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.
Posterolateral corner injuries of knee joint Samir Dwidmuthe
Missed posterolateral corner injuries of knee joint is a common cause for failure of ACL and PCL reconstruction only next to malpositioned tunnels.
Isolated PLC injuries are uncommon, making up <2% of all acute knee ligamentous injuries. Covey JBJS 2001
Incidence of PLC injuries associated with concomitant ACL and PCL disruptions are much more common (43% to 80%). Ranawat JAAOS 2008
A recent (MRI) analysis of surgical tibialplateau fractures demonstrated an incidence of PLC injuries in 68% of cases. Gardner JOT 2005
Take home message
PLC injuries to be ruled out in every case of ACL& PCL rupture.
Neurovascular integrity to be checked in every case.
Grade I & II can be managed conservatively.
Grade III Acute- Repair.
Grade III Chronic- Anatomic PLC recon.
Beware of varus knee alignment.
Posterolateral corner injuries of knee joint Samir Dwidmuthe
Missed posterolateral corner injuries of knee joint is a common cause for failure of ACL and PCL reconstruction only next to malpositioned tunnels.
Isolated PLC injuries are uncommon, making up <2% of all acute knee ligamentous injuries. Covey JBJS 2001
Incidence of PLC injuries associated with concomitant ACL and PCL disruptions are much more common (43% to 80%). Ranawat JAAOS 2008
A recent (MRI) analysis of surgical tibialplateau fractures demonstrated an incidence of PLC injuries in 68% of cases. Gardner JOT 2005
Take home message
PLC injuries to be ruled out in every case of ACL& PCL rupture.
Neurovascular integrity to be checked in every case.
Grade I & II can be managed conservatively.
Grade III Acute- Repair.
Grade III Chronic- Anatomic PLC recon.
Beware of varus knee alignment.
Elbow is the most common joint to dislocate in children. Posterior dislocation is most common.
Simple dislocations are those without fracture.
Complex dislocations are those that occur with an associated fracture
Defined as fracture occurring at or proximal to the surgical neck
It is the commonest fracture affecting the shoulder girdle in adults.
Proximal humeral fracture 80% of all humeral fractures.
In pts above the age of 65 years, proximal humeral fractures are the 2nd most frequent upper extremity fractures
ANATOMY -
The proximal humerus is retroverted 35 to 40 degrees relative to the epicondylar axis.
Most common is fall onto outstretched upper extremity from a standing height, in older & osteoporotic woman.
Younger pts present following high energy trauma with significant soft tissue injury.
Less common with excessive shoulder abduction, direct trauma, electric shock and seizures r seizures
Hoffa's Fracture: Diagnosis, management & New Classification System by BAGARI...Vaibhav Bagaria
Hoffa's Fracture - coronal split fracture of distal femur, its diagnosis, management strategy, a new classification and tips and tricks of management. First described Hoffa, a new classification system by Bagaria et al helps plan the surgery for these tricky fracture. The most crucial step is not to miss these fractures in ER.
Elbow is the most common joint to dislocate in children. Posterior dislocation is most common.
Simple dislocations are those without fracture.
Complex dislocations are those that occur with an associated fracture
Defined as fracture occurring at or proximal to the surgical neck
It is the commonest fracture affecting the shoulder girdle in adults.
Proximal humeral fracture 80% of all humeral fractures.
In pts above the age of 65 years, proximal humeral fractures are the 2nd most frequent upper extremity fractures
ANATOMY -
The proximal humerus is retroverted 35 to 40 degrees relative to the epicondylar axis.
Most common is fall onto outstretched upper extremity from a standing height, in older & osteoporotic woman.
Younger pts present following high energy trauma with significant soft tissue injury.
Less common with excessive shoulder abduction, direct trauma, electric shock and seizures r seizures
Hoffa's Fracture: Diagnosis, management & New Classification System by BAGARI...Vaibhav Bagaria
Hoffa's Fracture - coronal split fracture of distal femur, its diagnosis, management strategy, a new classification and tips and tricks of management. First described Hoffa, a new classification system by Bagaria et al helps plan the surgery for these tricky fracture. The most crucial step is not to miss these fractures in ER.
Objectives:
-Recognize the anatomy of the proximal tibia
-Describe initial evaluation and management
-Identify common fracture patterns
-Apply treatment principles and strategies for Partial articular fractures and Complete articular fractures
-Discuss rehabilitation and complications
-Learn Management in selected tibial plateau case scenarios
Distal femur fractures are traumatic injuries involving the region extending from the distal metaphyseal-diaphyseal junction to the articular surface of the femoral condyles.
