The document discusses clavicle fractures and acromioclavicular (AC) joint injuries. It begins by describing shoulder anatomy and the clavicle bone. It then discusses types of clavicle fractures, including proximal/medial, distal/lateral, and midshaft fractures. Treatment options are provided for each type, including nonsurgical and surgical methods like plating and coracoclavicular screws. Complications of clavicle fractures like nonunion are also outlined. The document concludes by reviewing the Rockwood classification system for AC joint injuries and discussing nonsurgical and surgical treatment approaches.

1. Clavicle Fractures
By Hiren M Divecha (CT2)
30/9/2009

2. Shoulder Anatomy
• 4 joints:
1. Sternoclavicular
2. Acromioclavicular
3. Glenohumeral
4. Scapulothoracic

4. 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

6. SCM
Trapezius
Pec & Lat
Weight of arm

7. Clinical
• Mechanism
– Fall onto point of shoulder
– Direct blow
• Symptoms
– Pain
– Unable to raise arm
– Supports injured arm

8. • Examination
– Localised
tenderness, crepitus, swelling, deformity
, bruising
– Skin
– Lateral – sags
– Medial – elevated
– Neurovascular
• Esp. high energy trauma
– Lung
• 3% assoc. pneumo/haemothorax
• Rib #s

9. 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

10. 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%

11. Classification
• Craig (1991)
1. Middle third
2. Distal third (types 1-5)
3. Proximal third (types 1-5)
• Edinburgh (Robinson 1998)

12. Proximal/ medial #s

13. 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

14. Distal/ lateral #s

15. 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

16. • K wire
– Neer
– High infection and non-union
• Coracoclavicular screw
– Technically demanding
– 8% failure
– Remove at 8-12 weeks

17. • 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

18. Coracoclavicular screw

19. Hook Plate

20. Tightrope Technique

21. PDS Sling

22. Midshaft #s

23. • 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

24. • 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

25. • 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

29. • IM nail
– Knowles/ Hagie/
Rockwood pins
– ? Less invasive
– Poor outcomes
• Breakages, shorteni
ng

30. 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

31. 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

32. Shoulder Suspensory Complex
• Soft tissue/ bony
ring
• Superior and
inferior bony struts
• Double disruption
= unstable =
mal/nonunion
Goss 1995

33. ACJ Injuries
By Hiren M Divecha (CT2)
30/9/2009

34. 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)

35. Rockwood & Young

36. Treatment
• Grades 1 & 2
– Sling, rest, ice, NSAIDS, mobilise
• Grade 3
– Grey area
– Indications for operative repair
• Throwing athlete
• Grades 4-6
– Operative repair

37. 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

38. Coracoclavicular screw

39. Surgilig

40. Questions?

41. 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