Classification of the clavicle fracture

According to Allman, clavicle fractures can be classified as Type I, II and III. Further classification possibilities are provided by Neer, as well as for injuries to the acromioclavicular joint according to Rockwood and Dameron. Allman I describes a fracture in the middle third of the clavicle.

Allman II can be further differentiated by Rockwood and Neer classifications, but basically describes a fracture in the outer third of the clavicle. Allman III describes fractures in the inner third of the clavicle, which leads to the sternum. This is also where further differentiation can be made (according to Salter-Harris).

Therapy

In children, the basic rule is that bones heal very well. Even strongly displaced fractures usually heal by themselves if they have been reduced (the fracture surfaces are pushed together). Even with clavicle fractures, as few operations as possible are performed.

In most cases, immobilisation of the shoulders is sufficient for a few weeks. A backpack bandage is applied to the children for this purpose. This is a bandage that is applied like a backpack and exerts traction on the shoulders to the back.

This reduces the fracture, i.e. the ends of the fracture are pushed together and fixed. The bandage must be worn for 1-4 weeks depending on the age of the child. Children under 5 years of age wear it for about 1-2 weeks.

Children between 5 and 10 years wear it for 2-3 weeks. And from the age of 10 years on, 4 weeks wearing time is indicated. During this time, the backpack bandage must be retightened in the first weeks to maintain the tension on the fracture site.

It is also important to note that during the time the bandage is worn, pulses, as well as sensitivity and motor functions in the arms are tested at regular intervals to rule out the possibility of nerves or vessels being pinched off. In the case of complicated fractures, surgical treatment of the collarbone fracture may be necessary. In fractures involving injury to nerves and vessels, as well as in open fractures, surgery is required in the majority of cases.

In open fractures, the soft tissue structures above the fracture are severed and there is a gap until the fracture occurs. Often, surgery is also performed if the collarbone fracture is the result of an accident that has caused many other injuries (polytrauma). In addition, surgery can also be performed if the skin is pierced or if there is a threat of piercing the skin.

Surgery is also indicated for fractures that have been classified as Rockwood IV-VI fractures by radiological imaging – fractures where the fracture is located in the outer (lateral) portion of the clavicle.If the conservative treatment, i.e. wearing the rucksack bandage, has not (sufficiently) helped, surgery is usually also performed, as there is reason to worry that a fake joint (pseudeoarthosis) will develop at the fracture site that has not grown together properly, which could cause pain to the child in the long term. If surgery is performed, various techniques can be used to fix the fracture gap. One possibility is plate osteosynthesis.

Here the fracture is fixed from the outside with a plate, which is fixed with nails in both parts of the fracture. However, this method leaves relatively large scars and requires a relatively large surgical access route. Another method is to fix the fracture with intramedullary Kirschner wires.

These are wires that are inserted longitudinally through the inner part of the bone, the medullary canal. There are other alternatives with elastic nails, which are intended to reduce the risk of injury to surrounding structures. The advantage of the wires is that a significantly smaller access route is required for fixation, thus causing fewer injuries to the tissue.

The backpack bandage is placed around both shoulders and fixed to the back. This causes the shoulders to be slightly straightened up, so that the two fracture parts of the clavicle are brought together. By placing the fracture parts next to each other, the healing process can begin without obstacles and the fracture grows together smoothly. The rucksack bandage should be worn for up to two weeks in children, and for adults, therapy of between 3 and 4 weeks is necessary.