Diagnosis is made radiographically with CT studies often required to assess for intra-articular extension.
Treatment is generally operative with ORIF, intramedullary nail, or distal femur replacement depending on available bone stock, age of patient, and patient activity demands.
Patella Fractures are traumatic knee injuries caused by direct trauma or rapid contracture of the quadriceps with a flexed knee that can lead to loss of the extensor mechanism.
Diagnosis can be made clinically with the inability to perform a straight leg raise and confirmed with radiographs of the knee.
Treatment is either immobilization or surgical fixation depending on fracture displacement and integrity of the extensor mechanism.
Proximal third tibia fractures are relatively common fractures of the proximal tibial shaft that are associated with high rates of soft tissue compromise and malunion (valgus and procurvatum).
Diagnosis is made with orthogonal radiographs of the tibia with CT scan often required to assess for intra-articular extension.
Treatment generally consists of surgical open reduction and internal fixation (ORIF) versus intramedullary nail fixation.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
2. CONTENTS OF CLAVICLE FRACTURE
• EPIDEMOLOGY
• ANATOMY
• MECHANISM OF INJURY
• ASSOCIATED INJURIES
• CLINICAL FEATURES
• IMAGING MODALITIES
• TREATMENT
3. EPIDEMOLOGY
• Clavicle fractures account for approximately 2.6% of all fractures &
44-66% fractures above the shoulder.
• Middle third fractures account for 80% of all clavicle fractures
whereas lateral third fractures account for 15% ,&medial third 5%.
4. ANATOMY
• S shape
• Subcutaneous bone
• No true medullary canal .
• 1st bone to ossify and last to fuse.
• Form by intra membranous ossification.
• Medial 1/3rd protects neuro vascular structures and superior lung.it is
strongest in axial load.
• Distal clavicle contains coracoclavicular ligament (trapezoid & conoid
ligaments) which provides verticular stability to Acromioclavicular
joint.
• Middle 1/3rd is the vulnerable area to fracture, especially with axial
loading as it lacks reinforcement by muscles/ ligaments distal to
subclavian insertion resulting in additional vulnerability.
5.
6.
7. MECHANISM OF INJURY
• In infants -1.birth injury
2.child abuse
• In children & adults-1.direct trauma in high velocity injuries
2.fall on outstretched hand.
3.compression force from the lateral side.
• Rarely secondary to muscle contraction due to seizures or secondary
to minor trauma due to pathological bone or stress fracture .
8.
9. DEFORMING FORCES ON CLAVICULAR FRACTURE
• Pectoralis &wt of arm – lateral fragment
inferiomedially
• SCM-medial fragment
posteriosuperiorly
10. ASSOCIATED INJURIES
• Most brachial plexus injuries are associated with proximal third
clavicle fractures(tractional injury).
• Lung injuries like pneumothorax/hemothorax.
• Head and chest injuries.
• Vascular injuries.
11. CLINICAL EVALUATION
• HISTORY:
• c/o Pain, swelling, bruising, decreased movement of the affected limb.
• Examination : Tenderness, crepitus, pressure on overlying skin palpable.
• PRESENTATION:
-Arm held across the chest with the opposite limb.
-Tilts the head towards the injured limb .
-Shoulder ptosis with droopy medially driven and shortened shoulder
-Shoulder translates and rotates forward.
-Observe for complications like :
• neurovascular injury of affected arm,
• pneumothorax, subcutaneous emphysema.
