Clavicle Fractures & ACJ Injuries

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Clavicle Fractures & ACJ Injuries

  1. 1. Clavicle Fractures By Hiren M Divecha (CT2) 30/9/2009
  2. 2. Shoulder Anatomy• 4 joints: 1. Sternoclavicular 2. Acromioclavicular 3. Glenohumeral 4. Scapulothoracic
  3. 3. Clavicle• First bone to ossify• Last to fuse (medial epiphysis)• Articulates: – Medially – sternum – Laterally – acromion• Double curvature• Only bony connection to axial skeleton• Stabilises glenohumeral joint (strut)• Fulcrum for lateral movement of the arm• Protects subclavian vessels and brachial plexus
  4. 4. SCM Trapezius Pec & LatWeight of arm
  5. 5. Clinical• Mechanism – Fall onto point of shoulder – Direct blow• Symptoms – Pain – Unable to raise arm – Supports injured arm
  6. 6. • Examination – Localised tenderness, crepitus, swelling, deformity , bruising – Skin – Lateral – sags – Medial – elevated – Neurovascular • Esp. high energy trauma – Lung • 3% assoc. pneumo/haemothorax • Rib #s
  7. 7. Investigation• X-rays – AP – AP 45 cephalad – Include SCJ, clavicle, ACJ, GHJ, prox humerus • Exclude „floating shoulder injury‟ – CXR• CT – Useful for non-union assessment• Arteriography – If vascular injury suspected
  8. 8. Fractures• 5% of adult #s• 35% of shoulder injuries• Peak incidences – Males <30yrs – HIGH ENERGY (shaft) – Females 70-80yrs – LOW ENERGY• Position – Medial – 6% – Shaft – 82% – Lateral – 12%
  9. 9. Classification• Craig (1991) 1. Middle third 2. Distal third (types 1-5) 3. Proximal third (types 1-5)• Edinburgh (Robinson 1998)
  10. 10. Proximal/ medial #s
  11. 11. Proximal/ medial #s• Stability depends on costoclavicular ligament• Usually un/minimally displaced – Sling & mobilise• Displaced – Superior mediastinal compromise – Emergent closed reduction – ORIF controversial • risk of migration of metal
  12. 12. Distal/ lateral #s
  13. 13. Distal/ lateral #s• Un/minimally displaced – Conservative – If persistent pain - excision• Displaced – Potentially high risk of non-union – Comparable outcomes (operative vs conserv) – Role for delayed operative Rx ? – Indications: • Young active • Skin compromise • Disruption of superior shoulder suspensory complex • Mal/ non-union
  14. 14. • K wire – Neer – High infection and non-union• Coracoclavicular screw – Technically demanding – 8% failure – Remove at 8-12 weeks
  15. 15. • Plate – Contoured, hooked, AO mini-T – Shoulder stiffness, osteolysis around hook, plate # – Remove at 12 weeks• Suture & Sling – Reconstruct coracoclavicular ligaments – Primary fixation or to stabilise other methods – Dacron graft, PDS suture, Endobuttons
  16. 16. Coracoclavicular screw
  17. 17. Hook Plate
  18. 18. Tightrope Technique
  19. 19. PDS Sling
  20. 20. Midshaft #s
  21. 21. • Un/minimally displaced – Sling then mobilise – Figure 8 bandage • Lower pt satisfaction, axillary sores, no benefit (Andersen et al, 1987)• Displaced – Debate as to patient selection – Conservative vs Operative Rx
  22. 22. • Key Papers – “Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures” Canadian Orthop Trauma Soc, JBJS 2007 • Better functional outcome, lower mal/non- union rate – “Does delay matter? Immediate vs delayed reconstruction...” Potter et al, J Shoulder Elbow Surg 2007 • No sig difference in DASH and functional outcomes
  23. 23. • Indications for ORIF – Displaced >2cm – Open or skin threatened – Neurovascular injury requiring exploration – Floating shoulder – Symptomatic non-union• Plate fixation – Early mobilisation – DCP, LC-DCP, recon, contoured, locking – Superior – best biomech fix – Antero-inferior – lower complication rate – Plate removal if prominent
  24. 24. • IM nail – Knowles/ Hagie/ Rockwood pins – ? Less invasive – Poor outcomes • Breakages, shorteni ng
  25. 25. Complications• Nonunion – Increasing age, displacement, comminution and female – 15-30% in non-operative Rx – Plate +/- graft• Malunion – Usually asymptomatic – Osteotomy + plate fixation if not• Neurological – Hypertrophic callus (mal/non-union)• OA
  26. 26. References• “Current concepts review: Fractures of the Clavicle” Khan et al, JBJS 2009;91:447-60• “Fractures of the clavicle in adults” Hughes et al, Current Orthop 2002;16:133-38• “Clavicle fractures” Pecci et al, Am Fam Physician 2008;77:65-70• “Non-operative treatment compared with plate fixation of displaced midshaft clavicular fractures” Canadian Orthopaedic Trauma Society, JBJS 2007;89:1-10• “Non-operative treatment compared with plate fixation of displaced midshaft clavicular fractures. Surgical technique” Altamimi, JBJS 2008;90:1-8
  27. 27. Shoulder Suspensory Complex • Soft tissue/ bony ring • Superior and inferior bony struts • Double disruption = unstable = mal/nonunion Goss 1995
  28. 28. ACJ InjuriesBy Hiren M Divecha (CT2) 30/9/2009
  29. 29. Clinical• Mechanism – Fall onto shoulder point• Symptoms – Pain, unable to use arm – Injured arm supported• Signs – Localised tenderness, swelling, deformity• X-ray – AP 10 cephalic (Zanca view)
  30. 30. Rockwood & Young
  31. 31. Treatment• Grades 1 & 2 – Sling, rest, ice, NSAIDS, mobilise• Grade 3 – Grey area – Indications for operative repair • Throwing athlete• Grades 4-6 – Operative repair
  32. 32. Weaver Dunn Procedure• Distal clavicle excision• CA ligament used to reconstruct CC ligament• Supplemented with coracoclavicular screw• Luis et al 2007 JOSR – ACJ capsulolig repair
  33. 33. Coracoclavicular screw
  34. 34. Surgilig
  35. 35. Questions?
  36. 36. References• “Acromioclavicular joint injuries” Beim, Journal of Athletic Training 2000;35:261-267• “Acromioclavicular joint dislocation: a comparative biomechanical study of the palmaris-longus tendon graft reconstruction with other augmentative methods in cadaveric models” Luis et al, JOSR 2007;2:1-10

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