This document reviews injuries to the clavicle, acromioclavicular joint, and sternoclavicular joint. It begins by reviewing the anatomy of these areas. It then discusses imaging and classifications of fractures of the clavicle, injuries to the acromioclavicular joint, and injuries to the sternoclavicular joint. For each type of injury, the document reviews treatment options such as nonoperative treatment versus surgical repair or reconstruction. Complications are also discussed.
The document describes several classification systems for femoral fractures:
1. The Singh Index grades femoral head osteoporosis on a scale of 1-6 based on the visibility and integrity of trabecular groups in the proximal femur on radiographs. Grades 3 and below indicate definite osteoporosis.
2. Boyd and Griffin classify intertrochanteric femoral fractures into 5 types based on the trabecular structure of the proximal femur which provides strength.
3. The primary blood supply to the femoral head comes from the medial femoral circumflex artery, with minor contributions from cervical arteries and the foveal artery.
The document outlines the evolution of AO principles from their founding in 1958 to present day. The original principles emphasized anatomical reduction, rigid fixation, and preservation of soft tissues. However, over time the principles shifted to emphasize functional reduction, stable fixation, and preservation of blood supply as it was realized this approach better supported biological healing. The document traces this evolution from the original AO pioneers to modern techniques like minimally invasive plating that further the goal of improving patient outcomes.
Osteotomy around the elbow is commonly performed to correct cubitus varus and cubitus valgus deformities. For cubitus varus, the most common cause is a malunited supracondylar fracture. Surgical options include lateral closing wedge osteotomy, oblique osteotomy with derotation, and medial opening wedge osteotomy with bone grafting. For cubitus valgus, causes include nonunion of a lateral condyle fracture. Surgical options are a closing wedge medial osteotomy or opening wedge lateral osteotomy. Complications of elbow osteotomy can include stiffness, persistent deformity, myositis ossificans, loss of fixation, and neurovascular injury.
Floating knee injury refers to simultaneous fractures above and below the knee, usually from high-energy trauma like car accidents. These injuries have high rates of open fractures and associated injuries to other parts of the body. Treatment requires stabilization of both fractures while prioritizing any non-orthopedic injuries. Surgical fixation usually involves retrograde nailing of the femur followed by nailing or plating of the tibia. Ligament injuries are also common and may require MRI evaluation and treatment. Proper stabilization, treatment of associated injuries, and rehabilitation can lead to the best outcomes for these severe injuries.
A Lisfranc injury involves fracture or ligament disruption of the tarsometatarsal joint complex of the midfoot. It results from high-energy twisting or axial loading injuries and often requires surgical fixation to achieve proper anatomical reduction. Non-operative treatment may be considered for non-displaced or minimally displaced injuries. Proper diagnosis involves weight-bearing radiographs to assess joint congruity, and sometimes CT or MRI. Surgical management focuses on anatomical reduction and stable fixation of the joints to allow early weight bearing and prevent post-traumatic arthritis.
1. The clavicle is the only long bone that lies horizontally in the body and connects the thorax to the shoulder girdle.
2. Clavicle fractures are classified based on their location as medial, middle, or lateral thirds. Common causes are falls on an outstretched hand or lateral shoulder.
3. Treatment depends on the fracture type and patient factors, ranging from sling immobilization to surgical fixation with plates or screws.
External fixation is a stabilization device placed outside the skin using pins or wires connected to bars. It has several advantages over internal fixation, including less soft tissue damage, adjustable rigidity, and lower risk of infection. However, it also has disadvantages like restricted motion and pin site complications. Proper pin placement and construct design are important to provide adequate stability while avoiding stress risers. Ring and hybrid fixators allow weight bearing and motion but pin fixators come in various configurations of increasing stiffness.
This document provides a review of rotator cuff tears, including their anatomy, function, pathophysiology, clinical presentation, diagnostic tests, differential diagnosis, imaging, and treatment options. It describes the rotator cuff muscles and their role in stabilizing the shoulder joint. Common causes of tears include repeated impingement against bony structures or age-related degeneration. Clinical exams aim to isolate each muscle while imaging such as MRI can determine the size and location of tears. Conservative treatment includes corticosteroid injections and physical therapy, while surgical repair is considered for larger or symptomatic tears.
The document describes several classification systems for femoral fractures:
1. The Singh Index grades femoral head osteoporosis on a scale of 1-6 based on the visibility and integrity of trabecular groups in the proximal femur on radiographs. Grades 3 and below indicate definite osteoporosis.
2. Boyd and Griffin classify intertrochanteric femoral fractures into 5 types based on the trabecular structure of the proximal femur which provides strength.
3. The primary blood supply to the femoral head comes from the medial femoral circumflex artery, with minor contributions from cervical arteries and the foveal artery.
The document outlines the evolution of AO principles from their founding in 1958 to present day. The original principles emphasized anatomical reduction, rigid fixation, and preservation of soft tissues. However, over time the principles shifted to emphasize functional reduction, stable fixation, and preservation of blood supply as it was realized this approach better supported biological healing. The document traces this evolution from the original AO pioneers to modern techniques like minimally invasive plating that further the goal of improving patient outcomes.
Osteotomy around the elbow is commonly performed to correct cubitus varus and cubitus valgus deformities. For cubitus varus, the most common cause is a malunited supracondylar fracture. Surgical options include lateral closing wedge osteotomy, oblique osteotomy with derotation, and medial opening wedge osteotomy with bone grafting. For cubitus valgus, causes include nonunion of a lateral condyle fracture. Surgical options are a closing wedge medial osteotomy or opening wedge lateral osteotomy. Complications of elbow osteotomy can include stiffness, persistent deformity, myositis ossificans, loss of fixation, and neurovascular injury.
Floating knee injury refers to simultaneous fractures above and below the knee, usually from high-energy trauma like car accidents. These injuries have high rates of open fractures and associated injuries to other parts of the body. Treatment requires stabilization of both fractures while prioritizing any non-orthopedic injuries. Surgical fixation usually involves retrograde nailing of the femur followed by nailing or plating of the tibia. Ligament injuries are also common and may require MRI evaluation and treatment. Proper stabilization, treatment of associated injuries, and rehabilitation can lead to the best outcomes for these severe injuries.
A Lisfranc injury involves fracture or ligament disruption of the tarsometatarsal joint complex of the midfoot. It results from high-energy twisting or axial loading injuries and often requires surgical fixation to achieve proper anatomical reduction. Non-operative treatment may be considered for non-displaced or minimally displaced injuries. Proper diagnosis involves weight-bearing radiographs to assess joint congruity, and sometimes CT or MRI. Surgical management focuses on anatomical reduction and stable fixation of the joints to allow early weight bearing and prevent post-traumatic arthritis.
1. The clavicle is the only long bone that lies horizontally in the body and connects the thorax to the shoulder girdle.
2. Clavicle fractures are classified based on their location as medial, middle, or lateral thirds. Common causes are falls on an outstretched hand or lateral shoulder.
3. Treatment depends on the fracture type and patient factors, ranging from sling immobilization to surgical fixation with plates or screws.
External fixation is a stabilization device placed outside the skin using pins or wires connected to bars. It has several advantages over internal fixation, including less soft tissue damage, adjustable rigidity, and lower risk of infection. However, it also has disadvantages like restricted motion and pin site complications. Proper pin placement and construct design are important to provide adequate stability while avoiding stress risers. Ring and hybrid fixators allow weight bearing and motion but pin fixators come in various configurations of increasing stiffness.
