Midshaft clavicle fractures & ACJ dislocations

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  • 1. Cardiff School of EngineeringCoursework Cover SheetPersonal DetailsStudent No:1056984Family Name: DivechaFirst Name:HirenPersonal Tutor:Prof Sam Evans Discipline:MMMModule DetailsModule Name: Surgical PracticeModule No: ENT547Coursework Title:Weekend 2 Coursework - ShoulderLecturer:Submission Deadline: 10/1/2012DeclarationI hereby declare that, except where I have made clear and full reference to the work ofothers, this submission, and all the material (e.g. text, pictures, diagrams) contained in it, ismy own work, has not previously been submitted for assessment, and I have not knowinglyallowed it to be copied by another student. In the case of group projects, the contribution ofgroup members has been appropriately quantified.I understand that deceiving, or attempting to deceive, examiners by passing off the work ofanother as my own is plagiarism. I also understand that plagiarising anothers work, orknowingly allowing another student to plagiarise from my work, is against UniversityRegulations and that doing so will result in loss of marks and disciplinary proceedings. Iunderstand and agree that the Universitys plagiarism software Turnitin may be used tocheck the originality of the submitted coursework.Signed: ...... Date:

2. Coursework 2 Midshaft ClavicleFractures & ACJ DislocationsHiren Maganlal DivechaCandidate Number: 1056984ENT547 Surgical PracticeWord count 3402 3. Contents1.Classify clavicle shaft fractures ....................................................................................................12.Discuss management of midshaft clavicle fractures with reference to biomechanics ...................3 a)Undisplaced ............................................................................................................................3 b)Displaced.................................................................................................................................33.Classify ACJ injuries .....................................................................................................................64.Critique this classification ............................................................................................................75.Describe the biomechanics of ACJ stabilisers ...............................................................................8 a)Static stabilisers.......................................................................................................................8 b)Dynamic stabilisers ..................................................................................................................96.Describe treatment options for Type IV/V ACJ injuries. Give biomechanical advantages/disadvantages of these options ......................................................................................................... 107.With respect to ACJ injuries, review the literature and discuss treatment options for all groups 12 a)Type I/ II ................................................................................................................................ 12 b)Type III .................................................................................................................................. 12 c)Types IV/ V/ VI....................................................................................................................... 138.How would you have a Type III injury treated if it was your shoulder? How would you manage anelite rugby player with the same acute injury? .................................................................................. 159.References ................................................................................................................................ 16 4. 1. Classify clavicle shaft fracturesOne of the earliest clavicle fracture classifications was described by Allman (Allman, 1967) and simplygrouped the fractures according to location and in descending order of incidence: Group 1 middle 1/3rd Group 2 distal to coraco-clavicular ligaments (non-union common) Group 3 proximal 1/3rdMost modern classifications are based on this, but subdivide each group further. Craigs (1990) andRobinsons (1998) classifications are commonly used (table 1) and take into account fracturelocation, displacement, stability and joint involvement. This may make the day to day use of suchsystems a bit more difficult, but including these variables allows for some guidance as to the risk ofdelayed/ non-union (and of post-traumatic OA in the case of intra-articular involvement). In acomparison of prognostic value in predicting delayed/ non-union between 5 classification systems,ONeill et al (2011) found that Craigs classification had the greatest prognostic value for lateral thirdfractures whilst Robinsons classification had the greatest prognostic value for middle third fractures.1 5. RobinsonCraig a1. Undisplaced - Extra-articular