Midshaft clavicle fractures & ACJ dislocations

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Midshaft clavicle fractures & ACJ dislocations

  1. 1. Cardiff School of Engineering Coursework Cover SheetPersonal DetailsStudent No: 1056984Family Name: Divecha First Name: HirenPersonal Tutor: Prof Sam Evans Discipline: MMMModule DetailsModule Name: Surgical Practice Module 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 University’s plagiarism software ‘Turnitin’ may be used tocheck the originality of the submitted coursework.Signed: …..…………………………………….………... Date: ……………………
  2. 2. Coursework 2 – Midshaft ClavicleFractures & ACJ DislocationsHiren Maganlal DivechaCandidate Number: 1056984ENT547 – Surgical PracticeWord count – 3402
  3. 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. 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. Craig’s (1990) andRobinson’s (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,O’Neill et al (2011) found that Craig’s classification had the greatest prognostic value for lateral thirdfractures whilst Robinson’s classification had the greatest prognostic value for middle third fractures. 1
  5. 5. Robinson Craig 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 - Undisplaced Type 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, segmental Type 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. 6. 2. Discuss management of midshaft clavicle fractures with reference to 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. 7. 3. Associated neurovascular compromise/ injury may necessitate exploration and repair followed by 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 for removal of prominent hardware, usually. Antegrade or retrograde IM pin fixation allows for relative stability but benefits from better cosmesis 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. 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 less evidence of screw loosening in the locked group.It remains apparent that good results may be achieved operatively, but the ideal fixation deviceremains uncertain. Future work should be directed at clinically based, comparative/ controlled,functional outcome related research in this area. An example of this is the multicentre randomisedcontrolled trial in progress in the UK (Longo, et al., 2011). 5
  9. 9. 3. Classify ACJ injuriesAcromio-clavicular joint injures were originally classified by Tossy et al in 1963 (1963) and later byAllman in 1967 (1967) into three groups. This was then expanded in 1989 to 6 groups by Williams etal (1989) to describe the Rockwood classification (table 2), which remains in current use:Type AC Lig CC Ligs Delto-trapezial fascia Instability Radiographic CC distance I Sprained Intact Intact None Normal (1.1-1.3 cm) II Torn Sprained Intact AP <25% III Torn Torn Intact AP and vertical 25-100% IV Torn Torn Torn Unstable (posterior displacement into trapezius) V Torn Torn Torn Unstable 100-300% VI Torn Intact Torn DecreasedTable 2: Rockwood classification of ACJ injuries (AC – acromio-clavicular; CC – coraco-clavicular). Adapted from(Simovitch, et al., 2009)Physeal separations of the distal clavicle and fractures of the base of the coracoid (CC ligamentsremain intact and attached) may be falsely described as Type III injuries. In Type IV injuries, it isimportant to exclude a concomitant anterior dislocation of the sterno-clavicular joint. In Type Vinjuries, the delto-trapezial fascia tears and the resulting increase in CC separation is large. Theweight of the arm results in the scapula being pulled downwards and anteriorly (unopposed pull ofserratus anterior). Type VI injuries are rare and are seen in high-energy polytrauma scenarios. Thedistal clavicle dislocates inferiorly into a subacromial or subcoracoid position (can result in brachialplexus or vascular compression/ injury). Mechanism – hyperabduction and external rotation of thearm combined with retraction of the scapula). 6
  10. 10. 4. Critique this classificationThe Rockwood classification system defines injuries to the ACJ by increasing soft tissue damage(table 2). Structures fail in sequence (AC ligaments, CC ligaments, delto-trapezial fascia) withresulting increased disruption and instability of the ACJ. The classification system stratifies injuriesaccording to increasing energy and can therefore guide treatment (generally non-operative for TypesI-III; operative for some type III and all Types IV-VI). However, a diagnosis based on a single, staticsagittal radiograph may result in over-/under-estimation of the extent of the injury. For this reason,attempts have been made to correlate radiographic classification with USS, MRI and intra-operativefindings.Heers and Hedtmann (2005) found that USS was 80% sensitive and 100% specific for diagnosingdeltoid/ trapezial detachment and fascial disruption (intra-operatively confirmed). Interestingly, 9/31Type III and 2/28 type II injuries were found to have damage to deltoid/ trapezius insertions or to thedelto-trapezial fascia. Nemec et al (2011) found that MRI findings were concordant