This document provides a review of rotator cuff tears, including their anatomy, function, pathophysiology, clinical presentation, diagnostic tests, differential diagnosis, imaging, and treatment options. It describes the rotator cuff muscles and their role in stabilizing the shoulder joint. Common causes of tears include repeated impingement against bony structures or age-related degeneration. Clinical exams aim to isolate each muscle while imaging such as MRI can determine the size and location of tears. Conservative treatment includes corticosteroid injections and physical therapy, while surgical repair is considered for larger or symptomatic tears.
1. Clavicle fractures most commonly occur in the midshaft region, resulting from a direct blow to the shoulder.
2. Physical examination reveals swelling, bruising, and deformity at the fracture site. X-rays are usually sufficient to diagnose the fracture.
3. Displaced midshaft fractures are often treated surgically using plates or intramedullary pins to restore length and alignment. Post-operatively, patients begin range of motion exercises and are weaned from immobilization over several weeks.
Can read freely here
https://sethiortho.blogspot.com/
Fracture Healing and
Mechanical stability
Perren`s strain theory
Fracture healing
Indirect Healing
Direct healing
Fixation techniques and stability
Nonunion and Management
Fracture healing
Biological environment
Age
Nutritional status
Blood supply
Metabolic
Mechanical stability
Absolute
Relative
Surgical procedure
Alters biological environment
Selection of fixation
Alters mechanical environment
Mechanical Stability
Parren's strain theory
Strain
Relative deformation of a material when a given force is applied
Relative changes in the fracture gap divided by original fracture gap = L / L
Stability determines the Strain at the fracture site
Stable fixation – less strain
Unstable fixation – high strain
Large gap fracture – less strain
Cross section of the fracture-
Fracture gap strain VS cells response
The degree of inter fragmentary strain appears to govern the cellular response.
Each of these tissues is able to tolerate a different amount of strain:
Perren's strain theory….
When the inter fragmentary strain is <2% bone repair occurs by direct healing
While for intermediate amount of IFS (5–10%) the fracture heals by indirect healing.
Stain theory of healing –Indirect healing
Indirect Healing
Indirect Healing…
Hard callus formation
Indirect Healing
Remodeling Stage
Months to years
Conversion of woven bone into lamellar bone
Formation of Medullary cavity
Return of biomechanical property
Influenced by wolf law – Remodeling based on stress
Stain theory of healing…pseudo arthrosis
Complete instability
Callus is unable to form because the strain is too much for it to tolerate.
The more strain-tolerant fibrous tissue forms
Bone ends are sealed over with cortical bone
Formation of false joint with synovial fluid in the gap
Hypertrophic nonunion
Unstable fracture
Excess callus formation unable to reduce the IFS
Creates a hypertrophic non union
Direct Healing
Anatomically reduced rigid fixed fractures
Formation of cutting cones
>100,000 remodeling units work at time
Direct osteonal remodeling
Without callous
Activation
resorption by osteoclasts
osteoid formation by osteoclasts
Primary osteons
Mineralization
Direct Healing….
Fixation techniques and stability
Relative stability
Intramedullary nailing
Load sharing device
Inter fragmentary micro motion
Fracture gap strain is usually 2-10%
Body responds by forming more soft callus to try and decrease the strain
Fixation of diaphyseal fractures – strength and less duration
Relative stability
Absolute stability
Absolute stability
TBW
Lag screw fixation
Interfragmentary strain,
Nonunion and Management
Nonunion ….
Fracture is fixed rigidly but a gap is present
Direct healing may not be able to bridge the gap
The lack of strain may inhibit callus formation and secondary healing
Predispose to non-union
Management –
This document discusses floating knee injuries, which involve ipsilateral fractures of the femur and tibia. It describes the classification system for floating knee injuries, which includes true floating knee injuries (extra-articular fractures of both bones) and various types involving articular fractures. These injuries often result from high-energy trauma and are associated with injuries to other body parts. Treatment involves stabilizing the patient, addressing any life-threatening injuries, and providing initial stabilization of the fractures often using external fixation before definitive surgical fixation of the fractures.
This document discusses the epidemiology, diagnosis, prevention and management of osteoporotic fractures in the elderly. It covers common fracture types including the femur, hip, ankle and proximal humerus. For each fracture, it discusses epidemiology, classification systems, radiographic evaluation, treatment options and outcomes. Surgical treatment is often recommended but fixation can be challenging due to osteopenia. The goal is to restore pre-injury function and mobility through prompt treatment and rehabilitation.
Tendoachilles rupture and its managementRohan Vakta
Achilles tendon is the strongest tendon of body. There are many causes of its rupture. It can be acute or chronic rupture. Management of chronic rupture by semitendinosus tendon is mentioned here.
Thoracolumbar fractures account for 50% of spinal fractures and often occur between the T9 and L2 vertebrae. They are commonly caused by high-energy trauma like motor vehicle accidents or falls. Assessment involves neurological examination, imaging like x-rays and CT scans to evaluate bone injury and MRI to assess soft tissues. Treatment depends on factors like degree of vertebral compression and kyphosis, with non-operative options for mild cases and surgical stabilization and fusion for more severe injuries or neurological compromise. Rehabilitation focuses on restoring function, preventing complications, and bracing to solidify healing.
The Achilles tendon is the largest tendon in the body, originating from the gastrocnemius and soleus muscles and inserting on the calcaneal tuberosity. It lacks a true synovial sheath and is surrounded by a paratenon with visceral and parietal layers that allows 1.5cm of tendon glide. The tendon has a blood supply from the musculotendinous junction, osseous insertion, and multiple vessels on the anterior surface of the paratenon. Ruptures most commonly occur in the watershed area 4cm proximal to the insertion in those aged 30-40 years old during eccentric loading. Treatment involves diagnosis, primary care, and either operative
Approximately 5% of fractures result in non-unions and more in delayed unions. A delayed union occurs when healing is slower than average, between 3-6 months. Non-union is defined as no healing after 9 months. Factors contributing to delayed or non-union include systemic factors like nutrition, smoking, and local factors like soft tissue injury and fracture characteristics. Treatment involves addressing factors preventing healing, stabilizing the bone, bone grafting, and in some cases electrical or ultrasound stimulation to promote healing. Surgical techniques depend on the type and severity of the non-union.
The "terrible triad" refers to an elbow dislocation with fractures of the coronoid process and radial head. This is an extremely unstable injury that often leads to recurrent instability, stiffness, and arthritis. Surgical treatment aims to address all fractures, repair ligaments, and restore stability through techniques like internal fixation, replacement, and external fixation. Postoperative rehabilitation focuses on early range of motion while protecting the repair.
This document discusses thoracolumbar fractures of the spine. It begins by describing the anatomy of the spine and functional spinal units. It then discusses the physiological anatomy of the thoracic and lumbar spine. It describes the etiology, classifications including the Denis three-column theory and AO/MAGREL classification, clinical presentations, investigations including x-rays, CT and MRI, and classifications of spinal instability for thoracolumbar fractures.
This document provides an overview of acetabular fractures including:
- Anatomy of the acetabulum and its components
- Mechanisms and classifications of acetabular fractures
- Evaluation through radiographs and CT scans
- Management considerations including operative vs non-operative treatment and various surgical approaches
- Specifics on fracture types, indications for surgery, timing of surgery, and surgical approaches for different fractures
The document contains detailed information on evaluating and treating acetabular fractures.