• Open fractures
19. TYPE-3:
• Fracture of articular surface
• conoid& trapezoid lig intact
• Non operative
20. TYPE -4:
• Periosteal sleeve fracture( in children)
• Conoid& trapezoid lig intact
• nonoperative
21. Type -5:
• Comminuted fracture
• Conoid& trapezoid lig
• attached to communited fragment
• operative
22. • Mechanism of injury
• Associated injuries
• Physical examination
• Imaging modalities
• Applied anatomy
• Treatment options
• Management of complications
Contents of clavicle fracture
23. • In infants
• 1) Birth injury
• 2) child abuse
• In children and Adults
• 1) Direct trauma in high velocity injuries
• 2) fall on out streched hand
• 3) compression force from lateral side
• Non traumatic / simple injures
Mechanism of injuries
25. Physical examination
History
Type of injury
1) Simple
- pathologic
- metabolic
2)Direct fall on shoulder
3)Traction injury(dockyard,
industrial injury –scapulothoracic dissociation)
4) Stress fractures
26. • In standing position – deformity
• Clavicle length measurement
• Vascular and neurological examination
• Patient tilts head towards injury to relax pull of trapezius
• Patient holds involved hand close to chest
• Asymmentric moro reflex
• Baby does not feed from one breast
Physical examination
27. Completely displaced mid shaft fracture
• Shoulder “ptosis,” with a droopy, medially driven, and shortened
shoulder
• In addition, the shoulder translates and rotates forward:
28. • Simple ap chest x ray – emergency
Medial clavicle fracture
• Serendipity view -Medial clavicle fracture with dislocation
• Ct scan
• Lateral clavicle fracture
Stress view – for coracoclavicuar integrity
Zanca’s view – for removing thoracic cage overlap
Imaging modalities
31. • Bone anatomy
• The relatively thin diaphysis is typically hard cortical
bone best suited for cortical screws
• whereas the medial and lateral expansions are softer
cancellous bone where larger pitch cancellous screws
can be inserted without tapping.
Applied anatomy
32. • Medial
• Sc capsule- thick posteriorly , prevent to anterior or
posterior translation of the medial clavicle
• Interclavicular ligament- tension wire :
prevents inferior angulation
• Stout ligaments-primarily resist translation of the
medial clavicle
Ligamentous anatomy
33. • Ac capsule joint
• Thickened superiorly prevent AP displacement
• Cc ligaments
• Trapezoid(lateral)
• Conoid (medial) , prevent superior displacement
Lateral ligaments
34. • Deformity is due to muscle pull and gravity effect
• Medial fragment is elevated by sternocleidomastoid
• lateral fragment is held inferiorly by deltoid and
medially by pectoralis major
Muscle anatomy
35. • supraclavicular nerves originate from cervical roots C3 and C4 and
exit from a common trunk behind the posterior border of the
sternocleidomastoid muscle
• Numbness postoperatively
• Neuroma formation
• Vascular structures at risk
- subclavian vessels
Neurovascular anatomy
36. • Medial – opposed to posterior cortex
• Middle – mean distance of 17 and 13 mm
• Lateral – mean distance of 63 and 76 mm
37. • Non operative
Hippocrates “Edwin smith papyrus’’
Figure of 8 bandage
- temporary lower trunk injury of brachial plexus injury
Arm sling
Treatment options
38. • Very rare
• Can be managed non operatively unless posterior
dislocation
• May dislocate
•anterior (more common)
•posterior (mediastinal structures at risk)
•important to distinguish from medial
clavicle physeal fracture (physis doesn't fuse until
age 20-25)
•MECHANISM
•usually high energy injury (MVA, contact sports)
Medial clavicle injuries
39. •Symptoms
•anterior dislocation
•deformity with palpable bump
•posterior dislocations
•dyspnea or dysphagia
•tachypnea and stridor worse when supine
•provocative maneuvers
•turning head to affected side may relieve
pain
40. • Imaging – serenpidity view , ct scan
• It is important to remember that the subclavian vessels are in close
proximity to the bone medially
• Following identification, debridement, and reduction of the fracture,
it can be temporarily held reduced with K-wires
• Definitive plate fixation
Management
41. • If the medial fragment is large enough, then standard
plate and screw fixation can be performed; a plate
with an expanded end section
• this allows for placement of longer (22 to 24 mm)
cancellous screws
• If there is insufficient purchase, than the plate can be
extended across the joint onto the sternum.
• construct will eventually loosen due to motion
• Rarely, fixation with a hook plate intrasternally or
retrosternally may be required
43. Nonoperative
•sling immobilization
•indications
•< 2cm shortening and displacement
•< 1cm displacement of the superior shoulder suspensory complex
•No neuro vascular injury
•technique
•immobilize using sling or figure-of-eight brace
•prospective studies have not shown a difference in functional or
cosmetic outcomes between sling and figure-of-eight braces
•no attempt at reduction should be made
•after 2-4 weeks begin gentle range of motion exercises
•strengthening exercises begin at 6-10 weeks
Management
45. • This method takes advantage of the intrinsic healing ability of the
clavicle and allows restoration of length and translation without the
scarring or morbidity of a surgical approach
• Unfortunately, the practical difficulties associated with the position
and prominence of the fixation pins, coupled with a lack of patient
acceptance
External fixation
46.
