Clavicle and scapular fractures are significant injuries, accounting for a notable percentage of shoulder girdle fractures, with various types and classifications based on their location and displacement. Non-operative treatment is often sufficient for certain types of fractures, while operative options include stabilization techniques for more severe cases, especially when accompanied by complications or associated injuries. Comprehensive evaluation using radiographic techniques is crucial for accurate diagnosis and determining the appropriate treatment plan.

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 .