Nonunion occurs when a fracture fails to heal in the expected time frame and is unlikely to heal without intervention. It can be caused by factors like smoking, diabetes, infection, inadequate stability, and soft tissue interposition. Diagnosis involves both radiological and clinical criteria. Treatment depends on the type and location of nonunion, and involves achieving stability, bone apposition, bone grafting, and sometimes correction of deformity. Common treatment methods include plating, intramedullary nailing, external fixation, and the Ilizarov technique.
This document discusses congenital vertical talus (CVT), a rare foot deformity. It begins by defining CVT and providing background information. It then describes the anatomy and pathoanatomy of CVT. Key points include that CVT results in an almost vertical talus bone and rigid flatfoot deformity. Treatment involves serial casting and manipulation to prepare for surgery, with the goal of restoring normal anatomical relationships in the foot. Surgical techniques described include open reduction and percutaneous fixation of the talonavicular joint with K-wires. Complications of surgery can include wound issues and stiffness.
Intertrochanteric fractures are fractures of the proximal femur that occur between the greater and lesser trochanters. They are most common in elderly patients following a fall and can be classified using systems like the Evans or AO classifications to determine stability. Treatment involves early surgery with internal fixation using devices like the dynamic hip screw or intramedullary nails. Precise reduction and implant positioning are important for optimal healing and outcomes. Non-operative management is reserved for patients who are poor surgical candidates.
This document discusses the classification and treatment of acromioclavicular (AC) joint dislocations. It classifies AC joint injuries using the Rockwood classification system, which involves 6 types of injuries based on the degree of ligament disruption and bone displacement. For types 1 and 2 injuries, conservative treatment with rest, ice, and sling is usually recommended. Treatment for type 3 injuries is controversial but often involves initial conservative treatment with possible later surgery. Surgical treatment is described for more severe injuries. Overall, the document indicates that outcomes are often comparable between conservative and surgical treatment, but surgery carries higher risks of complications.
This document discusses cubitus varus, which is a deformity where the forearm is deviated inward at the elbow joint, reducing the normal valgus angle. It describes the causes, types, clinical examination findings, measurements on x-rays, and treatment options. The most common treatment involves corrective osteotomy, with various techniques described such as lateral closing wedge osteotomy, medial open wedge osteotomy, oblique osteotomy, and dome osteotomy. Complications of osteotomy include stiffness, nerve injury, persistent or recurrent deformity, non-union, and skin issues.
This document discusses the management of thoracolumbar spine injuries. It begins by outlining common causes of injury and why the thoracolumbar junction is susceptible. It then covers fracture classification systems including Denis' three column concept and the AO/Magerl classification. Evaluation and management approaches are discussed including non-operative treatment with bracing and operative options depending on fracture pattern and neurological status. Surgical techniques like posterior instrumentation with or without decompression or combined anterior-posterior procedures are mentioned.
fractures of the proximal humerus are among the most common fractures of the upper limb and management options are wide according many variables mostly the age.
Management of acromioclavicular joint dislocationsIdrissou Fmsb
This document provides an overview of acromioclavicular joint dislocations. It begins with definitions and epidemiology, then reviews the anatomy and mechanisms of injury. It describes how to clinically evaluate and classify AC joint dislocations using Rockwood's classification system. Treatment depends on the type of dislocation, ranging from rest for minor injuries to open reduction and surgical repair for more severe injuries. Potential complications are also discussed.
Fractures of the olecranon are commonly caused by direct trauma or falling onto an outstretched arm. The anatomy of the elbow makes the olecranon vulnerable to injury. Treatment depends on the fracture pattern and degree of displacement. Nondisplaced fractures are treated nonsurgically with immobilization. Displaced fractures and those involving the articular surface typically require surgical fixation using techniques like tension band wiring, intramedullary screws, or plate fixation to restore function. Postoperative rehabilitation focuses on early range of motion while protecting the repair during healing. Complications can include hardware issues, stiffness, and nonunion.
Imaging of atlanto occipital and atlantoaxial traumatic injuriesSumiya Arshad
This document discusses imaging of injuries to the craniocervical junction (CCJ). It begins by reviewing the anatomy of the CCJ, including bones and ligaments. It then describes classifications of CCJ injuries and how CT and MR imaging can identify relevant injuries and clinical effects. Specific injuries covered include atlanto-occipital dissociation, occipital condyle fractures, fractures of C1 with transverse ligament rupture, and atlantoaxial distraction or rotatory deformity from alar ligament tears. Thin-slice CT is recommended for initial evaluation, while MR helps evaluate soft tissues and rule out spinal cord injury. Proper classification of CCJ injuries guides management of unstable or complex cases.
1. Clavicle fractures most commonly occur in the midshaft region, resulting from a direct blow to the shoulder.
2. Physical examination reveals swelling, bruising, and deformity at the fracture site. X-rays are usually sufficient to diagnose the fracture.
3. Displaced midshaft fractures are often treated surgically using plates or intramedullary pins to restore length and alignment. Post-operatively, patients begin range of motion exercises and are weaned from immobilization over several weeks.
Can read freely here
https://sethiortho.blogspot.com/
Fracture Healing and
Mechanical stability
Perren`s strain theory
Fracture healing
Indirect Healing
Direct healing
Fixation techniques and stability
Nonunion and Management
Fracture healing
Biological environment
Age
Nutritional status
Blood supply
Metabolic
Mechanical stability
Absolute
Relative
Surgical procedure
Alters biological environment
Selection of fixation
Alters mechanical environment
Mechanical Stability
Parren's strain theory
Strain
Relative deformation of a material when a given force is applied
Relative changes in the fracture gap divided by original fracture gap = L / L
Stability determines the Strain at the fracture site
Stable fixation – less strain
Unstable fixation – high strain
Large gap fracture – less strain
Cross section of the fracture-
Fracture gap strain VS cells response
The degree of inter fragmentary strain appears to govern the cellular response.
Each of these tissues is able to tolerate a different amount of strain:
Perren's strain theory….
When the inter fragmentary strain is <2% bone repair occurs by direct healing
While for intermediate amount of IFS (5–10%) the fracture heals by indirect healing.
Stain theory of healing –Indirect healing
Indirect Healing
Indirect Healing…
Hard callus formation
Indirect Healing
Remodeling Stage
Months to years
Conversion of woven bone into lamellar bone
Formation of Medullary cavity
Return of biomechanical property
Influenced by wolf law – Remodeling based on stress
Stain theory of healing…pseudo arthrosis
Complete instability
Callus is unable to form because the strain is too much for it to tolerate.
The more strain-tolerant fibrous tissue forms
Bone ends are sealed over with cortical bone
Formation of false joint with synovial fluid in the gap
Hypertrophic nonunion
Unstable fracture
Excess callus formation unable to reduce the IFS
Creates a hypertrophic non union
Direct Healing
Anatomically reduced rigid fixed fractures
Formation of cutting cones
>100,000 remodeling units work at time
Direct osteonal remodeling
Without callous
Activation
resorption by osteoclasts
osteoid formation by osteoclasts
Primary osteons
Mineralization
Direct Healing….
Fixation techniques and stability
Relative stability
Intramedullary nailing
Load sharing device
Inter fragmentary micro motion
Fracture gap strain is usually 2-10%
Body responds by forming more soft callus to try and decrease the strain
Fixation of diaphyseal fractures – strength and less duration
Relative stability
Absolute stability
Absolute stability
TBW
Lag screw fixation
Interfragmentary strain,
Nonunion and Management
Nonunion ….
