgery; 2011 [cited2018Juli16]. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/21481613
18. Houwert RM, Wijdicks FJ, Steins Bisschop C, Verleisdonk EJ, Kruyt M.
Plate fixation versus intramedullary fixation for displaced mid-shaft clavicle
fractures: a systematic review.[Internet]. Int Orthop.; 2012 [cited2018Juli16].
Available from: https://www.ncbi.nlm.nih.gov/pubmed/22146919
19. Wagner M.. General principles for the clinical use of the LCP[Internet].
PubMed; 2003 [cited2018December02]. Available from:
https://www.ncbi.nlm.nih.gov/m/pubmed/14580984/?
i=5&from=/14580982/related
20. M.D. Geissler WB. Locking Clavicle Plating System[Internet]. Acumed
Innovative Solutions; 2009 [cited2018Mai16]. Available from:
https://www.shoulderdoc.co.uk/docs/Acumed_clavicle.pdf
21. Formaini N, Taylor BC, Backes J, Bramwell TJ. Superior versus
anteroinferior plating of clavicle fractures[Internet]. Orthopedics; 2013
[cited2018Mai18]. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/23823047
22. Lorent H. Layout 1[Internet]. Synthes Inc. Or its affiliates; 2009
[cited2018december02]. Available from: http://metodebok-
ortopedi.ihelse.net/Metodebok_leger/Pdf/036.000.684.pdf
57

23. Sudheer Bhargav Reddy G. Management of Fracture Long Bones with
Locking Plates [dissertation]. Bangalore (MO): Rajiv Gandhi University of
Health Sciences Karnataka; 2006-2009.
24. Neer CS. Nonunion of the Clavicle[Internet]. Jama Network; 1960
[cited2018Mai16]. Available from:
https://jamanetwork.com/journals/jama/article-abstract/327722?redirect=true
25. Aiyer A. Nonunion[Internet]. Orthobullets; [cited2018Juli18]. Available
from: https://www.orthobullets.com/basic-science/9069/nonunion
26. Yates DW. Complications of fractures of the clavicle[Internet]. The British
Journal of Accident Surgery; [cited2018Juli18]. Available from:
https://www.injuryjournal.com/article/0020-1383(76)90211-4/pdf
27. Hill J, McGuire M, Crosby L. [Internet]. ; . Available from:
28. Postacchini F, Gumina S, De Santis P, Albo F. Epidemiology of clavicle
fractures[Internet]. PubMed; 2002 [cited2019April29]. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/12378163
29. Liu S, Liu B, Chang H, Chen W, Zhu Y , Zhang Y . Age-and gender-specific
characteristics of the clavicular fractures, data from 83 hospitals in
China[Internet]. Int J Clin Exp Med; 2017 [cited2019April29]. Available from:
http://www.ijcem.com/files/ijcem0050085.pdf
30. Kihlström C, Möller M, Lönn K, Wolf O. Closed treatment of displaced
middle-third fractures of the clavicle gives poor results[Internet]. PubMed;
1997 [cited2019April29]. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/9250733
31. Robinson C. Fractures of the clavicle in the adult. Epidemiology and
classification [Internet]. PubMed; 1998 [cited2019April29]. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/9619941
32. Nowak J, Mallmin H, Larsson S. The aetiology and epidemiology of
clavicular fractures. A prospective study during a two-year period in Uppsala,
Sweden[Internet]. PubMed; 2000 [cited2019April29]. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/10775691
33. Robinson C. Fractures of the clavicle in the adult. Epidemiology and
classification [Internet]. PubMed; 1998 [cited2019April29]. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/9619941
34. Allemann F, Heining S, Zelle B, Probst C, Pape HC. Risk factors for
complications and adverse outcomes in polytrauma patients with associated
upper extremity injuries[Internet]. Patient Safety in Surgery; 2019
[cited2019April30]. Available from:
https://pssjournal.biomedcentral.com/articles/10.1186/s13037-019-0187-3
35. Cho CH, Song KS, Min BW, Bae KC, Lee KJ. Operative Treatment of
Clavicle Midshaft Fractures: Comparison between Reconstruction Plate and
Reconstruction Locking Compression Plate[Internet]. Clin Orthop Surg.; 2010
58

[cited2019Mai01]. Available from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2915394/
Bibliography of Figures:
1-URL<http://undisclosedinjury.blogspot.ro/2015/02/patrick-kane.html>08.05.2018
2-URL< https://helpyourback.org/health/pain-around-the-collar-bone-area-clavicle-
pain/ >08.05.2018
3-URL< https://emedicine.medscape.com/article/398799-overview#a2 >13.05.2018
4-URL< https://www.orthobullets.com/shoulder-and-elbow/3048/distal-clavicle-
osteolysis >19.07.2018
5-URL< https://emdeicine.medscape.com/article/398799-overview#a2 >13.05.2018
6-URL< https://image.slidesharecdn.com/interestingcaseortho-
170215045022/95/interesting-case-orthokorat-calvicle-fracture-22-638.jpg?
cb=1487134298 >13.05.2018
7-URL< https://www.researchgate.net/figure/Robinsons-
classification_fig1_224821399 >19.07.2018
8-URL< https://eorif.com/sites/default/files/clavicle-sonoma2wk1.jpg >19.07.2018
9-URL< https://encrypted-tbn0.gstatic.com/images?
q=tbn:ANd9GcT5tCsb1Av2y6IjRv5FaLSVVvhCgstF3myO-
ehysW7EYUBg86yLgg >19.07.2018
10-URL< https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3609968/ >25.07.2018
11-URL<https://www2.aofoundation.org/wps/portal/!
ut/p/a0/04_Sj9CPykssy0xPLMnMz0vMAfGjzOKN_A0M3D2DDbz9_UMMDRyDXQ
3dw9wMDAzMjfULsh0VAbWjLW0!/?bone=Clavicle&classification=15-
2%20C3%20Complex%20shaft%2C%20Complex
%20irregular&implantstype=&method=ORIF%20Bridge
%20plate&preparation=Beach
%20chair&redfix_url=1429626466595&segment=Nonsegmented&showPage=prep
aration&treatment=&contentUrl=/srg/15/03-Preparations/Pr110_BeachChair-
Clavicle.jsp>25.07.2018
59

12-URL< http://www.jdrntruhs.org/viewimage.asp?
img=JNTRUnivHealthSci_2013_2_1_15_108506_f3.jpg >16.05.2018
13-URL< https://www.researchgate.net/figure/Stabilization-by-single-CC-suture-
fixation-with-Mersilene-tape-Surgical-procedure-A_fig1_262814911 >16.05.2018
60