Fracture in clavicle and scapula and approach to their management clavicle fracture scapula fracture Dr Kuldeep Singh AIIMS Bhopal Ortho resident

1. CLAVICLE AND SCAPULAR
NAME- Dr. KULDEEP SINGH
Ortho Resident
AIIMS Bhopal

2. Clavicle fracture
• Clavicle fractures are common injuries
• Account for 2.6% of all fractures
• Up to 44% of injuries to the shoulder girdle
• Easy to recognize
• Majority unite uneventfully

3. Incidence & Classification
• Group 1 (middle one third of the clavicle - the shaft) 80-85%.
• Group 2 (lateral one third - the acromial end)15-20%.
• Group 3 (medial one third - the sternal end) 0-5%.

4. Mechanism of Injury
• Trauma
– Fall against lateral shoulder (90%)
– Fall on Outstretched Hand (5%)
– Direct blow to clavicle (5%)
• Non traumatic (in children)
– Tumor
– Rickets
– Osteogenesis imperfecta
– Physical Abuse

5. Displacement mechanism

6. Diagnosis
 C/F-
• Symptoms- Pain and swelling , decreased movement of the
affected limb.
• Sign-
 Bruising,
 Tenderness
 Crepitation,
 Pressure on the overlying skin & palpable deformity.

7. Radiographs
 Different angles:
• AP – evaluate superior-inferior displacement
• 45’ cephalic tilt(Serendipity view) view
» Evaluate AP displacement
• Stress views useful in lateral 1/3 fractures
to assess AC & CC ligaments injury.
• Chest x-ray
• CT

8. Classification
Based on the position of the fracture:[“Allman”]
1. Distal third (Group II)
2. Middle third (Group I)
3. Proximal (Group III).
• “Neer” divided distal clavicle fractures into three subgroups,
based on their ligamentous attachments and degree of
displacement.

9. Classifications
Group-II:
Type I: Distal clavicle fracture with the intact coracoclavicular
ligaments.

10. Classifications
Group II-TYPE II
TYPE-IIA TYPE-IIB
• (Rockwood): Conoid
detached from the medial
fragment
• (Rockwood): Both conoid and
trapezoid attached to the
distal fragment

11. • Group II:
• Type III: Distal clavicle fracture with extension into the AC
joint.
• Group III: Medial clavicular fracture- subgroups are
• Type 1 :Minimal displacement
• Type 2: Displaced
• Type-3: Intra-articular
• Type-4: Epiphyseal seperation
• Type-5: Comminuted

12. Other Classifications
1. AO/OTA classification scheme of clavicle fractures.
2. Robinson classification scheme of clavicle fractures.

13. Non-operative Treatment
 Indications: Majority cases
– Non-displaced Group I (middle
third)
– Stable Group II fractures
– Group III (medial third)
 Technique
– Sling or figure-of-8
– 2-4 weeks-gentle ROM exercises.
– No attempt at reduction should
be made.

14. Clavicle fracture rehabilitation Protocol
Lädermann et al. Functional recovery following early mobilization & rehabilitation after clavicle fractures : A case-control study.
Orthop Traumatol Surg Res. 2017;103(6):885–9.

16. Operative management
• Stabilization techniques include
– Plate fixation
– Intramedullary fixation
– External fixation
– Coracoclavicular ligament repair or reconstruction in Group II
• Postoperative rehabilitation
– Sling for 2wk followed by active motion
– Strengthening exercise at 6-8 weeks when pain free motion
and radiographic evidence of union
– Full activity including sports at ~ 3 months

17. MID CLAVICULAR FRACTURE

19. DISTAL CLAVICULAR FRACTURE

20. Direct fixation of the fracture site without
coraco-clavicular stabilization
1.Plate Fixation
• The distal fragment is large enough to hold a minimum of two,
and ideally three, bi-cortical screws

21. 2.The clavicular hook plate:
 If distal fragment is too small .
 Usually removal at 3 month post-op.

22. 3. intramedullary nailing-
• Completely displaced transverse fracture.
• Advantages- smaller, more cosmetic skin incision
less soft tissue stripping at fracture site
decreased hardware prominence
• Disadvantages- 1.inferior in resisting displacement as compare
to plate fixation
2.Implant failure
3. Infection
4. nail protrusion/irritation on the medial side

24. 4.Kirschner Wire Fixation
Inherent risk of wire breakage and migration.
High nonunion and infection rates.
So not used now a days.

