clavicle fractures&acromio clavicular joint injuries
TRANSCRIPT
CLAVICLE FRACTURES,ACROMINO CLAVICULAR
JOINT INJURIES AND STERNOCLAVICULAR JOINT
DISLOCATIONS
Dr AMRUTH RAM REDDYPOST GRADUATE
GANDHI MEDICAL COLLEGE
ANATOMY
The name clavicle derives from Latin It means ‘little key‘ as it is shaped like
the key that the Romans used to lock their doors.
It is a long bone. It transmits the weight of limb to sternum It has a shaft and two ends medial and
lateral. Lateral end articulates with acromion to
form acrominoclavicular joint
Medial end articulates with manubrium sterni to form sternoclavicular joint
Articular surface extends to inferior aspect for articulation with first costal cartilage
SHAFT:lateral 1/3>superior surface sub cutaneous
Inferior surface has elevation called conoid tubercle and ridge called trapezoid ridge.
They give attachments to conoid and trapezoid parts of coracoclavicular ligaments.
INFERIOR SURFACE
SUPERIOR SURFACE
Lateral 1/3 shaft :gives origin to deltoid and trapezius.
Medial 2/3 shaft:origins of pectoralis major and clavicular head of sternocleidomastoid.
Subclavian groove gives insertion to subclavius muscle.
It functions as an osseous protector of brachial plexus,jugular and subclavian vessels.
PECULIARITIES OF CLAVICLE
Only long bone that lies horizontally Sub cutaneous through out. First bone to start ossifying Only long bone which ossifies in
membrane Only long bone which has two primary
centres of ossification It is occasionally pierced by middle
supraclavicular nerve.
Mechanism of Injury
Moderate or high-energy traumatic impacts to the shoulder
1. Fall from height2. Motor vehicle accident3. Sports injury4. Blow to the point of the shoulder5. Rarely a direct injury to the clavicle6. The most common mechanism of clavicle
fracture is a fall on the superolateral shoulder
PHYSICAL EXAMINATION
Swelling,bruising,ecchymosis at the fracture site
deformity of shoulder girdle best seen with patient standing
In completely displaced mid shaft fractures there is shoulder ptosis.
Foreward translation and rotation of shoulder Shortening of clavicle Careful neurologic and vascular examination
of involved limb is mandatory
•stabilizing on the medial segment by•sternoclavicular ligaments•superior on the medial segment through the sternocleidomastoid•inferior and medial on the lateral segment through the pectoralis major•inferior on the lateral segment through the weight of the arm pulling through coracoclavicular ligaments
For more lateral fractures•superior on the medial segment through the sternocleidomastoid and trapezius•medial on the distal segment through the pull of the pectoralis major, pectoralis minor, and latissimus dorsi•inferior on the distal segment through the weight of the arm
IMAGING
Simple A-P view is is sufficient to establish the diagnosis of clavicle fracture.
Chest radiograph is useful to compare with the normal side
Should be taken in upright position,where gravity will demonstrate the deformity.
Radiographic beam should be angled 20 degrees superiorly
This eliminates the overlap of the thoracic cage
Radiographic Evaluationof the Clavicle
Anteroposterior View
30-degree Cephalic Tilt View
Radiographic Evaluation of the Clavicle
Quesana View 45-degree angle superiorly and a 45-
degree angle inferiorly Provide better assessment of the
extent of displacement
Radiographic Evaluationof the AC Joint
Zanca View AP view centered at AC joint with 10
degree cephalic tilt Less voltage than used for AP
shoulder
Stress views may be taken to determine the integrity of coracoclavicular ligaments.
Fractures of medial clavicle especially those involving SC joint are difficult to assess on plain radioraphs.
CT scan is modality of choice here It can distinguish between medial
epiphyseal # and true SC dislocations.
Clavicular diastasis greater than 1 cm hints scapulothoracic dissociation and brachial plexus traction injury.