47. • approach
• beach chair or supine
• posterolateral incision 3-4cm
• “retrograde” technique
• instrumentation
• cannulated screw
• specialized screw systems (e.g, Dual Trak)
• titanium elastic nail
• smooth wires
• Locking im nail
• Contraindications
• substantial comminution
• segmental fractures
Closed Reduction and Intramedullary Fixation
48.
49.
50. • advantages
• smaller incision
• less soft-tissue disruption
• less prominent hardware
• avoids the supraclavicular cutaneous nerves commonly
injured with plating
• disadvantages
• higher complication rate including hardware migration,
hardware breakage, temporary brachial plexus palsy, and
skin breakdown over the entry portal
• Since no lock- failure to control axial length and rotation
• biomechanically inferior to plating
• (maximal load, cyclical stress)
51. delayed if required
•approach
•beach chair vs. supine
•direct superior vs. anterior incision
•instrumentation
•most common
•limited contact, pre-controured, dynamic compression plate
•k-wires for preliminary fixation
•Lag screw for vertically oriented anterosuperior fragment
•other options
•3.5mm reconstruction plate
•locking plates
Open Reduction Internal Fixation with plating
52. Anteroinferior
easier screw trajectory
ability to insert longer screws in
the wider AP dimension
easier to contour a small-fragment
compression plate
plate tends to
obscure the fracture site
radiographically
Anterosuperior.
• general familiarity
• ability to extend it simply to both
the medial and lateral ends
• benefit of clear radiographic views
of the clavicle postoperatively.
• length of screws inserted range
from 14 to 16 mm in females to 16
to 18 mm in males
53. • If a lag screw has been placed, it is usually sufficient to secure the
fracture with three bicortical screws (six cortices) both proximally and
distally.
• If lag screw not possible, four screws should be inserted both
proximally and distally
• stable configuration, compression holes can be used to apply
compression
• comminuted or of an unstable pattern, then the plate should be
applied in a “neutral” mode
• Valsalva manouere
54. •advantages
•improved results with ORIF for clavicle fractures with > 2cm
shortening and > 100% displacement
•improved functional outcomes/less pain with overhead
activity
•faster time to union
•decreased symptomatic malunion rate
•improved cosmetic satisfaction
•improved overall shoulder satisfaction
•increased shoulder strength and endurance
•disadvantages
•increased risk of need for future procedures
•implant removal
•debridement for infection
55.
56. • Nonoperative
• sling immobilization with gentle ROM exercises at 2-4 weeks and
strengthening at 6-10 weeks
• indications
• stable fractures (Neer Type I, III, IV)
• pediatric distal clavicle fractures (skeletally immature)
Lateral clavicular fractures
57. Operative
•open reduction internal fixation
•indications
•absolute
•open or impending open fractures
•subclavian artery or vein injury
•floating shoulder (distal clavicle and scapula neck fractures
with > 10mm of displacement)
•symptomatic nonunion
•relative
•unstable fracture patterns (Neer Type IIA, IIB, V)
•brachial plexus injury (questionable because 66% have
spontaneous return)
•closed head injury
•seizure disorder
•polytrauma patient
58. Open Reduction Internal Fixation with plate or hook plate
•position
•beach chair vs. supine
•approach
•superior approach to AC joint
•temporary fixation with k wires
•instrumentation
•locking plates
•precontoured anatomic plates
• hook plates vary in hook depth and number of holesproper hook depth
ensures the AC joint is not over- or under-reduction
•Since the primary deforming force at the fracture site is superior
displacement of the proximal fragment
59. • The fracture is reduced and it may be held with either
a K-wire or a lag screw
• larger distal fragment needed for multiple locking screws
• > 3-4 bicortical screws into medial fragment should be the goal
to reduce the risk of screw pull-out
• If fixation is judged to be inadequate- long screw typically 30 to
40 mm long, helps secure the proximal fragment to the
coroacoid and prevents this superior displacement
• it may be necessary to augment fixation by using a hook plate
with fixation under the acromion to prevent superior migration
of the proximal fragment
60. hook plate
•technique
•hook plates are generally used when there is insufficent bone in the distal
fragment for conventional clavicle plate fixation
•An entrance into the subacromial space is then made with a pair of heavy
curved scissors
•this space is made posteriorly, so that there will be no impingement of the
rotator cuff
