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Dr AMRUTH RAM REDDY
POST GRADUATE
GANDHI MEDICAL COLLEGE
 The name clavicle derives from Latin
 It means „little key„ as it is shaped like the key
that the Romans used to lock t...
 Medial end articulates with manubrium
sterni to form sternoclavicular joint
 Articular surface extends to inferior
aspe...
 Lateral 1/3 shaft :gives origin to deltoid and
trapezius.
 Medial 2/3 shaft:origins of pectoralis major
and clavicular ...
 Only long bone that lies horizontally
 Sub cutaneous through out.
 First bone to start ossifying
 Only long bone whic...
Moderate or high-energy traumatic impacts to
the shoulder
1. Fall from height
2. Motor vehicle accident
3. Sports injury
4...
 Swelling,bruising,ecchymosis at the fracture site
 deformity of shoulder girdle best seen with patient
standing
 In co...
•stabilizing on the
medial segment by
•sternoclavicular
ligaments
•superior on the medial
segment through the
sternocleido...
For more lateral
fractures
•superior on the medial
segment through the
sternocleidomastoid and
trapezius
•medial on the di...
 Simple A-P view is is sufficient to establish the
diagnosis of clavicle fracture.
 Chest radiograph is useful to compar...
 Anteroposterior
View
 30-degree
Cephalic Tilt View
 Quesana View
 45-degree angle superiorly and a 45-degree
angle inferiorly
 Provide better assessment of the extent of
...
 Zanca View
 AP view centered at AC joint with 10
degree cephalic tilt
 Less voltage than used for AP shoulder
 Stress views may be taken to determine the
integrity of coracoclavicular ligaments.
 Fractures of medial clavicle espec...
Clavicular
diastasis
greater than 1
cm hints
scapulothoracic
dissociation
and brachial
plexus traction
injury.
 ALLMANS CLASSIFICATION
 Group I: middle third fractures
 Group II: lateral third fractures
 Group III: medial third f...
 Type I-nondisplaced
 Between the CC and AC
ligaments with ligament
still intact
From Nuber GW and Bowen MK, JAAOS, 5:11...
•A. Conoid and trapezoid attached
to distal fragment
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
•Type IIB: Conoid
torn, trapezoid attached
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
 Type III:articular
fractures
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
 CRAIG CLASSIFICATION: advantage of
including more unusual injuries, such as
epiphyseal separations and periosteal sleeve...
 ADVANTAGES:analyses fractures of clavicle
in thirds
 Prognostically important variables such as
extension,degree of dis...
 MID SHAFT FRACTURES:most midshaft clavicle
fractures are effectively treated nonoperatively.
 They include 1)simple arm...
 useful For fractures with shortening also as
this retracts the scapula and allows to maintain
length.
 For fractures in...
 forward elevation and external rotation
stretches performed supine to negate the
displacing effects of gravity.
 major ...
 Cuff and collar should never be used in
treatment of clavicle fractures.
 Simple sling that elevates the shoulder is al...
 Absolute
 Shortening of >20 mm
 Open injury
 Impending skin disruption and irreducible
fracture
 Vascular compromise...
 Relative
 Displacement of >20 mm
 Neurologic disorder
 Parkinson's
 Seizures
 Head injury
 Multi trauma
 Expected...
 Traditional means of ORIF
 Plate applied superiorly or inferiorly
 Inferior plating associated with lower risk of
hard...
 For transverse fractures, compression across the
fracture site is achieved.
 For oblique fractures or butterfly fragmen...
 Two surgical approaches are commonly used
 1)anterosuperior:most popular operative
method of fixation of clavicle.
 Ad...
 Antero inferior approach:less commonly used.
 ADVANTAGES:less liklihood of injury to
underlying structures.
 Technical...
 Large threaded cannulated screws
 Flexible elastic nails
 K-wires
 Associated with risk of
migration
 Useful when pl...
 Type II fractures, alternatively, are unstable
injuries, secondary to four displacing forces
 the weight of the arm
 t...
 Kirschner wires inserted into the distal
fragment
 Dorsal plate fixation
 CC screw fixation
 Tension-band wire or sut...
 Type I and Type III distal clavicle fractures are
treated nonoperatively
 The main deforming force and source of
discom...
