Clavicle “S”-shaped bone Medial - sternoclavicular joint Lateral - acromioclavicular joint and coracoclavicular ligaments Muscle attachments: Medial: sternocleidomastoid Lateral: Trapezius, pectoralis major
AC Joint Diarthrodial joint between medial facet of acromion and the lateral (distal) clavicle. Contains intra-articular disk of variable size. Thin capsule stabilized by ligaments on all sides: AC ligaments control horizontal (anteroposterior ) displacement Superior AC ligament most important
Distal Clavicle Coracoclavicular ligaments “Suspensory ligaments of the upper extremity” Two components: Trapezoid Conoid Stronger than AC ligaments Provide vertical stability to AC joint
Mechanism of Injury Moderate or high-energy traumatic impacts to the shoulder 1. Fall from height 2. Motor vehicle accident 3. Sports injury 4. Blow to the point of the shoulder 5. Rarely a direct injury to the clavicle
Physical Examination Inspection Evaluate deformity and/or displacement Beware of rare inferior or posterior displacement of distal or medial ends of clavicle Compare to opposite side.
Physical Examination Palpation Evaluate pain Look for instability with stress
Physical Examination Neurovascular examination Evaluate upper extremity motor and sensation Measure shoulder range-of-motion
Radiographic Evaluation of the Clavicle Anteroposterior View 30-degree Cephalic Tilt View
Classification ofClavicle Fractures Group I : Middle third Most common (80% of clavicle fractures) Group II: Distal third 10-15% of clavicle injuries Group III: Medial third Least common (approx. 5%)
Nonoperative Treatment “Standard of Care” for most clavicle fractures. Continued questions about the need to wear a specialized brace.
Simple Sling vs.Figure-of-8 Bandage Prospective randomized trial of 61 patients Simple sling Less discomfort Functional and cosmetic results identical Alignment of healed fractures unchanged from the initial displacement in both groups Andersen et al., Acta Orthop Scand 58: 71-4, 1987.
Nonoperative Treatment It is difficult to reduce clavicle fractures by closed means. Most clavicle fractures unite rapidly despite displacement Significantly displaced mid-shaft and distal-third injuries have a higher incidence of nonunion.
Nonoperative Treatment There is new evidence that the outcome of nonoperative management of displaced middle-third clavicle fractures is not as good as traditionally thought, with many patients having significant functional problems.
Deficits following nonoperative treatment ofdisplaced midshaft clavicular fractures A patient-based outcome questionnaire and muscle- strength testing were used to evaluate 30 patients after nonoperative care of a displaced midshaft fracture of the clavicle. At a minimum of twelve months (mean 55 mos), outcomes were measured with the Constant shoulder score and the DASH patient questionnaire. In addition, shoulder muscle-strength testing was performed with the Baltimore Therapeutic Equipment Work Simulator, with the uninjured arm serving as a control.McKee et al. J Bone Joint Surg Am 2006;88-A:35-40.
Deficits following nonoperative treatment ofdisplaced midshaft clavicular fractures The strength of the injured shoulder was 81% for maximum flexion, 75% for endurance of flexion, 82% for maximum abduction, 67% for endurance of abduction, 81% for maximum external rotation, 82% for endurance of external rotation, 85% for maximum internal rotation, and 78% for endurance of internal rotation (p < 0.05 for all). The mean Constant score was 71 points, and the mean DASH score was 24.6 points, indicating substantial residual disability.McKee et al. J Bone Joint Surg Am 2006;88-A:35-40.
Displaced midshaft clavicle fractures can cause significant, persistent disability, even if they heal uneventfully.
Definite Indications for SurgicalTreatment of Clavicle Fractures 1) Open fractures 2) Associated neurovascular injury
Relative Indications for AcuteTreatment of Clavicle Fractures 4) Floating shoulder 5) Seizure disorder 6) Cosmetic deformity 7) Earlier return to work.
Clavicular Displacement < 5 mm shortening: acceptable results at 5 years (Nordqvist et al, Acta Orthop Scand 1997;68:349-51. > 20 mm shortening associated with increased risk of nonunion and poor functional outcome at 3 years (Hill et al, JBJS 1997;79B: 537-9)
Plate Fixation Traditional means of ORIF Plate applied superiorly or inferiorly Inferior plating associated with lower risk of hardware prominence Used for acute displaced fractures and nonunions.