•the hook should be placed posterior to AC joint and positioned as far lateral as
possible to avoid hook escape
•> 3-4 bicortical screws should be placed into the proximal (medial) fragment to
reduce the risk of screw pull-out
•Alternatively, the plate can be “walked down”
•onto the clavicular shaft by sequential placement of the screws from distal to
proximal
•Hook plate allows some motion at ac joint unlike static fixation
61. • ipsilateral fractures of the clavicle and scapular neck
• ‘1. A clavicle fracture that warrants, in isolation, fixation
• 2. Glenoid displacement of greater than 2.5 to 3 cm
• 3. Displaced intra-articular glenoid fracture extension
• 4. Patient-associated indications (i.e., polytrauma with a requirement for
early upper extremity weight bearing)
• 5. Severe glenoid angulation, retroversion, or anteversion >40 degrees
(Goss Type II)
• 6. Documented ipsilateral coracoacromial and/or AC ligament disruption or
its equivalent (coracoid fracture, i.e., AC joint disruption)
Floating shoulder
63. • Associated injuries
• Signs and symptoms
• Physical examination
• Imaging modalities
• Treatment options
• Management of complications
• Role of arthroscopy
Ac joint injury
64. • Glenohumeral Intra-Articular Pathology
• grade III to V injuries, arthroscopic evaluation determined superior
labral anterior to posterior (SLAP) lesion
• As there is overlapping innervation to this region of the shoulder
through the lateral pectoral and suprascapular nerves it may be
difficult for the patient to completely localize their pain
Associated injuries
65. • Fractures
• Distal clavicle fracture
• base or neck of the coracoid process
• clavicle shaft in conjunction with an AC joint
separation
• Bipolar Injuries: AC and SC Joint Dislocations
• Floating clavicle
• SC is anteriorly displaced and AC posteriorly displaced
• Bilateral (Balser) hook plates
• Branchial plexus injuries – Rare
• Scapulothoracic Dissociation
66. • CC Ossification
• Secondary to healing
• No pain , only radiological finding
• must be removed to facilitate full reduction of the AC joint
and CC distance at the time of operative intervention
• OSTEOLYSIS OF DISTAL CLAVICLE
• pain at the AC joint with cross-arm adduction and
overhead lifting.
• repeated microtrauma with a recurrent inflammatory
process was part of the etiology
• rheumatoid arthritis, hyperparathyroidism, and
scleroderma – if bilateral
• Gorham’s massive osteolysis, gout , multiple myeloma
67. • Symptoms
• pain
• usually over AC joint
• can also be referred to the trapezius
• After pain subsided -deformity
• lateral clavicle or AC joint tenderness
• abnormal contour of the shoulder compared to
contralateral side
• stability assessment
Signs and symptoms
68. • Diffuse Shoulder Pain—anterolateral neck, Ac joint,
anterolateral deltoid Point tender at Ac joint ±
deformity (prominence) Positive
• cross-arm adduction test (arm flexed 90 degrees,
adducted across chest) produces compression pain
localized to Ac joint
• O’Brien’s active compression test with
localized pain over AC joint
• Paxinos test (thumb pressure directed anterior at the
posterior Ac joint
69. • clinical triad
• point tenderness at the AC joint
• pain exacerbation with cross-arm adduction,
• relief of symptoms by injection of a local anesthetic agent
70. Radiographs
bilateral anteroposterior (AP) view of AC joints
•In standing position to detect deformity
•compare displacement to contralateral side
•measured as distance from top of
coracoid to bottom of clavicle
•use 1/3 penetration on AP to visualize AC
joint
•axillary lateral view
•required to diagnose Type IV (posterior)
•zanca view
•Stress view gives integrity of deltopectoral fascia
71. • Stryker Notch View A variant of an AC joint injury
involves a fracture of the coracoid process
• cross-arm stress view—Basmania view (AP with arm
adducted)
72. •brief sling immobilization, rest, ice, physical therapy
•indications
•type I and II
•type III in most individuals
•good results when clavicle displaced < 2cm
•rehab
•early shoulder range of motion
•regain functional motion by 6 weeks
•return to normal activity at 12 weeks
•consider corticosteroid injections
•outcomes
•type III treated non-op had higher DASH scores at 6 weeks and
3 months, and equal function at 1 year with lower rate of
secondary surgery (removal of hardware) compared to those
treated operatively
•complications
•AC joint arthritis
•chronic subluxation and instability
Nonoperative
73. Cc interval restoration (ORIF vs. Ligament Reconstruction)
•indications
•acute type IV, V or VI injuries
•acute type III injuries in laborers, elite athletes, patients with cosmetic