CLASSIFICATION
ALLMANS CLASSIFICATION Group I: middle third fractures Group II: lateral third fractures Group III: medial third fractures NEERS CLASSIFICATION Type I: coracoclavicular ligaments intact Type II: coracoclavicular ligaments detached
from the medial segment but trapezoid intact to distal segment
Type III: intra-articular extension into the acromioclavicular joint
Classification of Distal Clavicular Fractures(Group II Clavicle Fractures)
Type I-nondisplaced Between the CC and
AC ligaments with ligament still intact
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
Type IIA
•A. Conoid and trapezoid attached to distal fragment
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
Type IIB
•Type IIB: Conoid torn, trapezoid attached
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
Classification of Distal Clavicular Fractures
Type III:articular fractures
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
CRAIG CLASSIFICATION: advantage of including more unusual injuries, such as epiphyseal separations and periosteal sleeve fractures.
ROBINSON CLASSIFICATION
ADVANTAGES:analyses fractures of clavicle in thirds
Prognostically important variables such as extension,degree of displacement,degree of comminution.
DISADVANTAGES: Un usual fracture types included by craig
are not mentioned here. Number scheme used do not correpond
to those used by allman.
TREATMENT
MID SHAFT FRACTURES:most midshaft clavicle fractures are effectively treated nonoperatively.
They include 1)simple arm sling 2)figure of eight brace. There is no change in functional outcome
between these two methods. If injury occurs in dominant shoulder figure
of 8 brace is given. dominant hand can remain free for writing,
keyboarding, and other activities
useful For fractures with shortening also as this retracts the scapula and allows to maintain length.
For fractures in non dominant extremity simple sling will suffice.
This is more comfortable and tolerable. This is maintained for 4 to 6 weeks. Immobilisation is discontinued when
there is no pain or no palpable fracture motion.
forward elevation and external rotation stretches performed supine to negate the displacing effects of gravity.
major displacing force for this injury is the weight of the arm
so, pendulum exercises will magnify the displacing moment and should be avoided.
Cuff and collar with strapping should be avoided.
This will allow weight of elbow to generate traction force and distract the fracture.
Cuff and collar should never be used in treatment of clavicle fractures.
Simple sling that elevates the shoulder is all that required.
Displaced mid shaft clavicle fractures cause persistent disability even if they heal uneventfully.
INDICATIONS FOR OPEN REDUCTION AND INTERNAL FIXATION OF MIDSHAFT
DISPLACED FRACTURES Absolute Shortening of >20 mm Open injury Impending skin disruption and irreducible
fracture Vascular compromise Progressive neurologic loss Displaced pathologic fracture with associated
trapezial paralysis Scapulothoracic dissociation
Relative Displacement of >20 mm Neurologic disorder Parkinson's Seizures Head injury Multi trauma Expected prolonged recumbency Floating shoulder Intolerance to immobilization Bilateral fractures Ipsilateral upper extremity fracture Cosmesis
Plate Fixation
Traditional means of ORIF Plate applied superiorly or inferiorly
Inferior plating associated with lower risk of hardware prominence
Used for acute displaced fractures and nonunions.
3.5-mm locking dynamic compression plate less desirably, a 3.5-mm reconstruction
plate. There are several advantages to this type
of fixation over intramedullary fixation.
For transverse fractures, compression across the fracture site is achieved.
For oblique fractures or butterfly fragments, lag screw fixation is possible .
Secure rotational control of the fracture is achieved. Fixation is rigid enough to allow the patient to
minimally weight-bear on the extremity. Minimal soft-tissue disruption is necessary. Often, the injury itself has caused fairly extensive
local soft-tissue stripping. For plate application, only soft-tissue along the
superior aspect of the clavicle need be elevated
SURGICAL APPROACHES
Two surgical approaches are commonly used
1)anterosuperior:most popular operative method of fixation of clavicle.
Advantages:incision can be extended to both medial and lateral ends of clavicle.
Clear radiographic views postoperatively. Disadvantages:underlying neurovascular
structures and lung are at risk. Hard ware prominence can be
problematic.
Antero inferior approach:less commonly used.
ADVANTAGES:less liklihood of injury to underlying structures.
Technically easy to contour small fragment compression plate along anterir border compared to superior border.
DISADVANTAGES:lack of familiarity of this approach to most surgeons.
Biomechanical studies revealed superior position for plate placement is advantageous.
