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Malaysian Orthopaedic Journal 2017 Vol 11 No 3

Ogawa T, et al

doi: http://dx.doi.org/10.5704/MOJ.1711.003

Internal Fixation of Only the Distal End in a Bipolar
Segmental Clavicle Fracture: A Case Report
Ogawa T, MD, Sasaki T*, MD, Masayuki-Kawashima MK*, PhD, Okawa A, PhD,
Mahito-Kawashima MK*, PhD
Department of Orthopaedics, Tokyo Medical and Dental University, Tokyo, Japan*Department of Orthopaedics, Kawashima Orthopedic Hospital, Oita, Japan

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use,distribution, and reproduction in any medium, provided the original work is properly cited

Date of submission: 21st April 2017
Date of acceptance: 22nd September 2017

ABSTRACT

Bipolar segmental clavicle fractures are simultaneousclavicle fractures of both proximal and distal ends. Few casereports describing these fractures have been published, andthe management of these injuries have remained
controversial. Non-operative treatment is likely to result inpoor shoulder function due to the instability of the fracture inpatients with high physical demands. In contrast, surgicaltreatment with fixation of both proximal and distal ends ofthe clavicle possibly may cause life-threatening
complications. We present a 74-year old female farmer who
had injured her left shoulder and was diagnosed with abipolar segmental clavicle fracture. Taking the fracture
mechanism into consideration, we surgically treated only thedistal end of the clavicle fracture with a locking plate. The
proximal end of the clavicle fracture was treated without
surgical intervention. Both fracture sites achieved bonyunion after four months and she returned to her activities asa farmer. Quick DASH score was 5.0 with excellent results
at three years after operation.
Key Words:
bipolar segmental clavicle fracture, surgical fixation,
unilateral locking plate fixation, distal-only fixation
INTRODUCTION

Clavicle fractures are common and most occur in the midshaft of the clavicle. Simultaneous fractures of the proximaland distal end of the clavicle, however, are rare and known as
bipolar segmental clavicle fractures1. Management of bipolar
segmental clavicle fractures has been controversial, ranging
from non-operative to surgical treatments. For surgery, mostauthors have reported fixation as a treatment option for bothproximal and distal ends of the clavicle fractures due tofracture instability1,2. However, the fixations of the proximal
clavicle fracture may cause severe complications3. In thisarticle, we report a case of a left bipolar segmental clavicle
fracture in an elderly female who underwent surgicaltreatment. Surgery was performed only for the distal end of theclavicle alone, while the proximal end was treated nonoperatively.
CASE REPORT

A 74-year old female farmer had injured her shoulder against
the side view mirror of a moving car. After the accident, she
was unable to lift her left arm due to shoulder pain andattended our hospital. On physical examination, a deformity
was observed on the left clavicle. Standard radiographrevealed a fracture at the distal end of the left clavicle (Fig.
1a). Three-dimensional computer tomography (CT) scanrevealed in addition a displaced fracture of the proximal endof the clavicle, and a diagnosis of bipolar segmental clavicle
fracture was made (Fig. 1b). The proximal and distal
displaced fractures were extra-articular (Robinson Type1B1) and intra-articular (Robinson Type 3B2), respectively.
The proximal end of the clavicle was displaced anteriorly
and the distal end posteriorly (Fig. 1c), with floatingintermediate fracture fragments. This indicated fracture
instability and a high risk of non-union1. Therefore, we
decided to treat with open reduction, and it was performed
seven days after injury with the patient’s consent.
The patient underwent surgery under general anaesthesia inthe beach chair position. A skin incision was made over thedistal fracture site. The distal end of the clavicle wasdisplaced posteriorly. The floating bone fragment was foundrotated opposite to the direction of the displacement. As thedistal end of the clavicle was reduced, the proximal end wassimultaneously reduced to a good anatomical position. A 3hole locking plate [LCP™ Superior Clavicle Plate, DePuy
Synthes Trauma, West Chester, USA] was used to provide
fixation between the distal end of the clavicle, as theCorresponding Author: Takahisa Ogawa, Department of Orthopaedics, Tokyo Medical and Dental University, Bunkyo-ku, Japan
Email: takahisa.o@gmail.com

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Malaysian Orthopaedic Journal 2017 Vol 11 No 3

Ogawa T, et al

(a)

(c)

(b)

Fig. 1: (a) Preoperative standard radiograph, (b) Preoperative three-dimensional CT scan image, (c) Proximal end of the clavicle wasdisplaced anteriorly and the distal end posteriorly.

