Hook plating versus tension band wiring in treatment of displaced lateral end clavicle fracture

Clinical assessment

Clavicle fractures typically induce pain, swelling, bruising and obvious deformity with limited range of motion with neurovascular examination to exclude brachial plexus or vascular injury.

Radiological investigation:

 a single antero-posterior view erect position to demonstrate maximal deformity of the clavicle by the effect of gravity especially when considering surgery with chest radiograph  to evaluate the deformity relative to the normal side.

Surgical approach

Hook plate method

Skin incision about 7cm was done along anterior border then soft tissue dissection  down to the bone, periosteal elevation, exposure of fracture ends then reduction maintained by reduction clamp and fixation of the fracture by AO hook plate  which was placed along superior surface and inserted behind acromion process then irrigation of the wound by saline 0.9% was performed then covering of wound with dressing was done after closure.

Fig. 1:  A picture showing incision and fixation of lateral end clavicular fracture  hook plate.

Fig. 1:  fluroscopic image showing fixation of lateral third clavicle by hook plate.

Tension band wire method

Skin incision about 7cm was done along anterior border then soft tissue dissection  down to the bone, periosteal elevation, exposure of fracture ends and reduction maintained by reduction clamp. Under c-arm guidance, first k-wire was inserted through anterior aspect of lateral end intramedullary and engaged into the posterior border and the second k-wire was inserted through posterior aspect of lateral end intramedullary and engaged into the anterior border. 3.2 Drill Bit was done proximal to k-wire ends anterio-posteriorly to put transosseus tention band to augment and overcome migration. Then closure of the wound by layers.

Fig. 3: Tension band wire insertion under image.

Fig. 4:  Wound closure

Post-operative care and follow up

Antibiotics for 48 hours  with arm sling applied  for 2 to 3 weeks then removal of stitches was done after 2 weeks at least provided that wound healing was complete. Passive motion was initiated second day after surgery as tolerated in the form of pendulum exercises and active motion was initiated after 3 weeks as tolerated with regular visits in amanar of 2 weeks, 1 month, 3months and 6months postoperatively. 

Methods of assessment

The patient was evaluated clinically and radiologically for at least 6 months and comparison was done according to operative time, union time, constant –Murley score and complication.

RESULTS

According to operative time and union time there was no significant difference between studied groups as P value > .001. According to Costant-Murley score, there was highly significant difference between studied groups as P value < .001.

Table 2: Comparison between studied groups as regard  operative time, union time and Costant-Murley score.

According to complications, there were significant differences between studied groups as regard symptomatic hardware, subacromial impingment, coracoclavicular widening and wound infection due to P value < 0.05 and non-significant differences according to implant failure, osteolysis and shoulder impingment as P value > 0.05.

Table 3: Comparison between studied groups as regard complications.

Cases Presentation

Case 1

Male patient 36 yrs old with distal end clavicular fracture fixed by hook plate.

Fig. 5:  preoperative x ray.

Fig. 6:  Immediate post operative  x-ray.

Fig. 7: Four months post operative.

Fig. 8: a-b showing ROM after removal.

Case 2

Female patient 38 yrs old with distal end clavicular fracture fixed by TBW.

Fig. 9: Pre operative x-ray.

Fig. 10: Immediate Post operative x ray.

Fig. 11: 4 months post operative x –ray.

Fig. 12: a-b showing ROM post removal.

DISCUSSION

Comparison between two types of treatment with reasonable sample sizes in distal clavicular fracture is chalenging. Its anatomical properties (narrow, less dense ) make fixation with screws difficult. The subcutaneous position gives rise to skin irritation caused by the implants  thus requires  removal.⁶ All fixation methods have superiorities or deficiencies when compared to each other and none of them has been nominated as the ‘gold standard.⁷ In this study, lateral end clavicular fracture Neer type II was more common among young active patients. The  patients age ranged from 23 years old to 54 years old with mean age of 35.5 years in hook plate group and 37.4 years in TBW group and this is comparable to Daglar B,et al.⁸ in which the mean age was 29,8 ± 8,7 years (range 19-51), also comparable to Daniel W, et al .⁹in which the mean age was 36.2 years range (22-60) years and Kalamares M, et al.¹⁰ in which the mean age was 28.8 years range from (16 to 41). In this study, lateral end clavicular fracture Neer type II is predominant in males than females as the study included 25 males and 15 females and this is comparable to Daglar et al .⁸ which included 11 males and 3 females, also comparable to Daniel et al .⁹ which included 26 males and 10 females and to Kalamares et al .¹⁰ which included 7 males and 2 females. In this study, bone union occured in 37 cases (92%) and non union occurred in 2 cases (5%) in TBW group due to implant failure   and infection and 1 case (2.5%) in hook plate group due to implant failure. The bone union was 10 weeks avarage in two groups (Ranged from 9 to 12 weeks) and this is comparable to Daniel et al. ⁹ in which the rate of union was 95% with 3 months avarage union time. In this study, all patients acquired satisfactory motion range compared to the normal side with excellent shoulder function. Mean constant murley score was 86.5 in HP group (ranged from 84 to 89) and 87.6 in TBW group (ranged from 85.25-90) so, this indicates a satisfactory joint function and This is comparable to Daglar et al .⁹ in which the mean Constant score was 95.4±3.0 at 12 months and this mean excellent shoulder function according to these scores.  There was a good results in most of patients. The best results were obtained  when the HP was removed before 6 months, which was done in most of cases and This is also comparable to Kalamares et al .¹⁰ in which the mean constant shoulder score was 96. These results may be due to use of this type of fixation that allows early rehabilitation resulting in normal range of motion. In this study, infection was recorded in 4 cases with TBW fixation (10%)   and was controlled with  antibiotics with no recorded cases in HP group and this is comparable to Kalamares et al.¹⁰ in which wound infection occurred in one case (11% of cases).

CONCLUSION

Surgical treatment of lateral end clavicular fractures using different methods of fixating results in a good functional outcome with   low complication rate. Plating of lateral third clavicular fractures has many advantages such as easy application, less complications, short stay in hospital and early mobilization of the affected shoulder.