Fracture is fixed rigidly but a gap is present
Direct healing may not be able to bridge the gap
The lack of strain may inhibit callus formation and secondary healing
Predispose to non-union
Management –
This document discusses floating knee injuries, which involve ipsilateral fractures of the femur and tibia. It describes the classification system for floating knee injuries, which includes true floating knee injuries (extra-articular fractures of both bones) and various types involving articular fractures. These injuries often result from high-energy trauma and are associated with injuries to other body parts. Treatment involves stabilizing the patient, addressing any life-threatening injuries, and providing initial stabilization of the fractures often using external fixation before definitive surgical fixation of the fractures.
This document discusses the epidemiology, diagnosis, prevention and management of osteoporotic fractures in the elderly. It covers common fracture types including the femur, hip, ankle and proximal humerus. For each fracture, it discusses epidemiology, classification systems, radiographic evaluation, treatment options and outcomes. Surgical treatment is often recommended but fixation can be challenging due to osteopenia. The goal is to restore pre-injury function and mobility through prompt treatment and rehabilitation.
Tendoachilles rupture and its managementRohan Vakta
Achilles tendon is the strongest tendon of body. There are many causes of its rupture. It can be acute or chronic rupture. Management of chronic rupture by semitendinosus tendon is mentioned here.
Thoracolumbar fractures account for 50% of spinal fractures and often occur between the T9 and L2 vertebrae. They are commonly caused by high-energy trauma like motor vehicle accidents or falls. Assessment involves neurological examination, imaging like x-rays and CT scans to evaluate bone injury and MRI to assess soft tissues. Treatment depends on factors like degree of vertebral compression and kyphosis, with non-operative options for mild cases and surgical stabilization and fusion for more severe injuries or neurological compromise. Rehabilitation focuses on restoring function, preventing complications, and bracing to solidify healing.
The Achilles tendon is the largest tendon in the body, originating from the gastrocnemius and soleus muscles and inserting on the calcaneal tuberosity. It lacks a true synovial sheath and is surrounded by a paratenon with visceral and parietal layers that allows 1.5cm of tendon glide. The tendon has a blood supply from the musculotendinous junction, osseous insertion, and multiple vessels on the anterior surface of the paratenon. Ruptures most commonly occur in the watershed area 4cm proximal to the insertion in those aged 30-40 years old during eccentric loading. Treatment involves diagnosis, primary care, and either operative
Approximately 5% of fractures result in non-unions and more in delayed unions. A delayed union occurs when healing is slower than average, between 3-6 months. Non-union is defined as no healing after 9 months. Factors contributing to delayed or non-union include systemic factors like nutrition, smoking, and local factors like soft tissue injury and fracture characteristics. Treatment involves addressing factors preventing healing, stabilizing the bone, bone grafting, and in some cases electrical or ultrasound stimulation to promote healing. Surgical techniques depend on the type and severity of the non-union.
The "terrible triad" refers to an elbow dislocation with fractures of the coronoid process and radial head. This is an extremely unstable injury that often leads to recurrent instability, stiffness, and arthritis. Surgical treatment aims to address all fractures, repair ligaments, and restore stability through techniques like internal fixation, replacement, and external fixation. Postoperative rehabilitation focuses on early range of motion while protecting the repair.
This document discusses thoracolumbar fractures of the spine. It begins by describing the anatomy of the spine and functional spinal units. It then discusses the physiological anatomy of the thoracic and lumbar spine. It describes the etiology, classifications including the Denis three-column theory and AO/MAGREL classification, clinical presentations, investigations including x-rays, CT and MRI, and classifications of spinal instability for thoracolumbar fractures.
This document provides an overview of acetabular fractures including:
- Anatomy of the acetabulum and its components
- Mechanisms and classifications of acetabular fractures
- Evaluation through radiographs and CT scans
- Management considerations including operative vs non-operative treatment and various surgical approaches
- Specifics on fracture types, indications for surgery, timing of surgery, and surgical approaches for different fractures
The document contains detailed information on evaluating and treating acetabular fractures.
Nonunion occurs when a fracture fails to heal in the expected time frame and is unlikely to heal without intervention. It can be caused by factors like smoking, diabetes, infection, inadequate stability, and soft tissue interposition. Diagnosis involves both radiological and clinical criteria. Treatment depends on the type and location of nonunion, and involves achieving stability, bone apposition, bone grafting, and sometimes correction of deformity. Common treatment methods include plating, intramedullary nailing, external fixation, and the Ilizarov technique.
This document discusses congenital vertical talus (CVT), a rare foot deformity. It begins by defining CVT and providing background information. It then describes the anatomy and pathoanatomy of CVT. Key points include that CVT results in an almost vertical talus bone and rigid flatfoot deformity. Treatment involves serial casting and manipulation to prepare for surgery, with the goal of restoring normal anatomical relationships in the foot. Surgical techniques described include open reduction and percutaneous fixation of the talonavicular joint with K-wires. Complications of surgery can include wound issues and stiffness.
Intertrochanteric fractures are fractures of the proximal femur that occur between the greater and lesser trochanters. They are most common in elderly patients following a fall and can be classified using systems like the Evans or AO classifications to determine stability. Treatment involves early surgery with internal fixation using devices like the dynamic hip screw or intramedullary nails. Precise reduction and implant positioning are important for optimal healing and outcomes. Non-operative management is reserved for patients who are poor surgical candidates.
This document discusses the classification and treatment of acromioclavicular (AC) joint dislocations. It classifies AC joint injuries using the Rockwood classification system, which involves 6 types of injuries based on the degree of ligament disruption and bone displacement. For types 1 and 2 injuries, conservative treatment with rest, ice, and sling is usually recommended. Treatment for type 3 injuries is controversial but often involves initial conservative treatment with possible later surgery. Surgical treatment is described for more severe injuries. Overall, the document indicates that outcomes are often comparable between conservative and surgical treatment, but surgery carries higher risks of complications.
This document discusses cubitus varus, which is a deformity where the forearm is deviated inward at the elbow joint, reducing the normal valgus angle. It describes the causes, types, clinical examination findings, measurements on x-rays, and treatment options. The most common treatment involves corrective osteotomy, with various techniques described such as lateral closing wedge osteotomy, medial open wedge osteotomy, oblique osteotomy, and dome osteotomy. Complications of osteotomy include stiffness, nerve injury, persistent or recurrent deformity, non-union, and skin issues.
This document discusses the management of thoracolumbar spine injuries. It begins by outlining common causes of injury and why the thoracolumbar junction is susceptible. It then covers fracture classification systems including Denis' three column concept and the AO/Magerl classification. Evaluation and management approaches are discussed including non-operative treatment with bracing and operative options depending on fracture pattern and neurological status. Surgical techniques like posterior instrumentation with or without decompression or combined anterior-posterior procedures are mentioned.
fractures of the proximal humerus are among the most common fractures of the upper limb and management options are wide according many variables mostly the age.
Management of acromioclavicular joint dislocationsIdrissou Fmsb
This document provides an overview of acromioclavicular joint dislocations. It begins with definitions and epidemiology, then reviews the anatomy and mechanisms of injury. It describes how to clinically evaluate and classify AC joint dislocations using Rockwood's classification system. Treatment depends on the type of dislocation, ranging from rest for minor injuries to open reduction and surgical repair for more severe injuries. Potential complications are also discussed.