 Type 2 fractures are usually treated with
operative fixation.
 direct fixation of the fracture site without
coracoclavi...
 Indications :
 (a) very distal fracture in a young individual
 (b) fractures that involve the clavicular
insertion of ...
 comminuted lateral clavicular segment;
 (b) older patients in whom potential healing of
a small lateral clavicular segm...
 Nonunion
 Malunion
 Neurovascular Sequelae
 Post-Traumatic Arthritis
 clavicle nonunion is defined as lack of evidence
of healing 4 to 6 months after injury
 Factors Associated with Develop...
 Restore length of clavicle
 May need intercalary bone graft
 Rigid internal fixation, usually with a plate
 Iliac cre...
 Electrical Stimulation and Low-Intensity Pulse
Ultrasound
 Open Bone Graft and Immobilization
 Open Bone Graft and Scr...
 Symptoms of pain, fatigue, cosmetic
deformity.
 Initially treat with strengthening, especially
of scapulothoracic stabi...
 Occasionally, fracture fragments or abundant
callus can cause brachial plexus symptoms.
 Treatment is reduction and fix...
 It is a plane synovial joint.
 Formed by the articulation of small facets
between lateral end of clavicle and medial
ma...
 Initially classified by both Allman and Tossy
et al. into three types (I, II, and III).
 Rockwood later added types IV,...
 Sprain of
acromioclavicular
ligament
 AC joint intact
 Coracoclavicular
ligaments intact
 Deltoid and
trapezius muscl...
 AC joint disrupted
 < 50% Vertical
displacement
 Sprain of the
coracoclavicular
ligaments
 CC ligaments intact
 Delt...
 AC ligaments and CC
ligaments all disrupted
 AC joint dislocated and
the shoulder complex
displaced inferiorly
 CC int...
 AC and CC
ligaments disrupted
 AC joint dislocated
and clavicle
displaced posteriorly
into or through the
trapezius mus...
 AC ligaments
disrupted
 CC ligaments
disrupted
 AC joint dislocated and
gross disparity
between the clavicle
and the s...
 AC joint dislocated
and clavicle displaced
inferior to the
acromion or the
coracoid process
 AC and CC ligaments
disrup...
 Nonoperative: Ice and protection until pain
subsides (7 to 10 days).
 Return to sports as pain allows (1-2 weeks)
 No ...
 Type II operative treatment
 Generally reserved only for the patient with chronic
pain.
 Treatment is resection of the...
 Imaging:normal AP view including opposite
shoulder for comparision
 ZANCA view with 15 degree cephalic tilt.
 Stryker ...
 Nonoperative treatment
 Closed reduction and application of a sling and
harness to maintain reduction of the clavicle
...
 Type III Injuries: Need for acute surgical
treatment remains very controversial.
 Most surgeons recommend conservative
...
 Type III injuries in
highly active patients
 Type IV, V, and VI
injuries
 Coracoid process transfer to distal transfer
(Dynamic muscle transfer)
 Primary AC joint fixation
 Primary Coracoclavi...
 The distal clavicle is excised.
 The CA ligament is
transferred to the distal
clavicle.
 The CC ligaments are
repaired...
 Migration of Pins
 Failure of Soft Tissue Repairs
 Complications Related to Nonabsorbable Tape
or Suture.
 Acromino c...
 Diarthrodial
Joint
 “Saddle shaped”
 Poor congruence
 Intra-articular
disc ligament.
Divides SC joint
into two separa...
 Interclavicular ligament- Connects the
superomedial aspects of each clavicle with the
capsular ligaments and the upper s...
 Medial Physis- Last of the ossification centers
to appear in the body and the last epiphysis to
close.
 Does not ossify...
 Mediastinal
Compression
 Pneumothorax
 Laceration of the
superior vena cava
 Tracheal erosion
 Nonoperative treatment
 Analgesics and immobilization
 Functional outcome usually good
 Closed reduction
 Often not ...
 Careful examination of the patient is extremely
important to rule out vascular compromise.
 Consider CT to rule out med...
 Abduction traction
 Adduction traction
 “Towel Clip” - anterior force applied to
clavicle by percutaneously applied to...
 Resection arthroplasty
 May result in instability of remaining
clavicle unless stabilization is done.