Intramedullary Fixation
Large threaded cannulated screws Flexible elastic nails K-wires
Associated with risk of migration
Useful when plate fixation contra-indicated Bad skin Severe osteopenia
Fixation less secure
Lateral Clavicular FracturesNonoperative Treatment
Type II fractures, alternatively, are unstable injuries, secondary to four displacing forces
the weight of the arm the pull of the pectoralis major, pectoralis
minor, and latissimus dorsi scapular rotation, which affects the distal
segment but not the proximal the trapezius muscle, which draws the
medial segment posterior and superior
Techniques for Acute Operative Treatment of Distal Clavicle Fractures
Kirschner wires inserted into the distal fragment
Dorsal plate fixation CC screw fixation Tension-band wire or suture Transfer of coracoid process to the clavicle Clavicular Hook Plate
Type I and Type III distal clavicle fractures are treated nonoperatively
The main deforming force and source of discomfort is the weight of the arm.
a simple sling is more effective than a figure-of-eight brace or shoulder immobilizer at countering this force.
those with Type III injuries, are warned of the possibility of late acromioclavicular arthrosis with the possible need for subsequent distal clavicle excision
Type 2 fractures are usually treated with operative fixation.
direct fixation of the fracture site without coracoclavicular stabilization
direct fixation of the fracture site with coracoclavicular stabilization
coracoclavicular stabilization with or without excision of the lateral clavicular segment
Direct Fixation of the Fracture with Coracoclavicular Stabilization
Indications : (a) very distal fracture in a young
individual (b) fractures that involve the clavicular
insertion of the coracoclavicular ligaments.
Coracoclavicular Stabilization With or Without Excision of the Lateral Clavicular Segment
comminuted lateral clavicular segment; (b) older patients in whom potential
healing of a small lateral clavicular segment would be difficult
(c) underlying acromioclavicular arthropathy
(d) fractures lateral to the trapezoid origin
(e) fractures that involve the coracoclavicular ligament origin as an inferiorly displaced fragment.
Complications of Clavicular Fractures and its Treatment
Nonunion Malunion Neurovascular Sequelae Post-Traumatic Arthritis
NON UNION
clavicle nonunion is defined as lack of evidence of healing 4 to 6 months after injury
Factors Associated with Development of Nonunion
Type II fracture Fracture shortening of >20 mm Fracture displacement of >20 mm Increasing patient age Increasing severity of trauma Refracture
Principles for the Treatment of Clavicular Nonunions
Restore length of clavicle May need intercalary bone graft
Rigid internal fixation, usually with a plate
Iliac crest bone graft Role of bone-graft substitutes not yet
defined.
MANAGEMENT
Electrical Stimulation and Low-Intensity Pulse Ultrasound
Open Bone Graft and Immobilization Open Bone Graft and Screw Fixation Open Bone Graft and Plate Fixation Open Bone Graft and Intramedullary
Fixation Clavicular Excision
Clavicular Malunion Symptoms of pain, fatigue, cosmetic
deformity. Initially treat with strengthening, especially
of scapulothoracic stabilizers. Consider osteotomy, internal fixation in rare
cases in which nonoperative treatment fails.
Correction of malunion with thoracic outlet sx
Neurologic Sequelae
Occasionally, fracture fragments or abundant callus can cause brachial plexus symptoms.
Treatment is reduction and fixation of the fracture, or resection of callus with or without osteotomy and fixation for malunions.
ACROMINOCLAVICULAR JOINT
It is a plane synovial joint. Formed by the articulation of small facets
between lateral end of clavicle and medial margins of acromion process of scapula.
Cavity of joint has articular disc occasionally,which may be perforated.
Classification for Acromioclavicular Joint
Injuries Initially classified by both Allman and
Tossy et al. into three types (I, II, and III).
Rockwood later added types IV, V, and VI, so that now six types are recognized.
Classified depending on the degree and direction of displacement of the distal clavicle.