Fractures of the olecranon are commonly caused by direct trauma or falling onto an outstretched arm. The anatomy of the elbow makes the olecranon vulnerable to injury. Treatment depends on the fracture pattern and degree of displacement. Nondisplaced fractures are treated nonsurgically with immobilization. Displaced fractures and those involving the articular surface typically require surgical fixation using techniques like tension band wiring, intramedullary screws, or plate fixation to restore function. Postoperative rehabilitation focuses on early range of motion while protecting the repair during healing. Complications can include hardware issues, stiffness, and nonunion.
Imaging of atlanto occipital and atlantoaxial traumatic injuriesSumiya Arshad
This document discusses imaging of injuries to the craniocervical junction (CCJ). It begins by reviewing the anatomy of the CCJ, including bones and ligaments. It then describes classifications of CCJ injuries and how CT and MR imaging can identify relevant injuries and clinical effects. Specific injuries covered include atlanto-occipital dissociation, occipital condyle fractures, fractures of C1 with transverse ligament rupture, and atlantoaxial distraction or rotatory deformity from alar ligament tears. Thin-slice CT is recommended for initial evaluation, while MR helps evaluate soft tissues and rule out spinal cord injury. Proper classification of CCJ injuries guides management of unstable or complex cases.
Patella fracture and tibial condyle fracture Vivesh Singh
Patella and tibial condyle fractures are injuries to the knee. The patella is a triangular bone that articulates with the femur and protects the knee joint. Tibial condyle fractures involve breaks in the end of the tibia. Risk factors include trauma, osteoporosis, and falls. Treatment depends on the type and severity of the fracture, and may involve rest, casting, surgery such as open reduction and internal fixation, or external fixation for severe injuries. The goals of treatment are to restore alignment and joint stability to allow functional recovery of the knee.
1) Clavicle fractures are most commonly caused by falls onto the shoulder. Treatment is usually closed with immobilization, though surgery may be used for displaced or unstable fractures.
2) Proximal humerus fractures are also often caused by falls, and are evaluated clinically and radiographically. Treatment depends on fracture type and degree of displacement, ranging from immobilization to open reduction and internal fixation.
3) Shoulder dislocations, especially anterior dislocations, commonly cause Bankart lesions of the labrum and Hill-Sachs defects of the humeral head. Early surgical repair may be needed for recurrent instability.
This document provides information on clavicle fractures, including:
- Epidemiology: Middle third fractures account for 80% and lateral third fractures 15%.
- Treatment: Non-displaced fractures are typically treated non-operatively with slings or braces. Displaced or unstable fractures may require open reduction and internal fixation with plates or intramedullary nails.
- Complications: Include nonunion, hardware issues, infection, and injuries to nearby structures like blood vessels or the brachial plexus. Floating shoulder injuries involving both the clavicle and scapular neck often require surgical fixation.
The document discusses the anatomy and injuries of the elbow joint. It describes the elbow as a hinge joint formed by the articulation of the humerus, ulna, and radius. It then discusses the anatomy of the elbow in detail. A key point is made about intercondylar fractures of the humerus, which result from the ulna being driven into the distal humerus. Evaluation, classification, treatment, and potential complications of these fractures are summarized.
a summary of the pertinent elbow anatomy, mechanism of injury, primary and secondary stabilizers of the elbow, and treatment options of elbow terrible triad
This document discusses diagnosis and treatment of acromioclavicular (AC) joint injuries. It describes the anatomy of the AC joint and classifications of injuries. For type I and II injuries, conservative treatment with slings or harnesses is recommended. Types IV, V and VI generally require surgical treatment to reduce and reconstruct injured ligaments. Recent techniques focus on arthroscopic reconstruction of the coracoclavicular ligaments and stabilization of the AC joint with suture anchors, tightropes or tendon grafts. Arthroscopy allows better visualization and less invasive reconstruction of the ligaments compared to open surgery.
managements of the clavicle fracture.pptxzawmyohan2
This document discusses the management of clavicle fractures. It begins by describing the anatomy of the clavicle and associated injuries. Common mechanisms of injury are falls or motor vehicle accidents. Fractures are classified using the Neer system based on displacement and ligament involvement. Treatment options include slings, braces, plates, screws or intramedullary nails depending on stability. Complications can include nonunion, malunion or neurovascular issues. The risk of nonunion is higher for fractures of the outer third with marked displacement. Treatment of nonunions focuses on restoring length and using rigid internal fixation.
This document discusses elbow instability, including anatomy, stabilizing factors, classification, diagnosis, and management. It covers the soft tissue and bony anatomy of the elbow. Elbow stability relies primarily on the ulnohumeral joint, medial and lateral collateral ligaments. Injuries can range from subluxation to complete dislocation. Diagnosis involves clinical examination and imaging. Management depends on the injury, and may include repair, reconstruction, or fixation of bony and ligamentous injuries.
The document summarizes the anatomy, classification, treatment and complications of clavicle fractures and acromioclavicular (AC) joint injuries. Key points:
- Clavicle fractures are classified using the Allman or Neer system, with most (80%) occurring in the middle third.
- Treatment depends on fracture type and displacement, with non-displaced fractures typically treated non-operatively and displaced/unstable fractures often requiring surgery.
- AC joint injuries use the Rockwood classification, with Types I-III usually treated non-operatively and Types IV-VI requiring surgery.
- Surgical options include plate fixation, CC screw fixation, hook plates or ligament reconstruction,
The document discusses various fractures of the upper limb, including: pulled elbow in children, fractures of the proximal radius (head, neck), Monteggia and Galeazzi fractures involving the forearm bones and dislocations, fractures of both bones of the forearm, distal radius fractures including Colles' fracture, and scaphoid fractures. Treatment options depend on the type and location of the fracture, and may involve closed reduction, casting, external fixation, plating, or intramedullary nailing. Complications include nonunion, malunion, neurovascular injuries, and arthritis.
Trochanteric fractures occur in the region between the greater and lesser trochanters of the femur. They were traditionally treated conservatively but surgical fixation using devices like the sliding hip screw and proximal femoral nail are now preferred. Key factors in operative treatment include implant choice, surgical approach, and postoperative analysis of fixation parameters like tip-apex distance to minimize complications like screw cutout.
This document discusses the anatomy, physical exam findings, imaging, and classification and treatment of acromioclavicular (AC) joint dislocations. It describes the Rockwood classification system for AC joint injuries from Types I-VI. Treatment options include non-operative management with sling immobilization for lower grade injuries or operative fixation with techniques like ligament reconstruction using grafts or fixation methods like screws or hook plates for higher grade injuries. Complications of treatment can include residual pain, AC arthritis, and hardware issues.
This document provides an overview of olecranon and radial head fractures. It describes the anatomy and biomechanics of the elbow joint. For olecranon fractures, it discusses mechanisms of injury, classification systems, evaluation, treatment options including nonoperative management and operative techniques like tension band wiring and plating. For radial head fractures, it covers anatomy, mechanisms of injury, associated injuries, classification including the Mason system, and treatment approaches such as fragment excision, open reduction and internal fixation, and arthroplasty.
This document provides information on proximal humerus fractures, including:
1. The anatomy of the proximal humerus and forces that cause deformity.
2. Classification systems for proximal humerus fractures including Neer's classification.
3. Surgical techniques for open reduction and internal fixation of displaced proximal humerus fractures using a proximal humerus locking plate. The procedure is described in 4 steps.