 Suggest minimal...
Clavicle fractures&acromio clavicular joint injuries
Clavicle fractures&acromio clavicular joint injuries
Clavicle fractures&acromio clavicular joint injuries
Clavicle fractures&acromio clavicular joint injuries
Clavicle fractures&acromio clavicular joint injuries
Clavicle fractures&acromio clavicular joint injuries
Clavicle fractures&acromio clavicular joint injuries
Clavicle fractures&acromio clavicular joint injuries
Clavicle fractures&acromio clavicular joint injuries
Clavicle fractures&acromio clavicular joint injuries
Clavicle fractures&acromio clavicular joint injuries
Clavicle fractures&acromio clavicular joint injuries
Clavicle fractures&acromio clavicular joint injuries
Clavicle fractures&acromio clavicular joint injuries
Clavicle fractures&acromio clavicular joint injuries
Clavicle fractures&acromio clavicular joint injuries
Clavicle fractures&acromio clavicular joint injuries
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Clavicle fractures&acromio clavicular joint injuries

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Clavicle fractures&acromio clavicular joint injuries

  1. 1. Dr AMRUTH RAM REDDY POST GRADUATE GANDHI MEDICAL COLLEGE
  2. 2.  The name clavicle derives from Latin  It means „little key„ as it is shaped like the key that the Romans used to lock their doors.  It is a long bone.  It transmits the weight of limb to sternum  It has a shaft and two ends medial and lateral.  Lateral end articulates with acromion to form acrominoclavicular joint
  3. 3.  Medial end articulates with manubrium sterni to form sternoclavicular joint  Articular surface extends to inferior aspect for articulation with first costal cartilage  SHAFT:lateral 1/3>superior surface sub cutaneous  Inferior surface has elevation called conoid tubercle and ridge called trapezoid ridge.  They give attachments to conoid and trapezoid parts of coracoclavicular ligaments.
  4. 4.  Lateral 1/3 shaft :gives origin to deltoid and trapezius.  Medial 2/3 shaft:origins of pectoralis major and clavicular head of sternocleidomastoid.  Subclavian groove gives insertion to subclavius muscle.  It functions as an osseous protector of brachial plexus,jugular and subclavian vessels.
  5. 5.  Only long bone that lies horizontally  Sub cutaneous through out.  First bone to start ossifying  Only long bone which ossifies in membrane  Only long bone which has two primary centres of ossification  It is occasionally pierced by middle supraclavicular nerve.
  6. 6. 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 6. The most common mechanism of clavicle fracture is a fall on the superolateral shoulder
  7. 7.  Swelling,bruising,ecchymosis at the fracture site  deformity of shoulder girdle best seen with patient standing  In completely displaced mid shaft fractures there is shoulder ptosis.  Foreward translation and rotation of shoulder  Shortening of clavicle  Careful neurologic and vascular examination of involved limb is mandatory
  8. 8. •stabilizing on the medial segment by •sternoclavicular ligaments •superior on the medial segment through the sternocleidomastoid •inferior and medial on the lateral segment through the pectoralis major •inferior on the lateral segment through the weight of the arm pulling through coracoclavicular ligaments
  9. 9. For more lateral fractures •superior on the medial segment through the sternocleidomastoid and trapezius •medial on the distal segment through the pull of the pectoralis major, pectoralis minor, and latissimus dorsi •inferior on the distal segment through the weight of the arm
  10. 10.  Simple A-P view is is sufficient to establish the diagnosis of clavicle fracture.  Chest radiograph is useful to compare with the normal side  Should be taken in upright position,where gravity will demonstrate the deformity.  Radiographic beam should be angled 20 degrees superiorly  This eliminates the overlap of the thoracic cage
  11. 11.  Anteroposterior View  30-degree Cephalic Tilt View
  12. 12.  Quesana View  45-degree angle superiorly and a 45-degree angle inferiorly  Provide better assessment of the extent of displacement
  13. 13.  Zanca View  AP view centered at AC joint with 10 degree cephalic tilt  Less voltage than used for AP shoulder
  14. 14.  Stress views may be taken to determine the integrity of coracoclavicular ligaments.  Fractures of medial clavicle especially those involving SC joint are difficult to assess on plain radioraphs.  CT scan is modality of choice here  It can distinguish between medial epiphyseal # and true SC dislocations.
