fracture clavicle
Post on 02-Jun-2015
8.070 Views
Preview:
TRANSCRIPT
FRACTURE CLAVICLEWhen to Operate?
DR.K.ANJANEYULUConsultant Orthopaedic Surgeon
Anatomy
• strut bet. the the Axial Skeleton & the Upper Extremity
• Muscle attachments
• Ligamentous attachments
• Protects Neurovascular stru.
Muscular attachments
• Sternomastoid & Pectoralis Major medially
• Trapezius & Deltoid laterally
• Subclavius inferiorly
Neurovascular Structures
• Subclavian Vein
• Subclavian Artery
• Brachial Plexus
Mechanism of Injury
CLINICAL EXAMINATION
• Ideally in standing position - shoulder translates & rotates forwards• From behind - inf.angle of scapula prominence• Swelling, Bruising, Ecchymosis, Blanching skin• Deformity, Stepping• Shortening• Neurovascular examination
Local Examination
Shoulder asymmetryDifferent levels of A/C Joint
Prominence of inf.angle of Scapula
X RAY EXAMINATION
AP X Ray of Shoulder for Clavicle in standing position - gravity – max deformity
Chest Radiograph – Compare with opp. Clavicle for any shortening -- assoc. injury to Rib, Glenoid Scapula -- Haemo / Pneumothorax
Displaced # Clavicle, multiple Rib #s Pneumothorax
CT SCAN• Medial 1/3 clavicle # cannot be visualised properly
in Plain radiographs
• Fractures of Glenoid in “Floating Shoulder”
• Midshaft #s – rarely required – can demonstrate complex three dimensional deformity
• Lat 1/3 #s with intra articular extension
Clavicle # & Glenoid #
Angiography
• Although displaced #s can’t be reduced & maintained in good reduction by cons.Rx
*Cosmesis is acceptable*Functional results are excellent
• Bony prominence resorbed with time
• Throwing athlets – malunion did not significantly alter their throwing ability
• Traditionally clavicle #s have been managed non operatively, but recent studies have shown that union rate for displaced midshaft #s may not be as favourable as described
• No obvious dif. in the outcome bet. Rx by a sling or figure of 8 bandage
IS THERE A NEED TO OPERATE A CLAVICLE
FRACTURE ?
Indications for Surgery
1. Fracture specific
2. Associated injuries
3. Patient factors
Fracture specific1. Displacement > 2 cms2. Shortening > 2 cms3. Increasing comminution > 3 fragments4. Segmental fractures5. Open fractures6. Impending open #s with soft tissue comprom7. Obvious clinical deformity ( 1 & 2)8. Scapular malpositioning & winging
ASSOCIATED INJURIES
1. Vascular injury requiring repair2. Progressive neurological deficit3. Ipsilateral Upper Extremity injuries / fractures4. Multiple ipsilateral upper rib #s5. “Floating shoulder”6. Bilateral clavicle fractures
PATIENT FACTORS
1. Polytrauma with requirement for early upper limb weight bearing / arm usage
2. Patient motivation for rapid return of function - elite sports - self employed professionals
SURGICAL APPROACH
• Anterosuperior
• Anteroinferior
Anterosuperior approach
Advantages: 1. familiar to many 2. extendibility 3. clear fracture view – postop.xray
Disadva: 1. trajectory of screw placement difficult 2. inadvertent plunging of drill may
injure lung & neurovasc. Structures 3. clavicle is narrow in superoinf. direct. 4. hardware prominence - requires removal
Anteroinferior approach
Advantages: 1. easier screw trajectory 2. less likely iatrogenic injury
3. wider AP dimension – longer screws 4. less hardware prominence 5. easier to contour a plate along
ant.bord
Disadvantages: 1. lack of general familiarity 2. plate obscures # site on x ray
Methods of fixation
1. Plate & Screw fixationanatomic reduction, stable fixationsugical morbidity is more
2. Intramedullary Pinningsmaller cosmetic skin incision, minimal soft tissue stripping, decreased hardware prominence
3. External Fixationintrinsic healing, no scar, no morbidity,
no retained hardware
Plate & Screw Fixation
Fracture medial end
Plate crossing onto the sternum
Badly displaced midshaft #
Open Reduction
Pre op & Post op X rays
Union of # & Implant Removal
Fracture Lateral End fixed with Hooked Plate
Malunion (symtomatic)
Intra operative Picture
Intra op &
Post op
# Clavicle with Head InjuryAbundant Callus, Venous Obstruction & Brachial
Plexus compression
Abundant callus Excision and PlatingRelief of symptoms
Transthoracic displacementPseudoaneurysm of Subclavian Art.
ORIF WITH PLATE & SCREWS
Intramedullary Pinning
Comminuted displaced midshaft # Intramedullary Pinning
Intramedullary Pinning
Cerclage Wire – Inadequate purchase
Implant failure
POSTOPERATIVE PROBLEMS
1. Scar2. Sensitive or Painful # site3. Hardware irritation / prominence4. Incisional numbness
conclusions• Majority of fractures heal with non operative Rx with
prompt return of near normal funct.• Poor prognostic signs – increasing displ.of frag
- increasing commi.with number of fragments
• Young active pts. – completely displaced midshaft #s – superior results-primary fixation
• Operative plate fixation - more rapid return to a superior level of function - low compli.rate
conclusions• Antero inferior plating better than superior plating in
terms of soft tissue irritation
• Intramedullary fixation has many theoritical adv. and high rate of success in skilled hands
• Scapular winging – conservative Rx - symptomatic
• Malunion is a definite clinical entity – benefits from corrective osteotomy
THANK YOU
top related