Clavicle fractures are common injuries, especially in young active individuals. The majority occur in the midshaft region due to its thin bone and lack of muscle protection. Treatment depends on the location and degree of displacement/shortening. Nondisplaced fractures are usually treated nonsurgically with slings or strapping. Displaced fractures may require plate fixation, intramedullary nails, or coracoclavicular ligament repair/reconstruction to achieve union and restore function. Complications can include nonunion, malunion, hardware irritation, and neurovascular injury.
This document provides information on fractures of the radius and ulna shaft. It discusses the anatomy of the forearm bones and the deforming forces that can occur with certain fracture locations. Types of fractures covered include isolated radius or ulna shaft fractures, both bone fractures, Monteggia fractures, Galeazzi fractures, and reverse Galeazzi fractures. Treatment options including nonoperative management with casting or operative management with open reduction and internal fixation are described. Postoperative rehabilitation and potential complications are also summarized.
The document discusses elbow dislocations and terrible triad injuries, including simple elbow dislocations, radial head fractures, coronoid fractures, and injuries involving the ulna. Nonoperative and operative treatments are described for each condition. Nonoperative treatments involve splinting or bracing while operative treatments involve open reduction and internal fixation or joint replacement. Complications of both treatment approaches include stiffness, instability, and nerve injuries.
Version is a procedure to change the fetal lie or presentation. There are two main types: external cephalic version and internal podalic version. External cephalic version is done externally without anesthesia to flex the fetus and rotate the head into a vertex presentation. Internal podalic version requires anesthesia and is done when the cervix is dilated to grasp the fetal foot and bring the breech into position for delivery. Potential maternal complications include shock, bleeding, and infection, while fetal risks include asphyxia and complications of breech delivery.
Ultrasound is a non-invasive, safe, and effective tool used in obstetrics. It uses high frequency sound waves to produce images of the fetus. The transducer is placed on the abdomen or vagina to scan the fetus in slices. Reflected sound waves are used to create images on a monitor. Ultrasound can diagnose early pregnancy, assess fetal viability with heart activity, determine gestational age by measuring fetal anatomy, diagnose fetal abnormalities, locate the placenta, assess multiple pregnancies, and evaluate amniotic fluid levels. It is invaluable in obstetric care and fetal assessment.
This document discusses uterine rupture, a serious obstetric complication where the wall of the pregnant uterus tears. It has a high risk of maternal and perinatal mortality. Uterine rupture can occur during labor, delivery, or rarely during pregnancy. It has an incidence of 0.05% for all pregnancies, rising to 0.8% for those with a previous cesarean section. Causes include a weak scar from prior uterine surgery, obstructed labor, or uterine overstimulation from medications. Symptoms include abdominal pain, vaginal bleeding, and non-reassuring fetal heart rate. Diagnosis is usually made during emergency surgery, with ultrasound sometimes identifying signs of rupture. Treatment requires intensive resuscitation
Recurrent miscarriage syndrome, also known as recurrent pregnancy loss, is defined as three or more consecutive losses of clinically recognized pregnancies under 20 weeks gestation. Only about 50% of causes can be determined, which may include uterine, immunologic, endocrine, genetic, thrombophilic, or environmental factors. Evaluation involves a medical and family history, physical exam, laboratory tests, and imaging of the uterus to diagnose potential causes like uterine anomalies, immunologic issues like antiphospholipid syndrome, endocrine disorders, genetic abnormalities, or thrombophilia. Management depends on the underlying cause, with treating identified issues like uterine abnormalities, controlled diabetes or thyroid conditions, anticoagulation for antiphospholipid syndrome,
1. The puerperium is the 6-week period after childbirth where the body returns to its pre-pregnancy state as the placenta is removed and uterine involution occurs.
2. Major complications during this time include puerperal infection/sepsis, mastitis, postpartum hemorrhage, and mental health issues.
3. Puerperal infection is diagnosed based on fever within the first two weeks and requires investigation and treatment with antibiotics to prevent serious illness or death.
This document discusses puerperal sepsis and infections that can occur after childbirth. The most common infection is puerperal fever, caused by genital tract infections in the first 10 days postpartum. Risk factors for uterine infection include cesarean delivery, prolonged labor, and membrane rupture. Symptoms include fever, abdominal pain, and tenderness. Treatment involves intravenous antibiotics, with most women improving within 48-72 hours. Complications include wound infections, parametrial phlegmons, pelvic abscesses, and rarely necrotizing fasciitis or peritonitis.
This document discusses preterm labor and birth. It defines preterm birth as birth before 37 weeks of gestation. Between 28-37 weeks, organ systems like the lungs continue maturing and developing. Common risk factors for preterm birth include a previous preterm delivery, multifetal gestation, cervical surgery, smoking, and short interpregnancy intervals. The document outlines criteria for diagnosing preterm labor and discusses treatments like tocolytics and corticosteroids which can help delay delivery and improve neonatal outcomes. Complications of prematurity in infants are also reviewed.
This document discusses premature rupture of membranes (PROM), which is the spontaneous rupture of membranes before the onset of labor. It defines PROM as occurring beyond 28 weeks of gestation but before labor, and preterm PROM (PPROM) as occurring between 28-37 weeks.
The document outlines the risk factors, symptoms, diagnosis, and management of PROM depending on gestational age. Evaluation involves history, physical exam including speculum exam, and tests like nitrazine, ferning, fetal fibronectin, and ultrasound. Management often involves expectant monitoring, antibiotics, corticosteroids, and tocolytics to prolong the pregnancy if it is prior to 34 weeks. The goals are
Labour is considered prolonged if it lasts more than 12 hours. It can be caused by issues with the passageway (pelvis), passenger (baby), powers (contractions), or psyche (mental state). Prolonged labour risks maternal and fetal complications if neglected. Close monitoring is needed to detect obstruction early. Treatment depends on fetal viability but may include resuscitating the mother, controlling infection, relieving obstruction via c-section, and post-delivery care like antibiotics and bladder drainage. Abnormal uterine contractions can also prolong labour and are treated with oxytocin.
Postpartum haemorrhage (PPH) is a major cause of maternal mortality. It can be primary (within 24 hours of delivery) or secondary (24 hours to 6 weeks postpartum). Primary PPH is usually due to uterine atony or trauma during delivery. Management involves emptying the uterus, replacing blood loss, and ensuring haemostasis. Secondary PPH is often caused by infection or retained placental fragments. Treatment focuses on identifying and addressing the underlying cause while providing supportive care.
Placenta praevia is a condition where the placenta is partially or totally attached to the lower uterine segment. It occurs in around 0.5% of pregnancies and is more common in multiparous women and twin pregnancies. Placenta praevia can cause painless vaginal bleeding and is diagnosed using ultrasound imaging. Treatment depends on gestational age and amount of bleeding, and may involve bed rest, induction of labor, or caesarean section to deliver the baby safely. Complications for both mother and baby can include bleeding, prematurity, and difficulty during labor and delivery.
1. Hypertension is a common medical complication during pregnancy, affecting up to 5% of pregnancies. It can cause morbidity for both the mother and fetus.
2. There are several classifications of hypertensive disorders of pregnancy, including gestational hypertension, preeclampsia, eclampsia, chronic hypertension, and preeclampsia superimposed on chronic hypertension.
3. Preeclampsia is defined as new onset hypertension and proteinuria after 20 weeks of gestation. It is caused by placental ischemia and endothelial dysfunction leading to widespread vasoconstriction. Management involves monitoring, controlling blood pressure, delivering the baby if conditions warrant, and preventing seizures with magnesium sulfate.