  15. 15. Clavicular diastasis greater than 1 cm hints scapulothoracic dissociation and brachial plexus traction injury.
  16. 16.  ALLMANS CLASSIFICATION  Group I: middle third fractures  Group II: lateral third fractures  Group III: medial third fractures  NEERS CLASSIFICATION  Type I: coracoclavicular ligaments intact  Type II: coracoclavicular ligaments detached from the medial segment but trapezoid intact to distal segment  Type III: intra-articular extension into the acromioclavicular joint
  17. 17.  Type I-nondisplaced  Between the CC and AC ligaments with ligament still intact From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
  18. 18. •A. Conoid and trapezoid attached to distal fragment From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
  19. 19. •Type IIB: Conoid torn, trapezoid attached From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
  20. 20.  Type III:articular fractures From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
  21. 21.  CRAIG CLASSIFICATION: advantage of including more unusual injuries, such as epiphyseal separations and periosteal sleeve fractures.
  22. 22.  ADVANTAGES:analyses fractures of clavicle in thirds  Prognostically important variables such as extension,degree of displacement,degree of comminution.  DISADVANTAGES:  Un usual fracture types included by craig are not mentioned here.  Number scheme used do not correpond to those used by allman.
  23. 23.  MID SHAFT FRACTURES:most midshaft clavicle fractures are effectively treated nonoperatively.  They include 1)simple arm sling 2)figure of eight brace.  There is no change in functional outcome between these two methods.  If injury occurs in dominant shoulder figure of 8 brace is given.  dominant hand can remain free for writing, keyboarding, and other activities
  24. 24.  useful For fractures with shortening also as this retracts the scapula and allows to maintain length.  For fractures in non dominant extremity simple sling will suffice.  This is more comfortable and tolerable.  This is maintained for 4 to 6 weeks.  Immobilisation is discontinued when there is no pain or no palpable fracture motion.
  25. 25.  forward elevation and external rotation stretches performed supine to negate the displacing effects of gravity.  major displacing force for this injury is the weight of the arm  so, pendulum exercises will magnify the displacing moment and should be avoided.  Cuff and collar with strapping should be avoided.  This will allow weight of elbow to generate traction force and distract the fracture.
  26. 26.  Cuff and collar should never be used in treatment of clavicle fractures.  Simple sling that elevates the shoulder is all that required.  Displaced mid shaft clavicle fractures cause persistent disability even if they heal uneventfully.
  27. 27.  Absolute  Shortening of >20 mm  Open injury  Impending skin disruption and irreducible fracture  Vascular compromise  Progressive neurologic loss  Displaced pathologic fracture with associated trapezial paralysis  Scapulothoracic dissociation
  28. 28.  Relative  Displacement of >20 mm  Neurologic disorder  Parkinson's  Seizures  Head injury  Multi trauma  Expected prolonged recumbency  Floating shoulder  Intolerance to immobilization  Bilateral fractures  Ipsilateral upper extremity fracture  Cosmesis
  29. 29.  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.  3.5-mm locking dynamic compression plate  less desirably, a 3.5-mm reconstruction plate.  There are several advantages to this type of fixation over intramedullary fixation.
  30. 30.  For transverse fractures, compression across the fracture site is achieved.  For oblique fractures or butterfly fragments, lag screw fixation is possible .  Secure rotational control of the fracture is achieved.  Fixation is rigid enough to allow the patient to minimally weight-bear on the extremity.  Minimal soft-tissue disruption is necessary.  Often, the injury itself has caused fairly extensive local soft-tissue stripping.  For plate application, only soft-tissue along the superior aspect of the clavicle need be elevated
  31. 31.  Two surgical approaches are commonly used  1)anterosuperior:most popular operative method of fixation of clavicle.  Advantages:incision can be extended to both medial and lateral ends of clavicle.  Clear radiographic views postoperatively.  Disadvantages:underlying neurovascular structures and lung are at risk.  Hard ware prominence can be problematic.
  32. 32.  Antero inferior approach:less commonly used.  ADVANTAGES:less liklihood of injury to underlying structures.  Technically easy to contour small fragment compression plate along anterir border compared to superior border.  DISADVANTAGES:lack of familiarity of this approach to most surgeons.  Biomechanical studies revealed superior position for plate placement is advantageous.