a2. Undisplaced - Intra-articularType 1 (medial 1/5)Group I (mid. 1/3) b1. Displaced - Extra-articular b2. Displaced - Intra-articular Type1: Minimal displacement (inter-ligamentous) a1. Cortical alignment - UndisplacedType 2: Displacement secondary to fracture medial to ligaments a2. Cortical alignment - Angulated a. Conoid and trapezoid attachedType 2 (mid. 3/5) Group II (dist. 1/3) b. Conoid torn, trapezoid attached b1. Displaced - Simple, wedge Type 3: Intra-articular b2- Displaced - Multifrag, segmentalType 4: Ligaments attached to periosteal sleeve, displacement of prox. frag. Type 5: Comminuted, ligaments attached to comminuted inf. frag. a1. Undisplaced - Extra-articular Type1: Minimal displacement a2. Undisplaced - Intra-articular Type 2: Significant displacement (ligaments ruptured)Type 3 (lateral 1/5) Group III (prox. 1/3) Type 3: Intra-articular b1. Displaced - Extra-articular Type 4: Epiphyseal separation (paediatric) b2. Displaced - Intra-articular Type 5: Comminuted Table 1: Outline of Robinsons and Craigs classification systems of clavicle fractures 2 6. 2. Discuss management of midshaft clavicle fractures with referenceto biomechanicsThe goal of treatment of these injuries is to restore shoulder function to (near) normal levels.a) UndisplacedUndisplaced midshaft clavicular fractures can be treated non-operatively (Khan, et al., 2009). Initially,patients are immobilised in a sling for 2-4 weeks followed by physiotherapy and active motionthereafter. Depending on radiographic signs of union, full mobilisation can begin at 6 weeks andcontact sports at 3 months (Khan, et al., 2009) (Preston & Egol, 2009). A figure of eight bandagingtechnique used to be employed, however this has not been found to affect fracture healing outcomeand can be associated with patient discomfort, axillary pressure sores and neurovascularcompromise (Andersen, et al., 1987) (Stanley, et al., 1988). In a large systematic review, the non-union rate with non-operative treatment in undisplaced fractures was reported at 5.9% (increasing to15% in displaced fractures) (Zlowodzki, et al., 2005).b) DisplacedHistorically, displaced clavicular shaft fractures were treated non-operatively. Amongst reasons forthis was the reported increased non-union rates following attempted ORIF (Neer, 1968) (Rowe,1968)). More recent studies (McKee, et al., 2006) including a large prospective randomised trial bythe Canadian Orthopaedic Trauma Society (2007), have shown lower non-union rates and betterfunctional outcomes following ORIF for displaced midshaft clavicular fractures. Indications foroperative intervention include:1. Open fracture/ overlying skin compromise2. High energy injuries with more than 2 cm displacement (increased non-union risk) 16 3 7. 3. Associated neurovascular compromise/ injury may necessitate exploration and repair followedby fracture fixationRelative indications include:1. Polytrauma2. Floating shoulder injury3. Symptomatic mal/ non-unionOther studies have shown that non-union rates may be as high as 20% in displaced and comminutedfractures after nonsurgical treatment and that strength and endurance deficits are more common inthese cases.36,52 These reports, in combination with a more prognostic classification system, haveled many authors to recommend acute surgical fixation for these fracture subtypes.53Historically, K-wires and threaded pins (e.g.: Knowles pins) have been used to stabilise these fracturetypes. These methods have been associated with significant complication rates, non-union and inparticular the risk of pin migration into nearby vital structures (Grassi, et al., 2001). Osteosynthesis ofmidshaft clavicular fractures can be achieved with plate or intramedullary pin fixation. Plate fixation allows for accurate reduction and absolute fracture stability through rigid fixation.This allows early mobilisation. Use of anatomically contoured plates obviates the need forremoval of prominent hardware, usually. Antegrade or retrograde IM pin fixation allows for relative stability but benefits from bettercosmesis and less periosteal stripping. As they are not locked, they have little rotational stability(Golish, et al., 2008) (Renfree, et al., 2010).Renfree et al (2010) compared IM pins with unicortically locked plates and bicortically non-lockedplates in synthetic clavicle fracture models under cantilever and 3-point bending. They concludedthat both plate constructs provided similar rigid fixation (added advantage of unicortical screws 4 8. avoid plunging into underlying neurovascular structures). The IM pin was less stiff (greaterdisplacements) and provided little rotational stiffness. Interestingly, a clinical comparison of unionrates and functional outcomes between plate and IM fixation has reported similar good results withno differences in complication rates (Liu, et al., 2010). A clinical comparison between locked and non-locked plates by Cho et al (2010) similar times to union and functional outcome scores between the 2groups, with l