Pelvic inflammatory disease (PID) is an infection of the female upper genital tract including the uterus, fallopian tubes, and surrounding pelvic structures. It is usually caused by sexually transmitted infections like chlamydia and gonorrhea spreading from the vagina or cervix. Left untreated, PID can cause long-term complications like infertility, ectopic pregnancy, and chronic pelvic pain. Treatment involves antibiotics to cover the most common causative organisms.
Ovarian tumors can be primary (arise in the ovary) or secondary (spread from other sites). The most common primary ovarian tumor is epithelial ovarian cancer, which arises from ovarian surface cells. Germ cell tumors arise from egg-producing cells and are more common in children/teens. Stromal tumors produce hormones. Risk factors include nulliparity, family history of breast/ovarian cancer, and hereditary conditions. Epithelial tumors are classified as malignant, borderline, or benign. Staging involves assessing spread from ovaries to other pelvic/abdominal sites or distant metastasis. Treatment depends on stage but may include surgery and chemotherapy.
Ovarian cysts are sacs filled with liquid or semi-liquid material that arise in the ovaries. The majority are benign and not cancerous. There are several types of ovarian cysts including functional cysts (follicular, corpus luteum, and theca lutein cysts), endometriomas, and polycystic ovarian syndrome. Ovarian cysts may cause lower abdominal pain but many are asymptomatic. Ultrasound is used to examine cyst features and size while blood tests and further imaging can help determine if a cyst is benign or potentially cancerous. Most small, simple cysts can be monitored but larger or complex cysts may require surgical removal. The prognosis for benign ovarian cysts is
This document defines key obstetric terms related to fetal presentation, position, lie, attitude, engagement, and stations during childbirth. It explains that the most common presentation is cephalic, with the fetus facing head down. Position refers to how the fetal back relates to the mother's sides and whether it is facing anteriorly or posteriorly. Lie indicates the relation of the fetal and maternal long axes. Attitude describes how the fetal parts relate to each other. Engagement is when the widest fetal diameter passes through the pelvic inlet. Stations measure the descent of the presenting part through the pelvis in centimeters. Causes of non-engagement can be faults in the fetus, pelvis, or maternal muscles
Multiple pregnancies can involve twins, triplets or more. Twin pregnancies are the most common type and can be either dizygotic (fraternal) or monozygotic (identical). Risk factors include advanced maternal age, fertility treatments and genetic factors. Complications of twin pregnancies include preterm birth and low birth weight. Specific complications include twin-twin transfusion syndrome and discordant growth. Care involves monitoring for complications and intervening if needed to improve outcomes for both fetuses.
Malaria in pregnancy poses significant risks. Plasmodium falciparum is the most common and dangerous malaria parasite. It can accumulate in the placenta, posing risks to primigravid women and their babies like low birth weight. Intermittent preventive therapy with sulfadoxine-pyrimethamine and insecticide-treated nets can effectively prevent maternal anemia and reduce poor birth outcomes but coverage remains low. Malaria may also increase HIV viral load and mother-to-child transmission risk. Improved prevention and treatment strategies are still needed.
Labor and delivery involves three stages:
1) The first stage begins with contractions and ends with full cervical dilation. It includes early latent and active phases of dilation.
2) The second stage begins at full dilation and ends with baby's delivery. It involves baby's descent and delivery.
3) The third stage begins after delivery and ends with placenta delivery, usually within 30 minutes but sometimes requiring intervention.
This document discusses intrauterine growth restriction (IUGR), which can be symmetrical or asymmetrical depending on when it occurs during fetal development. Symmetrical IUGR occurs early in pregnancy and is usually caused by genetic or infectious issues intrinsic to the fetus, resulting in smaller total cell number but normal cell size. Asymmetrical IUGR occurs later and is caused by chronic placental insufficiency extrinsic to the fetus, resulting in a normal total cell number but smaller cell size. Management of IUGR depends on gestational age and severity, and may involve bed rest, nutrition, monitoring, termination of pregnancy if before 37 weeks, or corticosteroids and cesarean section for preterm delivery.
1. Injuries of the Clavicle,Injuries of the Clavicle,
Acromioclavicular Joint andAcromioclavicular Joint and
Sternoclavicular JointSternoclavicular Joint
FahadFahad
zakwanzakwan
2. Goals
•1) Review anatomy of clavicle, AC joint, and sternoclavicular1) Review anatomy of clavicle, AC joint, and sternoclavicular
jointjoint
•2) Review imaging of these areas.2) Review imaging of these areas.
•3) Clavicle Fractures3) Clavicle Fractures
Nonoperative RXNonoperative RX
Surgical RepairSurgical Repair
Nonunions and MalunionsNonunions and Malunions
•4) AC Joint Injuries4) AC Joint Injuries
•5) Sternoclavicular joint injuries5) Sternoclavicular joint injuries
3. THE CLAVICLETHE CLAVICLE
• The clavicle is a doubly curved (S – shaped) bone thatThe clavicle is a doubly curved (S – shaped) bone that
acts as a strut btw the scapula and the sternum, locatedacts as a strut btw the scapula and the sternum, located
directly above the first rib.directly above the first rib.
• Medially it articulates with manubrium of the sternum atMedially it articulates with manubrium of the sternum at
the sternoclavicular joint.the sternoclavicular joint.
• Laterally it articulates with the acromion of the scapulaLaterally it articulates with the acromion of the scapula
at the Acromioclavicular joint.at the Acromioclavicular joint.
• It has rounded medial end and a flattened lateral end.It has rounded medial end and a flattened lateral end.
5. 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
6. Distal Clavicle
•Coracoclavicular ligaments
• “Suspensory ligaments of the
upper extremity”
• Two components:
• Trapezoid
• Conoid
• Stronger than AC ligaments
• Provide vertical stability to AC
joint
7. Mechanism of Injury
• Direct impact to the anterior - superior
shoulder of moderate – high force.
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
8. 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.
9. Physical Examination
•Palpation
•Evaluate pain
•Look for
instability with
stress
• Neurovascular
examination
• Must be done thoroughly
and documented!
• Evaluate upper extremity
motor and sensation
• Measure shoulder range-
of-motion
11. Radiographic Evaluation of the Clavicle
• Quesana ViewQuesana View
• 45-degree angle45-degree angle
superiorly and a 45-superiorly and a 45-
degree angle inferiorlydegree angle inferiorly
• Provide betterProvide better
assessment of theassessment of the
extent ofextent of
displacementdisplacement
•Zanca View
•AP view centered at
AC joint with 10
degree cephalic tilt
•Less voltage than
used for AP shoulder
12. Stress Views of the Distal Clavicle &
AC Joint
• Rationale: demonstrate instability and differentiate
grade III AC separations from partial Grade I-II injuries.
• Performed by having patient hold 10# weight with
injured arm.
• Rarely used today, since most Grade I-III AC joint
injuries are treated the same anyway, and management
of distal clavicle fractures depends on initial
displacement and location of fracture.
13. Radiographic Evaluation of the Medial One
Third
•X-ray: Cephalic tilt
view of 40 to 45
degrees
•CT scan usually
indicated to best assess
degree and direction of
displacement S=sternum
C= medial clavicle
E= esophagus
15. Classification of Clavicle 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%)
21. 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.
22. 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.
23. Definite Indications for Surgical
Treatment of Clavicle Fractures
•1) Open
fractures
•2) Associated
neurovascular
injury
26. 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
nonunion.
27.
28.
29.
30.