concerns
•chronic type III injuries that failed non-op treatment
•historically it was thought acute injuries were treated with ORIF and
chronic injuries were treated with CC ligment reconstruction
•contraindications
•patient unlikely to comply with postoperative rehabilitation
•skin problems over fixation approach site
•First method is pins and screw fixation
operative
74. •has fallen out of favor
•technique
•screw placement from distal clavicle to coracoid, superior to
inferior
•pros
•rigid internal fixation
•cons
•danger of screw being too long and damage to critical structure
below coracoid
•routine screw removal at 8-12 weeks is advised to prevent screw
breakage
•due to normal motion between clavicle and scapula
•complications
•hardware irritation & failure at level of screw purchase in coracoid
ORIF with CC screw fixation
(Bosworth screw)
75. •technique
•suture placed either around or through clavicle and around the base of the
coracoid
•can also use suture anchors for coracoid fixation
•pros
•no risk of hardware failure or migration
•
•cons
•suture not as strong as screw fixation
•requires careful suture passage inferior to coracoid due to proximity of crucial
neurovascular structures
•complications
•suture erosion causing distal third clavicle fracture
•hardware irritation
ORIF with CC suture fixation
76. • ORIF with AC pin fixation (Phemister Technique)
• approach
• can be done percutaneously
• technique
• smooth wire or pin fixation directly across AC joint
• cons
• hardware irritation
• complications
• high incidence of pin migration
• generally not performed due to high complication rates
77. ORIF with AC hook plate fixation
•approach
•exposure of distal and middle clavicle
•technique
•use of standard hook plate over superior distal clavicle
•pros
•rigid fixation
•cons
•requires second surgery for plate removal
•complications
•acromial erosion , fracture
•hook pullout
78. CC ligament reconstruction with coracoacromial (CA) ligament
(Modified Weaver-Dunn)
•approach
•proximal aspect of anterolateral approach to the shoulder
•arthroscopic technique also described
•technique
•distal clavicle excision
•transfer of coracoacromial ligament to the distal clavicle to
recreate CC ligament
•reinforce with internal fixation
•cons
•coracoacromial ligament only 20% as strong as normal CC
ligament
•lack of internal fixation risks failure of soft tissue repair
79.
80. •Technique
• Saber incision
• The deltotrapezial fascia is then elevated from the distal clavicle as
full-thickness flaps
•. Tagging stitches are placed in the flaps to aid in retraction and then
facilitate accurate reapproximation at closure
•figure-of-eight passage of graft, looping around coracoid and
fixation through clavicular tunnels
•reinforce with internal fixation
CC ligament reconstruction with free
tendon graft
81. • Bone tunnel placement
• Guide pin placement for the conoid ligament tunnel is placed 45 mm
medial to the distal clavicle and posterior to the midline of the
clavicle in the coronal plane
• A second pin is placed lateral to the conoid pin by 20 mm and just
anterior to the clavicle midline again in the coronal plane-trapezoid
• should not be less than 15 mm from the end of the clavicle
• minimum of 20-mm bone bridge between the tunnels to prevent
fracture
• placed at least 3 mm from the edge of the clavicle toward the
midline
• “ream-in, pull-out” technique , made eccentrically
• made eccentrically
82. • type IV AC joint dislocation the bone tunnel positions can be adjusted
more posterior to the midclavicle line – anterior vector
• graft autograft
• palmaris longus
• semitendinosus
• allograft
• tibialis anterior
•pros
• graft reconstruction more closely recreates strength of native CC
ligament
•cons
•standard risks of allograft use or autograft harvest
•lack of internal fixation risks failure of soft tissue repair
83. • Migration of Pins in Acromioclavicular Joint Injuries
• AC arthritis
• more common with surgical management than with nonoperative treatment
• Hardware failure
• CC screw breakage/pullout
• Coracoid fracture
• can occur with coracoid tunnel drilling
• Clavicle fracture
• Failure of Soft Tissue Repairs in Acromioclavicular Joint Injuries
Complications
84. • The coracoid was visualized through the subcoracoid recess
• release the coracoacromial ligament from the undersurface of the
acromion and transfers it to the inferior clavicle
• Latest progression-anatomic placement of two suture–button devices
corresponding to the position of the ruptured trapezoid and conoid
ligaments using two independent 3.5-mm clavicle and coracoid bone
tunnels
Arthrosccopic repair