Fractures of the clavicle

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  • 1.FRACTURESOF THE CLAVICLELe Kim Trong MD., Le Nghi Thanh Nhan MD.

2. General Information

  • Clavicle fractures are common injuries
  • Account for 5-10% of all fractures
  • Up to 44% of injuries to the shoulder girdle
  • Easy to recognize
  • Majority unite uneventfully

3. Current Debate in Treatment

  • What are the indications for early or acute surgical treatment?

4. Ossification

  • 1 stbone in body to ossify at 5 weeks gestation
  • Intramembranous ossification
  • Epiphyseal growth plates develop at both ends, only medial end is evident on radiographs and accounts for 80% of its length
  • Sternal ossification occurs at 12-19 years of age and fuses at 22-25

5. Anatomy

  • The clavicle is an S-shaped bone that acts as a structure between the sternum and the glenohumeral joint.
  • The lateral third is flat and is the insertion site for the trapezius
  • The middle third is tubular and provides protection.
  • The medial third is quadrangular and is the insertion for sternocleidomustoid muscle

6. Anatomy Left Clavicle:Superior & Inferior Views Middle Third Weak to axial load Medial Third Protects brachial plexus, subclavian vessels, & superior lung Convex ventral on medial half Concave ventral on lateral half 7. Anatomy Weakest region of bone 8. Anatomy Subcutaneous along entire lengthSupraclavicular nerves are only structures to cross anterior to clavicle Scapula and clavicle bound securely by the AC & CC ligaments Main nutrient artery enters just medial to CC ligaments 9. Clavicle Function

  • Power and stability of arm
  • Motion of the shoulder girdle
  • Muscle attachment
  • Protects neurovascular structures

Facilitates the placement of the shoulder in a more lateral position, so the hand can be more effectively positioned to deal with a 3-D environment 10.

  • Epidemiology
  • Group 1(middle one third of the clavicle - the shaft) 76% ,13 years.
  • Group 2 (lateral one third - the acromial end) 21% ,47 years.
  • Group 3 (medial one third - the sternal end) 3%, 59 years.

11. Mechanism of Injury

  • Trauma
    • Fall against lateral shoulder (90%)
    • Fall on Outstretched Hand (5%)
    • Direct blow to clavicle (5%)
  • No trauma(in children)
    • Tumor
    • Rickets
    • Osteogenesis imperfecta
    • Physical Abuse

12. Diagnosis

  • History: trauma, tumor
  • Pain and swelling, decreased movement of the affected limb.
  • Bruising, tenderness, and crepitation,pressure on the overlying skin, palpable.
  • The arm will usually be held across the chest with the opposite limb used to support the weight of the injured limb
  • Observe for complications
  • - Neurovascular injury of affected arm , outlet thoracic
  • - Pneumothorax, open fracture
  • - Subcu t aneous Emphysema
  • http://www.fpnotebook.com/ortho/shoulder/ClvclFrctr.htm

13.

  • Displacement mechanism

14.

  • Radiographs
  • Different angles (anteroposterior and 45 cephalic tilt):
      • AP evaluate superior-inferior displacement
      • 45 ocephalic tilt view
          • Evaluate AP displacement
          • Tube directed from below, upward
      • Weighted views useful in lateral 1/3 fractures to assess CC ligaments
  • Chest x-ray
  • CT

15. VI.Classifications & Treatments Group I - Middle third (80-85%) Nondisplaced

  • less than 100% displacement

nonoperative Displaced

  • greater than 100% displacement
  • nonunion rate of 4.5%

operative 16. Group II - Lateral third(10-15%) Type I

  • fracture occurs lateral to coracoclavicular ligaments (trapezoid, conoid) or interligamentous
  • usually minimally displaced
  • stablebecause conoid and trapezoid ligaments remain intact

nonoperation Type I Group II 17. Group II - Lateral third(10-15%) Type IIA

  • fracture occurs medial to intact conoid and trapezoid ligament
  • medial clavicleunstable
  • up to 56% nonunion rate with nonoperative management

operative Type IIA G II 18. Group II - Lateral third(10-15%) Type IIB

  • fracture occurs either betweenruptured conoidand intact trapezoid ligament or lateral tobothligaments torn
  • medial clavicleunstable
  • up to 30-45% nonunion rate with nonoperative management

operative Type IIB G II 19. Group II - Lateral third(10-15%) Type III

  • Intraarticular fracture extending into AC joint
  • Conoid and trapezoid intact thereforestableinjury
  • Patients may develop posttraumatic AC arthritis

nonoperative Type IV

  • A physeal fracture that occurs in the skeletally immature
  • Displacement of lateral clavicle occurs superiorly through a tear in the thick periosteum
  • Clavicle pulls out of periosteal sleeve
  • Conoid and trapezoid ligaments remain attached to periosteum and overal the fracture pattern is stable

nonoperative Type V

  • Comminuted fx
  • Conoid and trapezoid ligaments remain attached to comminuted fragment
  • Medial clavicle unstable

operative 20.

  • Group III - Medial third (5-8%)
  • Anteriormost often non-operativenonoperative
  • rare injury (2-3%)
  • often physeal fracture-dislocation (age < 25)
  • Posteriormust assess airway and great vessel compromiseoperative
  • serendipity radiographs and CT scan to evaluate
  • surgical management with thoracic surgeon on standby

21. Classifications 22. Goals of Treatment

  • Achieve bony union with minimal morbidity
  • Minimal loss of function
  • Minimal residual deformity

23. Nonoperative Treatment

  • Indications:The vast majority of fractures can be treated closed with good results.
    • Nondisplaced Group I (middle third)
    • Stable Group II fractures (Type I, III, IV)
    • Anterior Group III (medial third)
  • Technique
    • Sling or figure-of-eight (prospective studies have not shown difference between sling and figure-of-eight).
    • After 2-4 weeks begin gentle range of motion exercises.
    • No attempt at reduction should be made.

24. Closed Reduction Techniques 25. Immobilisation 26. Researchs

  • Stanley and Norris reviewed a consecutive series of 140 patients with fractures of the clavicle. All had been treated with either a figure-of-eight bandage or a sling. There was no difference in either the rate or speed of recovery between the groups.
  • Stanley D, Norris SH. Recovery following fractures of the clavicle treated conservatively. Injury 1988;19:162-164

27. Researchs

  • Hill et al:
    • Evaluated 242 adult clavicle fractures treated closed
    • 66 (27%) completely displaced middle third
    • Nonunion 8/52=15%. Unsatisfactory result 16/52=31%
    • Mild-moderate pain 13/52=25%. Brachial plexus irritation 15/52=29%
    • Cosmetic complaints 28/52 with 11/52 considered corrective surgery
    • Initial shortening at fracture of > 2cm had a significant association with nonunion and chance of unsatisfactory result
    • Recommended ORIF of severely displaced fractures of the middle third of the clavicle in adult patients
      • Hill JM, McGuire MH, Crosby LA. Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg Br 1997;79:537539.

28. Researchs

  • Wick et al: clavicle fractures with greater than 20 mm of shortening were highly predisposed to develop a nonunion. Of middle third clavicle nonunions in their series, 91% (30/33) were shortened by at least 2 cm.
  • Wick M, Muller EJ, Kollig E, et al. Midshaft fractures of the clavicle with a shortening of more than 2 cm predispose to nonunion. Arch Orthop Trauma Surg 2001;121(4):207-211

29.

  • Operative Treatment
  • Indications of operative treatment
    • Absolute

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