Intramedullary Fixation Large threaded cannulated screws Flexible elastic nails K-wires Associated with risk of migration Useful when plate fixation contra- indicated Bad skin Severe osteopenia Fixation less secure
Complications of ClavicularFractures and its Treatment Nonunion Malunion Neurovascular Sequelae Post-Traumatic Arthritis
Risk Factors for the Developmentof Clavicular Nonunions Location of Fracture (outer third) Degree of Displacement (marked displacement) Primary Open Reduction
Principles for the Treatment ofClavicular Nonunions Restore length of clavicle May need intercalary bone graft Rigid internal fixation, usually with a plate Iliac crest bone graft Role of bone-graft substitutes not yet defined.
Clavicular Malunion Symptoms of pain, fatigue, cosmetic deformity. Initially treat with strengthening, especially of scapulothoracic stabilizers. Consider osteotomy, internal fixation in rare cases in which nonoperative treatment fails. Correction of malunion with thoracic outlet sx
Neurologic Sequelae Occasionally, fracture fragments or abundant callus can cause brachial plexus symptoms. Treatment is reduction and fixation of the fracture, or resection of callus with or without osteotomy and fixation for malunions.
Classification of Distal ClavicularFractures(Group II Clavicle Fractures) Type I-nondisplaced Between the CC and AC ligaments with ligament still intact From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
Classification of Distal ClavicularFractures Type II Typically displaced secondary to a fracture medial to the coracoclavicular ligaments, keeping the distal fragment reduced while allowing the medial fragmetn to displace superiorly Highest rate of nonunion (up to 30%) Two Types
•A. Conoid and trapezoidattached to distalfragment From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
•Type IIB: Conoidtorn, trapezoidattached From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
Classification of Distal ClavicularFractures Type III:articular fractures From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
Treatment of Distal-Third (Type II)Clavicle Fractures Nonoperative treatment 22 to 33% failed to unite 45 to 67% took more than three months to heal Operative treatment 100% of fractures healed within 6 to 10 weeks after surgery
Displaced Type II fractures of the distal clavicle are often treated more aggressively because of the increased risk of nonunion with nonoperative treatment
Techniques for Acute OperativeTreatment of Distal Clavicle Fractures Kirschner wires inserted into the distal fragment Dorsal plate fixation CC screw fixation Tension-band wire or suture Transfer of coracoid process to the clavicle Clavicular Hook Plate
For most techniques of clavicular fixation, coracoclavicular fixation is also needed to prevent redisplacement of the medial clavicle.
• The Hook Plate (Synthes USA, Paoli, PA) was specifically designed to avoid this problem of redisplacement.
Hook Plate - Results Recent series of distal clavicle fractuers treated with the Hook Plate document high union rates of 88% - 100%. Complications are rare but potentially significant, including new fracture about the implant, rotator cuff tear, and frequent subacromial impingement.
Indications for Late Surgery forDistal Clavicle Fractures Pain Weakness Deformity
Radiographic Evaluation of the Acromioclavicular Joint Proper exposure of the AC joint requires one-third to one-half the x-ray penetration of routine shoulder views Initial Views: Anteroposterior view Other views: Axillary: demonstrates anterior-posterior displacement Stress views: not generally relevant for treatment decisions.
Type I Sprain of acromioclavicular ligament AC joint intact Coracoclavicular ligaments intact Deltoid and trapezius muscles intact From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
Type II AC joint disrupted < 50% Vertical displacement Sprain of the coracoclavicular ligaments CC ligaments intact Deltoid and trapezius muscles intact From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
Type III AC ligaments and CC ligaments all disrupted AC joint dislocated and the shoulder complex displaced inferiorly CC interspace greater than the normal shoulder(25-100%) Deltoid and trapezius muscles usually detached from the distal clavicle From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
Type III Variants “Pseudodislocation” through an intact periosteal sleeve Physeal injury Coracoid process fracture
Type IV AC and CC ligaments disrupted AC joint dislocated and clavicle displaced posteriorly into or through the trapezius muscle Deltoid and trapezius muscles detached from the distal clavicle From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
Type V AC ligaments disrupted CC ligaments disrupted AC joint dislocated and gross disparity between the clavicle and the scapula (100-300%) Deltoid and trapezius muscles detached from the distal half of clavicle From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
Type VI AC joint dislocated and clavicle displaced inferior to the acromion or the coracoid process AC and CC ligaments disrupted Deltoid and trapezius muscles detached from the distal clavicle From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
Treatment Options for Types I - IIAcromioclavicular Joint Injuries Nonoperative: Ice and protection until pain subsides (7 to 10 days). Return to sports as pain allows (1-2 weeks) No apparent benefit to the use of specialized braces.
