Juhn and Simonian3 reported on a case of type VI separation with greenstick midshaft clavicle fracture in a hockey player seen 7 days after injury. The patient described some tingling in the upper extremity and had shoulder pain on initial presentation but was noted to have minimal displacement of both the AC joint and the midshaft clavicle fracture. Both injuries were treated nonsurgically with good outcome, and the patient returned to full activity (including hockey) within 14 weeks after injury.
Lancourt4 described the case of a patient with a type V AC dislocation and a displaced midshaft clavicle fracture. The AC joint was treated with Steinmann pin fixation, and the clavicle fracture was treated nonoperatively. The author cited high complication rates of plate fixation for clavicle fractures as the reason for not performing the additional procedure. The pins were removed 8 weeks after surgery. At 3-year follow-up, the patient had good radiographic and clinical outcome.
Yeh and colleagues6 described a patient who sustained a displaced midshaft clavicle fracture and a type IV AC dislocation in a fall from a horse. The patient underwent ORIF of the clavicle fracture with plate fixation. After the procedure, the AC joint was still unstable intraoperatively, and the AC and CC ligaments were reconstructed with semitendinosus allograft. The patient had full and painless ROM at 1-year follow-up.
The present case report serves as a reminder to obtain adequate shoulder radiographs when evaluating “just another clavicle fracture.” The radiographs should include a good axillary view to ensure there is not an associated AC dislocation. Increasingly, some authors have been advocating internal fixation for clavicle fractures, with reports of improved functional outcomes, improved cosmesis, and increased union rates.2 Indications for operative fixation include shortening and 100% displacement,8 and relative indications include open fractures.1 Operative fixation is perhaps more important for younger, athletic, and manual-labor populations. The trend in treatment of clavicle fractures toward operative fixation lends itself well to ORIF of the AC and CC joints; hence, a modern treatment for this rarely described combination injury should include internal plate fixation of the clavicle in addition to CC fixation. This additional procedure requires little extra time and energy in an operative scenario already requiring anesthesia, with easy insertion of the CC screw through the clavicle plate. Use of a CC screw obviates any potential risks associated with use of allograft tissue, and there is no anticipated difficulty with screw removal at 12 weeks.
Alternative options for AC stability include CC reconstruction with ligamentous allograft, ligamentous autograft, or suture/tightrope techniques. A noted advantage of these alternative techniques is less need to return to the operating room for the hardware removal that is recommended with CC screw fixation. However, these procedures potentially increase surgical exposure and operating time. In addition, screw fixation minimizes the possibility of donor-site morbidity from autograft transfers and potential complications from allograft tissue.
Hook plate fixation of the AC joint has also been described. In a recent case report of a similar injury pattern, plate fixation of the clavicle with simultaneous hook plate fixation of the AC joint was described.9 The patient did well but required removal of hardware of the hook plate and the clavicle plate 1 and 3 years after surgery, respectively. Although screw fixation is biomechanically stronger, debate persists about the clinical importance of this increase in strength.1 In the setting of plate fixation for the clavicle, these alternative AC fixations would require technique adjustments, including length of grafts and/or sutures, and raise concerns regarding interaction of the metal with the fixation material.
Critical evaluation of our technique revealed a lucency larger than the screw (Figure 5). However, the screw was not clinically loose at removal. This potential complication, in combination with the bent screw (Figure 4) before removal, highlights the concern for screw breakage with this technique, given the increased construct stiffness caused by the added plate.
Conclusion
As in the other reports mentioned, our patient had an excellent clinical and radiographic outcome. It could be inferred that, if fixation for isolated clavicle fractures demonstrates improved function, better outcomes would be seen for higher-energy fractures associated with AC dislocation. Given the current trend toward surgical fixation for certain clavicle fractures, we recommend that clavicle fractures associated with type IV AC dislocation be treated with ORIF of both injuries.