with theradiographic Rockwood type in 52% however, 36% were reclassified into a less severe type and 11%into a more severe type. Additional ligamentous injuries were found in 25%.Thus, whilst the Rockwood classification remains the main classification in use for ACJ injuries and iseasily used/ reproducible, investigative adjuncts such as USS and MRI may be useful in delineatingthe extent of soft tissue damage, which is not apparent on static radiography. This may beparticularly important in Type III injuries in aiding the management decisions. Outcomes in bothconservative and operative treatment are mixed in this group and this could be due to poorer resultsseen in those patients who have been conservatively managed that actually had more severe softtissue damage than appreciated radiographically. 7
  11. 11. 5. Describe the biomechanics of ACJ stabilisersThe ACJ is a diarthrodial joint formed between the lateral end of the clavicle and the medial end ofthe acromion. A fibrocartilaginous intra-articular disc may be found, though this degenerates by thefourth decade. The clavicle rotates approximately 5° to 8° relative to the acromion because ofsynchronous scapula-clavicular motion (Flatlow, 1993), which is probably why shoulder elevationremains normal after CCJ arthrodesis. The ACJ stabilisers can be grouped into static and dynamic.a) Static stabilisersThese include the following – ACJ capsule (thin, minimal contribution), AC ligaments, CC ligaments.Fukuda et al (1986) studied the contribution of each structure to the overall stability of the ACJ. TheAC ligamentous complex is comprised of anterior, superior, posterior and inferior ligaments. Theposterior and superior AC ligaments are the strongest and provide the majority of stability in the APplane. Excision of more than 1 cm of distal clavicle results in increased posterior translation of theclavicle (Branch, et al., 1996) (Corteen & Teitge, 2005).The CC ligaments are comprised of the medial conoid ligament and the lateral trapezoid ligament.The conoid ligament is the main vertical constraint, whilst the trapezoid resists compressive axialloading of the ACJ (Fukuda, et al., 1986). Interestingly, the contributions to stability of thesestructures differs with increasing loads (figure 1) – thus the AC ligaments are more important at smallloads whereas the conoid provided greater stability at larger loads. 8
  12. 12. Figure 1: Relative contributions of structures to ACJ vertical stability with increasing load (taken from pg 438(Fukuda, et al., 1986))b) Dynamic stabilisersThe anterior deltoid and trapezius muscles insert via the delto-trapezial fascia into the acromion/superior AC ligament and provide dynamic stability to the ACJ and repair of these structures shouldbe considered as part of the reconstructive process (Lizaur, et al., 1994). 9
  13. 13. 6. Describe treatment options for Type IV/V ACJ injuries. Give biomechanical advantages/ disadvantages of these optionsGenerally, Type IV/ V injuries require surgical management to reduce and stabilise the ACJ. The goalsof treatment are to reduce the ACJ, pain free movement and to restore strength to (near) normal.There are numerous procedures in use that can be broadly grouped into primary fixation, CC intervalfixation and anatomic CC reconstructions (ACCR). Some surgeons will combine procedures in anattempt to augment repairs performed.Primary fixation involves an open reduction of the joint, which is then stabilised by either K-wires,Steinmann pins or a hook-plate (passed under the acromion). The ligamentous structures are allowedto heal primarily whilst the joint is held reduced. The problems with these methods include loss ofreduction, hardware migration, ACJ OA and secondary metalwork removal (Lemos & Tolo, 2003).CC interval fixation can also be performed to hold the clavicle reduced whilst the ligaments heal.Older methods involved a CC screw (such as the Bosworth and Rockwood screws) whilst newermethods employ the use of synthetic loops (suture material, tape) placed around the coracoidprocess and clavicle. Disadvantages of these methods include breakage, fracture of coracoid/clavicle, foreign body reaction, clavicle osteolysis and cut-out/ loss of reduction (Stewart & Ahmad,2004). If screws are used, secondary hardware removal is also required. The use of tight-rope/ endo-button devices has also been described (Walz, et al., 2008). This cadaveric study found thereconstructed ACJ had greater loads to failure and less displacement than the native ACJ. Potentialcomplications include failure of the button device, fracture and loss of reduction.Ligament reconstruction techniques seem to give the best biomechanical results in restoring/maintaining ACJ reduction and providing a strong enough fixation to allow early mobilisation and 10