Type I
Sprain of acromioclavicular ligament
AC joint intact Coracoclavicular
ligaments intact Deltoid and
trapezius muscles intact
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
AC joint disrupted < 50% Vertical
displacement Sprain of the
coracoclavicular ligaments
CC ligaments intact Deltoid and
trapezius muscles intact
Type II
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
AC ligaments and CC ligaments all disrupted
AC joint dislocated and the shoulder complex displaced inferiorly
CC interspace greater than the normal shoulder(25-100%)
Deltoid and trapezius muscles usually detached from the distal clavicle
Type III
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
AC and CC ligaments disrupted
AC joint dislocated and clavicle displaced posteriorly into or through the trapezius muscle
Deltoid and trapezius muscles detached from the distal clavicle
Type IV
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
AC ligaments disrupted CC ligaments disrupted AC joint dislocated and
gross disparity between the clavicle and the scapula (100-300%)
Deltoid and trapezius muscles detached from the distal half of clavicle
Type V
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
AC joint dislocated and clavicle displaced inferior to the acromion or the coracoid process
AC and CC ligaments disrupted
Deltoid and trapezius muscles detached from the distal clavicle
Type VI
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
Treatment Options for Types I - II Acromioclavicular Joint Injuries
Nonoperative: Ice and protection until pain subsides (7 to 10 days).
Return to sports as pain allows (1-2 weeks)
No apparent benefit to the use of specialized braces.
Type II operative treatment Generally reserved only for the patient with
chronic pain. Treatment is resection of the distal clavicle
and reconstruction of the coracoclavicular ligaments.
Imaging:normal AP view including opposite shoulder for comparision
ZANCA view with 15 degree cephalic tilt. Stryker notch view for visualizing
coracoid fractures.
Treatment Options for Type III-VI Acromioclavicular Joint Injuries Nonoperative treatment
Closed reduction and application of a sling and harness to maintain reduction of the clavicle
Short-term sling and early range of motion Operative treatment
Primary AC joint fixation Primary CC ligament fixation Excision of the distal clavicle Dynamic muscle transfers
Type III Injuries: Need for acute surgical treatment remains very controversial.
Most surgeons recommend conservative treatment except in the throwing athlete or overhead worker.
Repair generally avoided in contact athletes because of the risk of reinjury.
Indications for Acute Surgical Treatment of Acromioclavicular Injuries
Type III injuries in highly active patients
Type IV, V, and VI injuries
Surgical Options for AC Joint Instability
Coracoid process transfer to distal transfer (Dynamic muscle transfer)
Primary AC joint fixation Primary Coracoclavicular Fixation Distal Clavicle Excision with CC ligament
reconstruction.
WEAVER-DUNN PROCEDURE
Weaver-Dunn Procedure
The distal clavicle is excised. The CA ligament is
transferred to the distal clavicle.
The CC ligaments are repaired and/or augmented with a coracoclavicular screw or suture.
Repair of deltotrapezial fascia
COMPLICATIONS
Migration of Pins Failure of Soft Tissue Repairs Complications Related to Nonabsorbable
Tape or Suture. Acromino clavicular arthritis
The Anatomy of the Sternoclavicular Joint
Diarthrodial Joint “Saddle shaped” Poor congruence Intra-articular disc
ligament. Divides SC joint into two separate joint spaces.
Costoclavicular ligament- (rhomboid ligament) Short and strong and consist of an anterior and posterior fasciculus
Interclavicular ligament- Connects the superomedial aspects of each clavicle with the capsular ligaments and the upper sternum
Capsular ligament- Covers the anterior and posterior aspects of the joint and represents thickenings of the joint capsule. The anterior portion of the ligament is heavier and stronger than the posterior portion.
Epiphysis of the Medial Clavicle
Medial Physis- Last of the ossification centers to appear in the body and the last epiphysis to close.
Does not ossify until 18th to 20th year Does not unite with the clavicle until the
23rd to 25th year
Injuries Associated with Sternoclavicular Joint Dislocations
Mediastinal Compression
Pneumothorax Laceration of the
superior vena cava
Tracheal erosion
Treatment of Anterior Sternoclavicular Dislocations
Nonoperative treatment Analgesics and immobilization Functional outcome usually good
Closed reduction Often not successful Direct pressure over the medial end of the clavicle may reduce the joint
Treatment of Posterior Sternoclavicular Dislocations
Careful examination of the patient is extremely important to rule out vascular compromise.
Consider CT to rule out mediastinal compression
Attempt closed reduction - it is often successful and remains stable.
Abduction traction Adduction traction “Towel Clip” - anterior force applied to
clavicle by percutaneously applied towel clip
Closed Reduction Techniques
Resection arthroplastyMay result in instability of
remaining clavicle unless stabilization is done.
Suggest minimal resection of bone and fixation of medial clavicle to first rib.
Sternoclavicular reconstruction with suture, tendon graft.
Operative Techniques