25. • 5.Endobutton Technique
• The use of two Endo-Buttons, toggled through drill-holes in
the clavicle and coracoid

26. 2. Direct Fixation of the Fracture with
Coracoclavicular Stabilization
• Indications :
-Very distal fracture in a young individual.
-Fractures that involve the clavicular insertion of the
coracoclavicular ligaments.
Bosworth screw

27. MEDIAL CLAVICULAR FRACTURES

28. TREATMENT
• Usually managed non-operatively.
• Except-
fracture displacement which produces superior
mediastinal compromise require urgent attempt at closed
reduction
or open reduction next if this is unsuccessful.

29. Complications
Complications of nonoperative treatment
- Nonunion (1-5%)
-Decreased shoulder strength and endurance
Complications of operative treatment(10%- 30%)
– Hardware complications : 30% request for plate removal.
– Infection (~4.8%)
– Mechanical failure (~1.4%)

30. Conclusion
• Completely displaced midshaft fractures: superior results with
primary fracture fixation.
• Anteroinferior plating- may reduce risk of symptomatic
hardware compared to superior plating.
• Outcome: No difference between regular sling & figure-of-
eight bandage.
• Outcome: No difference between plating & intramedullary
nailing of displaced midshaft fractures.

31. SCAPULAR FRACTURE

32. SCAPULA
• Is a flat triangular bone that lies on the posterior thorax wall
between 2-7 rib.
• It enveloped by :
 supraspinatus muscle
 Infraspinatus muscle
 Subscapularis muscle
• Attached to clavicle at acromioclavicular.
• Articulate with humerus at glenohumeral joint .

33. Fracture of scapula
• Uncommon - location and surrounding muscles protection .
• Result of high energy trauma with 60-98 % associated injuries
• 0.4% to 0.9% of all fractures.
• 3% to 5% of shoulder girdle #.

34. Associated life threatening injuries
• Pneumothorax
• Pulmonary contusion
• Arterial injury
• Abdominal injury
• Head injury (10% to 42% of all cases of scapula fracture.)
• Brachial plexus injury

35. Mechanism of injury
 From severe direct trauma
 Fall from height with direct landing on posterior aspect of
trunk.
 Fall on shoulder
 Fall on outstretched hand

36. Clinical picture
 Brusing over scapula or
chest area .
 Pain in movement .
 Swelling around back of
shoulder .
 Tenderness at site of # .
 Arm is held immobile .

37. Diagnosis
• X – ray : Anteroposterior view lateral axillary view.
 Neer I projection: true AP
 To assess glenohumeral joint space
 Displacement of the glenoid in relation to the lateral border
of the scapula
 To measure the glenopolar angle (GPA).

38. Diagnosis
 Neer II projection :Y-view- true lateral scapular projection.
 Allows-
 Assessment of scapular body fractures in terms of translation,
angulation, and overlap of fragments
 Displays relationship between the acromion and the lateral
clavicle
 To identify any avulsion of the anterior rim of the glenoid.
• CT scan : Useful in glenoid or body fracture.

39. Glenopolar angle (GPA)
• Angle b/w two lines,
• one connecting the most cranial & most caudal point of the
glenoid
• one connecting the most cranial point of the glenoid with the
most caudal part of the scapula.
GPA of less than 20 degrees is
associated with a poor functional
outcome
GPA of less than 20’ is one of the criteria
for operative treatment.

40. Ideberg Classification
• Type 1a-Anterior rim
• Type 1b-Posterior rim
• Type 2-Transverse to lateral margin
• Type 3-Transverse to superior
margin
• Type 4-Transverse to medial margin
• Type 5a-Transverse lateromedial
• Type 5b-Transverse superomedial
• Type 5c-Transverse
supero-medio-lateral
• Type 6-Comminuted crush-
irreparable

41. Classification (Tscherne and Christ )
1. Fractures of processes
2. Fractures of the scapular
body(~50%)
3. Fractures of the scapular neck
4. Fractures of the glenoid fossa
5. Combined and comminuted
fractures.

42. Fractures of processes
• A1—fractures of the superior border and the superior angle
• A2—fractures of the acromion and the lateral part of the
scapular spine
• A3—fractures of the coracoid process
A2 A3

43. Fracture of body :
• B1—anatomical body( fracture lines pass from the
supraspinous fossa-scapular spine-infraspinous fossa)
• B2—biomechanical body(only infraspinous fossa)

44. Fracture of neck :
Separating the glenoid from the scapular body.
• C1—Anatomical neck #
• C2—Surgical neck #-line passes through the suprascapular
notch.
• C3—Trans spinous neck #. line passes medial to the
suprascapular notch.
C3

45. Glenoid Fossa Fractures
• D1—superior glenoid #- d/t avulsion of the coracoid base.
• D2—avulsion of the anteroinferior rim of the glenoid +
anterior dislocation of the humeral head.
• D3—fractures of the inferior glenoid

46. Treatment
• Reduction is usually unnecessary .
• Sling for comfort and from start movement.
• Check repeatedly for dislocation of the shoulder.

