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