(a)

(b)

(c)

(d)

Fig. 2: (a,b) Standard radiographs at four months after operation, (c) and after implant removal at 14 months after operation, (d)Three-dimensional CT scan image after implant removal.

Fig. 3: CT scan image after implant removal at 14 months after operation. Bony union was achieved.

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Bipolar Segmental Clavicle Fractureintermediate floating fracture fragment was secured by morethan two screws to prevent rotational displacement. The
proximal clavicle fracture was left alone to avoid any criticalcomplications.

After the operation, the patient’s shoulder was placed in asling and allowed passive range of motion of the shoulder
below 90 degrees for one month as the proximal clavicle
fracture was not surgically fixed. Gradually active
movement of the shoulder was allowed as tolerated. Fourmonths after the operation, the patient was able to elevate hershoulder forward up to 160 degrees. Radiographs and CT
scans revealed bony union of both proximal and distal endsof the fracture (Fig. 2a and b). Because of discomfort due toimplant irritation, the implant was removed one year after
surgery and the symptoms diminished (Fig. 2c, d and Fig. 3).
Three years post operatively, the patient had neither pain nor
crepitation in both her proximal and distal fracture sites. The
ROM of shoulder was 165 degrees in anterior elevation and80 degrees in abduction. The Oxford shoulder score was 47
points and ASES shoulder score was 91.6 points. The Quick
DASH score was 5.0 points, demonstrating a better scorethan previous literatures (8 points without complication case,
66 points with complication case)3. The patient has continued
her activities as a farmer.
DISCUSSION

Bipolar segmental clavicular fracture was first described byPorral in 18314. There is still no consensus regarding thetreatment of bipolar segmental clavicle fractures. Previous
reports have suggested that bipolar segmental clavicle
fractures usually occur as a result of high energy trauma.
However, low energy trauma such as falling on theoutstretched hand can also cause this injury1.

Non-operative treatment is recommended for minimallydisplaced fractures in low-demand patients5. However, somestudies report gross deformity of the clavicle and poor
functional outcome following non-surgical treatment. Even
if the fracture is caused by low-energy trauma, the instabilityof the shoulder can persist; thus, operative treatment isrecommended1. According to previous reports, most surgicalmanagement includes fixation for both proximal and distal

ends of the clavicle1,3. With regard to surgical treatment,
proximal clavicle fractures lead to serious complications
during operation, such as screw penetration into thepericardium and pneumothorax3.

The injury mechanisms of segmental clavicle fractures havebeen unknown. In our case, a plausible explanation of theinjury mechanism is that the patient first hit her shoulderfrom the anterior to posterior direction that forced her upper
limb to displace in excessive stretch, inducing a rotational
force on her clavicle. Therefore, the sternoclavicular andcoracoclavicular joints acted as fulcrum and resulted insimultaneous fractures of the proximal and distal ends of theclavicle.

In consideration of the above injury mechanism, at operation
we rotated the patient’s intermediate clavicle fragment
towards the direction of displacement and provided fixation
by a locking plate. As a result, the angular stability of thelocking plate stabilized the fragment in the anatomical
position and dispersed the motion stress of both fracturesites. Because our treatment did not provide rigid fixation,
the patient’s shoulder was immobilized after operation.
Although early mobilization is possible with surgicalintervention, we believe the disadvantage of postoperative
immobilization does not outweigh the fatal complications
that may follow surgical fixation of the proximal clavicle
fracture. Ultimately, it was gratifying that both fracture sites
achieved bony union and acceptable shoulder function.

In conclusion, unilateral locking plate fixation of the distal
end can be a useful option for treating bipolar segmental
clavicle fractures.
ACKNOWLEDGEMENT

The authors would like to thank Sho Steven Sugita forproviding professional English editing and proofreading
services. We thank Dr. Yasuhiro Seki for his helpful advice
on this article.
CONFLICT OF INTEREST

The authors declare no conflicts of interest.

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Heywood R, Clasper J. An unusual case of segmental clavicle fracture. J R Army Med Corps. 2005; 151(2): 93-4.

Skedros JG, Knight AN, Mears CS, Langston TD. Temporary sternoclavicular plating for an unusual double clavicle fracture(medial nonunion, lateral acute) complicated by an intraoperative pneumothorax. Case Rep Orthop. 2014; 2014: 206125.

Porral A. Observation d’une double luxation de la clavicule droite. J Univ Hebd Med Chir. 1831; 2: 78-82.

Jain AS. Traumatic floating clavicle. A case report. J Bone Joint Surg Br. 1984; 66(4): 560-1.

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