31.
32.
33. 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
34. Titanium Elastic Nails
•Same as used in pediatric femur fractures.
•Accommodate three-dimensional anatomy
of the clavicle.
•Typically inserted “retrograde” (from
medial to lateral)
•Best in fractures without comminution
•Small incision at fracture site may be
needed.
35. Comparison of Techniques
•No studies available that compare one operative
technique to another.
•Both elastic nails and plates seem equivalent in
stable fractures; benefits of minimally invasive
approach used in elastic nailing awaiting study.
•Plate fixation best in comminuted fractures, but
again no evidence.
36. Complications of Clavicular Fractures and its
Treatment
•Nonunion
•Malunion
•Neurovascular Sequelae
•Post-Traumatic Arthritis
37. Risk Factors for the Development of
Clavicular Nonunions
•Location of Fracture
•(outer third)
•Degree of Displacement
•(marked displacement)
•Primary Open Reduction
38. Principles for the Treatment of
Clavicular 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.
42. 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
43. 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.
45. Classification of Distal Clavicular Fractures
(Group II Clavicle Fractures)
•Type I-nondisplacedType I-nondisplaced
•Between the CC and
AC ligaments with
ligament still intact
46. Type II
•Typically displaced secondary to a fracture
medial to the coracoclavicular ligaments,
keeping the distal fragment reduced while
allowing the medial fragment to displace
superiorly
•Highest rate of nonunion (up to 30%)
•Two Types
50. 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
51. •Displaced Type II fractures of the
distal clavicle are often treated
more aggressively because of the
increased risk of nonunion with
nonoperative treatment
52. Techniques for Acute Operative Treatment 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
53. •For most techniques of clavicular
fixation, coracoclavicular
fixation is also needed to
prevent redisplacement of the
medial clavicle.
54. The Hook Plate (Synthes USA, Paoli, PA) wasThe Hook Plate (Synthes USA, Paoli, PA) was
specifically designed to avoid this problem ofspecifically designed to avoid this problem of
redisplacement.redisplacement.
55.
56. Hook Plate - Results
•Recent series of distal clavicle fractures 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.
57. Preferred technique for fixation of
acute distal third clavicle fractures
•Horizontal incision
•Manual reduction of fracture
•Dorsal tension band suture and
reconstruction/augmentation of
coracoclavicular ligaments.
58. Look for avulsion fracture of CC ligament
attachment
• If present, this fragment can be sutured to proximal
(eg. medial) clavicle to restore stability, without
need for hardware.
• Jackson WFM, et al. J Trauma 2006;61:222-
225
59. Indications For Late Surgery For Distal
Clavicle Fractures
•Pain
•Weakness
•Deformity
60. Techniques For Late Surgery For Distal
Clavicle Fractures
•Excision of distal clavicle
•With or without reconstruction of
coracoclavicular ligaments (Modified
Weaver-Dunn procedure)
•Reduction and fixation of fracture
64. Case Example 2Case Example 2
This fragment likely has CC ligament attached; need
to reduce and hold clavicle shaft to this piece.
65. Case Example 2Case Example 2
This fragment likely has CC ligament attached; need
to reduce and hold clavicle shaft to this piece.
Sutures passed into this
fragment (not visible)
66. Case Example 2
This fragment likely has CC ligament attached; need
to reduce and hold clavicle shaft to this piece.
Sutures passed into this
fragment (not visible)
4 months
68. Mechanism
•Sports injury or trauma.Sports injury or trauma.
•Impact to superior acromion, drivingImpact to superior acromion, driving
the arm down and rupturing the ACthe arm down and rupturing the AC
joint capsule (first) and then the thejoint capsule (first) and then the the
coracoclavicular ligaments (second).coracoclavicular ligaments (second).
69. Physical Findings
•Pain over lateral clavicle / AC joint
•May have prominent distal clavicle
•May have skin abrasions
•Unwilling to lift arm.
•Should have full passive ROM of the
shoulder.
70. 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
• Zanca view (15 degree cephalic tilt)
• Other views:
• Axillary: demonstrates anterior-posterior displacement
• Stress views: not generally relevant for treatment decisions.
71. Classification For Acromioclavicular
Joint Injuries
•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.
72. Type IType I
•Sprain of
acromioclavicular
ligament
•AC joint intact
•Coracoclavicular
ligaments intact
•Deltoid and trapezius
muscles intact
73. • AC joint disrupted
• < 50% Vertical
displacement
• Sprain of the
coracoclavicular
ligaments
• CC ligaments intact
• Deltoid and trapezius
muscles intact
Type IIType II
74. Type IIIType 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
76. Type IVType 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
77. Type VType 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
78. Type VIType 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
79. Treatment Options For Types I - II
Acromioclavicular Joint Injuries
Nonoperative:Nonoperative:
•Ice and protection until pain subsides (7 to 10 days).Ice and protection until pain subsides (7 to 10 days).
•Return to sports as pain allows (1-2 weeks)Return to sports as pain allows (1-2 weeks)
•No apparent benefit to the use of specialized braces.No apparent benefit to the use of specialized braces.
operative treatmentoperative treatment
• Generally reserved only for the patient with chronic pain.Generally reserved only for the patient with chronic pain.
• Treatment is resection of the distal clavicle and reconstruction of theTreatment is resection of the distal clavicle and reconstruction of the
coracoclavicular ligaments.coracoclavicular ligaments.
80. Treatment Options For Type III-VI
Acromioclavicular 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 reconstruction (usually with allograft, often
with augmentation)
• Excision of the distal clavicle
• Dynamic muscle transfers
81. • 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.
82. Indications for Acute Surgical Treatment of
Acromioclavicular Injuries
• Type III injuries in highly
active patients
• Type IV, V, and VI injuries
83. Surgical Options for AC Joint Instability
• Coracoid process transfer to distal transfer (Dynamic muscle
transfer)
• Primary AC joint fixation
• Primary Coracoclavicular Fixation
• CC ligament reconstruction +/- distal clavicle excision.
84. 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
85. Indications for Late Surgical Treatment of
Acromioclavicular Injuries
• Pain
• Weakness
• Deformity
86. Techniques for Late Surgical Treatment of
Acromioclavicular Injuries
• Reduction of AC joint and repair of AC and CC
ligaments
• Resection of distal clavicle and reconstruction of CC
ligaments (Weaver-Dunn Procedure)
90. 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
91. • 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.
92. Epiphysis of the Medial Clavicle
•Medial Physis- Last of the ossificationMedial Physis- Last of the ossification
centers to appear in the body and thecenters to appear in the body and the
last epiphysis to close.last epiphysis to close.
•Does not ossify until 18th to 20th yearDoes not ossify until 18th to 20th year
•Does not unite with the clavicle untilDoes not unite with the clavicle until
the 23rd to 25th yearthe 23rd to 25th year
93. Radiographic Techniques for Assessing
Sternoclavicular Injuries
•40-degree cephalic
tilt view
•CT scan- Best
technique for
sternoclavicular joint
problems
94. Injuries Associated with Sternoclavicular
Joint Dislocations
•Mediastinal
Compression
•Pneumothorax
•Laceration of the
superior vena cava
•Tracheal erosion
95. Treatment of Anterior Sternoclavicular
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
96. Treatment of Posterior
Sternoclavicular 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.
97. Closed Reduction Techniques
• Abduction traction
• Adduction traction
• “Towel Clip” - anterior force applied to clavicle by
percutaneously applied towel clip
98. 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.