Type II operative treatment Generally reserved only for the patient with chronic pain. Treatment is resection of the distal clavicle and reconstruction of the coracoclavicular ligaments.
Treatment Options for Type III-VIAcromioclavicular Joint Injuries Nonoperative treatment Closed reduction and application of a sling and harness to maintain reduction of the clavicle Short-term sling and early range of motion Operative treatment Primary AC joint fixation Primary CC ligament fixation Excision of the distal clavicle Dynamic muscle transfers
Type III Injuries: Need for acute surgical treatment remains very controversial. Most surgeons recommend conservative treatment except in the throwing athlete or overhead worker. Repair generally avoided in contact athletes because of the risk of reinjury.
Indications for Acute SurgicalTreatment of AcromioclavicularInjuries Type III injuries in highly active patients Type IV, V, and VI injuries
Surgical Options for AC JointInstability Coracoid process transfer to distal transfer (Dynamic muscle transfer) Primary AC joint fixation Primary Coracoclavicular Fixation Distal Clavicle Excision with CC ligament reconstruction.
Weaver-Dunn Procedure The distal clavicle is excised. The CA ligament is transferred to the distal clavicle. The CC ligaments are repaired and/or augmented with a coracoclavicular screw or suture. Repair of deltotrapezial fascia From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
Indications for Late SurgicalTreatment of AcromioclavicularInjuries Pain Weakness Deformity
Techniques for Late SurgicalTreatment of AcromioclavicularInjuries Reduction of AC joint and repair of AC and CC ligaments Resection of distal clavicle and reconstruction of CC ligaments (Weaver-Dunn Procedure)
The Anatomy of the Sternoclavicular Joint Diarthrodial Joint “Saddle shaped” Poor congruence Intra-articular disc ligament. Divides SC joint into two separate joint spaces. Costoclavicular ligament- (rhomboid ligament) Short and strong and consist of an anterior and posterior fasciculus
Interclavicular ligament- Connects the superomedial aspects of each clavicle with the capsular ligaments and the upper sternum Capsular ligament- Covers the anterior and posterior aspects of the joint and represents thickenings of the joint capsule. The anterior portion of the ligament is heavier and stronger than the posterior portion.
Epiphysis of the Medial Clavicle Medial Physis- Last of the ossification centers to appear in the body and the last epiphysis to close. Does not ossify until 18th to 20th year Does not unite with the clavicle until the 23rd to 25th year
Radiographic Techniques for Assessing Sternoclavicular Injuries 40-degree cephalic tilt view CT scan- Best technique for sternoclavicular joint problems From Wirth MA and Rockwood CA, JAAOS, 4:268, 1996
Injuries Associated withSternoclavicular Joint Dislocations Mediastinal Compression Pneumothorax Laceration of the superior vena cava Tracheal erosion From Wirth MA and Rockwood CA, JAAOS, 4:268, 1996
Treatment of AnteriorSternoclavicular Dislocations Nonoperative treatment Analgesics and immobilization Functional outcome usually good Closed reduction Often not successful Direct pressure over the medial end of the clavicle may reduce the joint
Treatment of PosteriorSternoclavicular Dislocations Careful examination of the patient is extremely important to rule out vascular compromise. Consider CT to rule out mediastinal compression Attempt closed reduction - it is often successful and remains stable.
Closed Reduction Techniques Abduction traction Adduction traction “Towel Clip” - anterior force applied to clavicle by percutaneously applied towel clip
Operative Techniques Resection arthroplasty May result in instability of remaining clavicle unless stabilization is done. Suggest minimal resection of bone and fixation of medial clavicle to first rib. Sternoclavicular reconstruction with suture, tendon graft.