  14. 14. return to function. Furthermore, they provide a scaffold for revascularisation to occur. Disadvantagesinclude donor site morbidity. The Weaver Dunn procedure describes transfer of the CA ligament to the distal clavicle (with excision of the distal end of the clavicle). This technique has been extensively modified since its description. Suture loops (CC) can be used to strengthen the construct. However, this still only provides 25% of the strength of the intact CC complex with significant translations compared to the normal ACJ (Harris, et al., 2000) A similar procedure has been described using the lateral half of the conjoined tendon that is harvested distally (left attached to coracoid) and then attached to the distal clavicle to hold it reduced. This has been found to be stronger than using the CA ligament (which may be of variable quality) (Jiang, et al., 2007) ACCR using semitendinosus (or anterior tibialis) autograft can be used in a double bundled fashion to anatomically recreate both components of the CC ligament. The graft is passed through a coracoid bone tunnel, crossed into a figure-of-eight, secured with interference screws in 2 separate clavicular bone tunnels, the anterior limb of the graft is sutured over the repaired ACJ and the repair augmented with a suture loop. Mazzocca et al (2006) performed a cadaveric comparison of this technique to a modified Weaver-Dunn repair (with suture loop augmentation) and to an arthroscopic CC screw fixation (with suture loop augmentation). They reported that only the anatomic double bundled repair provided AP and superior stability similar to the intact ACJ. 11
  15. 15. 7. With respect to ACJ injuries, review the literature and discuss treatment options for all groupsa) Type I/ IIThese injuries are treated conservatively: analgesia, rest in broad arm sling for 1-3 weeks, ROM/strengthening exercises thereafter and return to activity when a pain-free ROM is achieved (usually3-6 weeks). This may be extended to delay return to heavy manual work or contact sports until 8weeks. Surgical intervention in these injuries is not supported although there are associatedmid/long-term complications. Minor symptoms (clicking, mild pain) may be found in 30% of Type Iand 42% of Type II injuries; severe symptoms (pain, limitation of activity) can be found in 9% of Type Iand 23% of Type II injuries (Bergfeld, et al., 1978). The same study reported the presence ofradiographic ACJ OA in 50%. Moushine et al (2003) reported that 27% of Type I/ II injuries treatedconservatively developed chronic ACJ symptoms (at mean of 6 months) requiring later surgery.b) Type IIIThe majority of Type III injuries should probably be treated conservatively given the findings ofequivalent satisfaction (87%-conservative; 88%-operative), return to activity, pain relief, ROM andstrength in the meta-analysis of conservative vs. operative management by Phillips et al (1998).Furthermore, surgically treated patients will have potential complications. Wojtys & Nelson (1991) etal found a statistically insignificant reduction in strength and endurance in labourers and athleteswith conservative management. Although they concluded that adequate strength could be recoveredwith conservative treatment, they felt that patients involved in activities requiring high-levelshoulder function might benefit from surgical intervention. This view is held by other authors(Simovitch, et al., 2009), though the lack of conclusive evidence is noted. Furthermore, the risk oflate sequale (distal clavicle osteolysis, persistent pain/ instability and ACJ OA) should be discussed 12
  16. 16. with patients during the decision making process as surgery may be required later for thesecomplications.An adequate structured rehabilitation programme (focus on strengthening deltoid, trapezius,sternocleidomastoid, subclavius, rotator cuff and periscapular stabilizers (Simovitch, et al., 2009)) isessential to proper conservative management of these injuries. Glick et al (1977) found no residualpain in professional and competitive amateur athletes managed in this fashion.The patients that do not do well with conservative treatment may represent a group with greatersoft tissue injury (than is appreciated by a single static radiograph) and therefore greater instabilitythat would do better with surgical intervention. This is an area that needs more clinically directed,outcome-based research to define the role of acute imaging in guiding acute treatment of theseinjuries.c) Types IV/ V/ VIThese can be grouped together as they all require surgical intervention, along with some acute typeIII injuries. There are numerous methods in use in the surgical management of these injuries (seeQuestion 6 for an overview of specific surgical methods and table 3). Ultimately, the aims oftreatment should be to reduce and stabilise the ACJ to allow pain-free ROM and return to (near)normal strength. Jari et al (2004) suggest that methods that preserve the ACJ articulation arepreferable as they reduce the joint contact forces. What is apparent is that, biomechanically, ACCRmethods most closely recreate the normal CC ligament strength and stability. However, long-termcomparative/ controlled clinical results are lacking in the literature. 13
