Document Type: RESEARCH PAPER

Authors

1 Hand and Upper Extremity Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA

2 Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, Texas, USA; 1400 Barbara Jordan Blvd. Suite 2.834; MC: R1800, Austin, TX 78723

Abstract

 
Background:
Previous anatomic and radiological studies have described the relationship of the clavicle to major neurovascular structures in healthy subjects. We were curious about this relationship in patients with a clavicle fracture and if it is different from non-fractured clavicles.
 
Methods:
We retrospectively identified all patients with a clavicle fracture between July 2001 and October 2013 in two level 1 trauma centers. Patients aged 18 years or greater with an acute unilateral clavicle fracture and a chest CT scan in the supine position displaying both clavicles and the complete fracture were included. Seventy patients were available for study. The distance was measured from the fracture site and from the closest clavicular cortex to the closest major artery, major vein, and inner surface of the thoracic cavity. CT data was evaluated in OsiriX DICOM viewer software with the use of three-dimensional Multiplanar Reconstruction.
Results:
Compared to the fractured side, the clavicle was significantly closer to the artery and vein on the non-fractured side (PP=0.0025 respectively). There was a significant difference in the median distance of the fracture site to the artery, vein, and inner surface of thoracic cavity between the different types of fractures (P<0.001). A post-hoc comparison showed significant differences in all distances between fracture types, except for the distance of proximal third compared to middle third fractures to the closest artery (P=0.41). There was no significant difference in distance when the arm is up overhead compared to down by the side of the body in computed tomography (CT) scans.
Conclusions:
A fracture of the clavicle changes the relationship of the clavicle to major vital structures. The minimum distance of the clavicle to the closest artery and vein is significantly less on the non-fractured side, compared to the fractured side.

Keywords

Main Subjects

1. Allman FL Jr. Fractures and ligamentous injuries of
the clavicle and its articulation. J Bone Joint Surg Am.
1967; 49(4):774-84.
2. Liu GD, Tong SL, Ou S, Zhou LS, Fei J, Nan GX, et
al. Operative versus non-operative treatment for
clavicle fracture: a meta-analysis. Int Orthop. 2013;
37(8):1495-500.
3. Khan LA, Bradnock TJ, Scott C, Robinson CM.
Fractures of the clavicle. J Bone Joint Surg Am. 2009;
91(2):447-60.
4. Qin D, Zhang Q, Zhang YZ, Pan JS, Chen W. Safe
drilling angles and depths for plate-screw fixation
of the clavicle: avoidance of inadvertent iatrogenic
subclavian neurovascular bundle injury. J Trauma.
2010; 69(1):162-8.
5. Sinha A, Edwin J, Sreeharsha B, Bhalaik V, Brownson
P. A radiological study to define safe zones for drilling
during plating of clavicle fractures. J Bone Joint Surg
Br. 2011; 93(9):1247-52.
6. Werner SD, Reed J, Hanson T, Jaeblon T. Anatomic
relationships after instrumentation of the midshaft
clavicle with 3.5-mm reconstruction plating: an
anatomic study. J Orthop Trauma. 2011; 25(11):657-
60.
7. Hussey MM, Chen Y, Fajardo RA, Dutta AK. Analysis of
neurovascular safety between superior and anterior
plating techniques of clavicle fractures. J Orthop
Trauma. 2013; 27(11):627-32.
8. Lo EY, Eastman J, Tseng S, Lee MA, Yoo BJ.
Neurovascular risks of anteroinferior clavicular
plating. Orthopedics. 2010; 33(1):21.
9. Shrout PE. Measurement reliability and agreement
in psychiatry. Stat Methods Med Res. 1998; 7(3):301-
17.
10. Kubo T, Lin PJ, Stiller W, Takahashi M, Kauczor HU,
Ohno Y, et al. Radiation dose reduction in chest CT: a
review. AJR Am J Roentgenol. 2008; 190(2):335-43.
11. Van de Velde J, Audenaert E, Speleers B, Vercauteren
T, Mulliez T, Vandemaele P, et al. An anatomically
validated brachial plexus contouring method for
intensity modulated radiation therapy planning. Int
J Radiat Oncol Biol Phys. 2013; 87(4):802-8.
12. Yates DW. Complications of fractures of the clavicle.
Injury. 1976; 7(3):189-93.
13. Lohse GR, Lee DH. Clavicle fracture with intrathoracic
displacement. Orthopedics. 2013; 36(8):e1099-102.
14. Barbier O, Malghem J, Delaere O, Vande Berg B,
Rombouts JJ. Injury to the brachial plexus by a
fragment of bone after fracture of the clavicle. J Bone
Joint Surg Br. 1997; 79(4):534-6.
15. Kachooei AR, Badiei Z, Zandinezhad ME,
Ebrahimzadeh MH, Mazloumi SM, Omidi-Kashani F,
et al. Influencing factors on the functional level of
haemophilic patients assessed by FISH. Haemophilia.
2014; 20(2):185-9.
16. Faisham WI, Mohammad P, Juhara H, Munirah NM,
Shamsulkamaruljan H, Ziyadi GM. Clavicle fracture
and subclavian vessels disruption with massive
haemothorax mimic intrathoracic injury. Malays J
Med Sci. 2011; 18(2):74-7.