47. Indications for operative treatment
• Scapular body and neck #-
 100% translation or 30’ to 40’ degree angulation of fragments of
the lateral border.
 Mediolateral displacement of the glenoid in relation to the
lateral border of the scapular body of >1-2 cm.
 GPA less than 20 degrees.
• Acromion or Coracoid #- Displacement of fragments of >1 cm
• Glenoid fractures- if displacement is, a gap/step off of ≥3 to 10
mm, with 20% to 30% involvement of the articular surface.

48. Surgical approach
• Judet posterior
• Anterior deltopectoral
 Judet approach provides an excellent exposure to
 Infraspinous fossa,
 Lateral and medial borders of the scapula
 Scapular spine
 Scapular neck
 Posterior and inferior rims of the glenoid.

49. Judet approach
• Skin incision along the scapular spine and the medial border
of the scapula. A skin flap is then raised and the posterior
border of the deltoid identified.
• Posterior deltoid is detached from the scapular spine and
turned back laterally and distally.
• Infraspinatus is mobilized and retracted proximally.

50. Complication
 Malunion –M/c
 Non-union : rare
 Glenohumeral arthritis . Limitation in range of motion.
 Post-op :
 Limited range of motion of the shoulder- quite common
 Infection
 Failure of internal fixation frequently requires reoperation
 Post traumatic arthritis
 Rotator cuff dysfunction

51. Associated injuries

52. Floating Shoulder
• Ipsilateral clavicle + scapular neck fracture.
• Unstable injury-may require operative fixation.
• Subgroup/ commonest type of the “double disruption of the
superior shoulder suspensory complex (SSSC).

53. Superior shoulder suspensory complex
(SSSC)
• Maintains anatomic relationship b/w upper extremity & axial
skeleton.
• Clavicle-only bony connection b/w the two
• Scapula is suspended from it by coracoclavicular and AC
ligaments.

54. Classification
• Williams GR et al. The floating shoulder: a biomechanical basis for classification and management. J Bone
Joint Surg Am. 2001 Aug;83(8):1182–7.

55. Classification
Williams GR et al. The floating shoulder: a biomechanical basis for classification and management. J Bone
Joint Surg Am. 2001 Aug;83(8):1182–7.

56. Classification
Williams GR et al. The floating shoulder: a biomechanical basis for classification and management. J
Bone Joint Surg Am. 2001 Aug;83(8):1182–7.

57. Treatment
• Indications for operative management-
1. Clavicle fracture that warrants, in isolation, fixation
2. Glenoid displacement > 2.5 to 3 cm
3. Patient-associated (Requirement for early upper extremity
wt bearing)
4. Severe glenoid angulation(retroversion/anteversion >40’)
5. Documented ipsilateral coracoacromial and/or AC ligament
disruption

58. Treatment
• If operative intervention is chosen;
o anatomic reduction and internal fixation of the clavicle
o Shoulder reimaged to see alignment of glenoid
Alignment is acceptable
No further intervention is
required
“Unacceptable "position
fixation of the glenoid
neck

59. Scapulothoracic Dissociation
 Separation of scapula from the thorax along with the upper
extremity.
 Characterized by a wide range of concomitant injuries
including-
 Clavicle fracture
 Sterno-clavicular dislocation
 Acromio-clavicular dislocation
 Tears of the levator scapulae, rhomboids,trapezius, latissimus
dorsi, pectoralis minor and deltoid muscles.
 Partial or complete avulsion of brachial plexus
 Vascular injuries to subclavian or axillary artery

60. Caused by-
 violent lateral distraction of the shoulder girdle
 rotational displacement of the shoulder girdle

61. Treatment
 scapulo-thoracic dissociation requires
• Internal fixation of clavicular fractures + Stabilization of
disrupted AC or SC joints.
 To prevent brachial plexus, Subclavian, and Axillary vessels
injury.
 To restore stability to the shoulder girdle.

62. Take Home Message
o Scapular fracture should alert the surgeon to presence of
other injuries .
o Sever chest injury should also raise suspicion of possible
scapular injury .