  17. 17. Study Methodology Outcome(Mazzocca, et al., 2006) Modified Weaver-Dunn procedure vs. Comparable vertical stability and load to failure arthroscopic suture fixation vs. ACCR ACCR had least AP translation (semitendinosus)(Jari, et al., 2004) CA ligament transfer vs. CC sling vs. Rockwood Largest vertical translations with after the CA ligament transfer (>300%) screw Largest posterior translations with CC sling (330%) Rockwood screw most rigid construct, but results in increased joint forces(Costic, et al., 2004) Intact ACJ vs. ACCR (semitendinosus) Stiffness and ultimate load to failure of the ACCR was significantly lower than in the normal ACJ with clinically insignificant elongation following cyclic loading(Deshmukh, et al., 2004) Weaver-Dunn vs. augmented Weaver-Dunn Greater load to failure in augmented Weaver-Dunn (319N vs. 177N) and less instability procedure No significant difference between suture anchor choice for the augmentation(Lee, et al., 2003) CA ligament transfer vs. CC Mersilene tape sling CA ligament transfer weakest, Mersilene tape better initial strength vs. ACCR (semitendinosus, gracilis, long toe ACCR superior to both (similar ultimate load to failure among different grafts) extensors)(Wilson, et al., 2005) Weaver-Dunn vs. Weaver-Dunn augmented Augmented Weaver-Dunn better approximated normal ACJ stability with CC suture anchor fixation(Harris, et al., 2000) CA ligament transfer vs. CC sling vs. 2 CC suture CA ligament transfer weakest. CC slings had high tensile strength but elongated at failure. anchors vs. unicortical Bosworth screw vs. Bicortical CC screws provided the highest tensile strength and stiffness bicortical Bosworth screwTable 3: Summary of ACJ reconstruction methods (adapted from pg 216-7 in (Simovitch, et al., 2009)) 14
  18. 18. 8. How would you have a Type III injury treated if it was your shoulder? How would you manage an elite rugby player with the same acute injury?I would manage my shoulder and an elite rugby player with an acute Type III ACJ injury the sameway. Whilst I am not a professional level athlete, my chosen career path (orthopaedic surgery)dictates that I maintain acceptable health and manual dexterity given the skilled (often fine/precision work) nature of surgery. Anything less than near-normal restoration of ACJ function couldpotentially affect my ability to operate as a surgeon now and in the future (in terms of latecomplications such as on-going pain/ instability and ACJ OA).I would have the injury fully assessed using USS (or MRI) to determine the extent of soft tissuedamage (including disruption of delto-trapezial fascia and deltoid/ trapezius muscle detachments)that would require surgical repair. Given the current evidence (Simovitch, et al., 2009) (whichunfortunately is based on small case series and controlled laboratory studies), I would support theuse of an anatomic double-bundle autograft (semitendinosus) reconstruction of the CC ligamentswith repair + superior augmentation of the ACJ followed by an appropriate early mobilisationphysiotherapy programme (pendular/ passive ROM till 8 weeks to allow graft maturation, activeROM thereafter). I would not allow resisted training to begin until after 3 months. In the case of anelite rugby player, I would anticipate a return to full contact by 6 months. 15
  19. 19. 9. ReferencesAllman, F. L., 1967. Fractures and ligamentous injuries of the clavicle and its articulation. J Bone JointSurg, 49(4), pp. 774-84.Andersen, K., Jensen, P. & Lauritzen, J., 1987. Treatment of clavicular fractures. Figure-of-eigthbandage versus a simple sling. Acta Orthop Scand, Volume 58, pp. 71-4.Bergfeld, J. A., Andrish, J. T. & Clancy, W. G., 1978. Evaluation of the acromioclavicular joint followingfirst- and second- degree sprains. Am J Sports Med, Volume 6, pp. 153-9.Branch, T. P. et al., 1996. The role of acromioclavicular ligaments and the effect of distal clavicleresection. Am J Sports Med, 24(3), pp. 293-7.Cho, C.-H.et al., 2010. Operative treatment of clavicle midshaft fractures: Comparison betweenreconstruction plate and reconstruction locking compression plate. Clin Orthop Surg, Volume 2, pp.154-9.Corteen, D. P. & Teitge, R. A., 2005. Stabilisation of the clavicle after distal resection: A biomechanicalstudy. Am J Sports Med, Volume 33, pp. 61-7.Costic, R. S., Labriola, J. E., Rodosky, M. W. & Debski, R. E., 2004. Biomechanical rationale fordevelopment of anatomical reconstructions of coracoclavicular ligaments after completeacromioclavicular joint dislocations. J Sports Med, Volume 32, pp. 1929-36.Craig, E., 1990. Fractures of the clavicle. In: C. A. Rockwood & F. A. Matsen, eds. The Shoulder.Philadelphia: Saunders, pp. 380-3.Deshmukh, A. V., Wilson, D. R., Zilberfarb, J. L. & Perlmutter, G. S., 2004. Stability ofacromioclavicular joint reconstruction: Biomechanical testing of various surgical techniques in acadaveric model. Am J Sports Med, Volume 32, pp. 1492-8.Flatlow, E. L., 1993. The biomechanics of the acromioclavicular, sternoclavicular and scapulothoracicjoints. Instr Course Lect, Volume 42, pp. 237-45. 16
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