  33. 33.  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
  34. 34.  Type II fractures, alternatively, are unstable injuries, secondary to four displacing forces  the weight of the arm  the pull of the pectoralis major, pectoralis minor, and latissimus dorsi  scapular rotation, which affects the distal segment but not the proximal  the trapezius muscle, which draws the medial segment posterior and superior
  35. 35.  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
  36. 36.  Type I and Type III distal clavicle fractures are treated nonoperatively  The main deforming force and source of discomfort is the weight of the arm.  a simple sling is more effective than a figure- of-eight brace or shoulder immobilizer at countering this force.  those with Type III injuries, are warned of the possibility of late acromioclavicular arthrosis with the possible need for subsequent distal clavicle excision
  37. 37.  Type 2 fractures are usually treated with operative fixation.  direct fixation of the fracture site without coracoclavicular stabilization  direct fixation of the fracture site with coracoclavicular stabilization  coracoclavicular stabilization with or without excision of the lateral clavicular segment
  38. 38.  Indications :  (a) very distal fracture in a young individual  (b) fractures that involve the clavicular insertion of the coracoclavicular ligaments.
  39. 39.  comminuted lateral clavicular segment;  (b) older patients in whom potential healing of a small lateral clavicular segment would be difficult  (c) underlying acromioclavicular arthropathy  (d) fractures lateral to the trapezoid origin  (e) fractures that involve the coracoclavicular ligament origin as an inferiorly displaced fragment.
  40. 40.  Nonunion  Malunion  Neurovascular Sequelae  Post-Traumatic Arthritis
  41. 41.  clavicle nonunion is defined as lack of evidence of healing 4 to 6 months after injury  Factors Associated with Development of Nonunion  Type II fracture  Fracture shortening of >20 mm  Fracture displacement of >20 mm  Increasing patient age  Increasing severity of trauma  Refracture
  42. 42.  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.
  43. 43.  Electrical Stimulation and Low-Intensity Pulse Ultrasound  Open Bone Graft and Immobilization  Open Bone Graft and Screw Fixation  Open Bone Graft and Plate Fixation  Open Bone Graft and Intramedullary Fixation  Clavicular Excision
  44. 44.  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
  45. 45.  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.
  46. 46.  It is a plane synovial joint.  Formed by the articulation of small facets between lateral end of clavicle and medial margins of acromion process of scapula.  Cavity of joint has articular disc occasionally,which may be perforated.
  47. 47.  Initially classified by both Allman and Tossy et al. into three types (I, II, and III).  Rockwood later added types IV, V, and VI, so that now six types are recognized.  Classified depending on the degree and direction of displacement of the distal clavicle.
  48. 48.  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
  49. 49.  AC joint disrupted  < 50% Vertical displacement  Sprain of the coracoclavicular ligaments  CC ligaments intact  Deltoid and trapezius muscles intact Type II From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
  50. 50.  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
  51. 51.  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
  52. 52.  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
  53. 53.  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
  54. 54.  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.
  55. 55.  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.
  56. 56.  Imaging:normal AP view including opposite shoulder for comparision  ZANCA view with 15 degree cephalic tilt.  Stryker notch view for visualizing coracoid fractures.
  57. 57.  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
  58. 58.  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.
  59. 59.  Type III injuries in highly active patients  Type IV, V, and VI injuries
  60. 60.  Coracoid process transfer to distal transfer (Dynamic muscle transfer)  Primary AC joint fixation  Primary Coracoclavicular Fixation  Distal Clavicle Excision with CC ligament reconstruction.
  61. 61.  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
  62. 62.  Migration of Pins  Failure of Soft Tissue Repairs  Complications Related to Nonabsorbable Tape or Suture.  Acromino clavicular arthritis
  63. 63.  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
  64. 64.  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.
  65. 65.  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
  66. 66.  Mediastinal Compression  Pneumothorax  Laceration of the superior vena cava  Tracheal erosion
  67. 67.  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
  68. 68.  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.
  69. 69.  Abduction traction  Adduction traction  “Towel Clip” - anterior force applied to clavicle by percutaneously applied towel clip
  70. 70.  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.

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