orthopedics subject

1. Anatomy review
The clavicle is an irregular S-shape.
Subcutaneous bone.
No true medullary canal.
Middle 1/3 is narrowest, no muscle
insertion (most common location of
fracture).
Form by Intramembranous ossification.
First bone to ossify and last to fuse.
It articulates with the manubrium of the
sternum medially through SC joint, and to
the acromion of the scapula laterally
through AC joint.
It is also stabilizied by the coracoclavicular
CC ligaments (conoid and trapezoid), and
costocalavicular ligament (medially)

2. Clavicular fracture
&
Acromio-Clavicular joint injury

3. Clavicular fracture

4. Mechanism of injury
Fall onto the shoulder
(87%)
direct blow to lateral aspect
of shoulder 6%
fall on an outstretched arm
or direct trauma

5. Classification:-
Allman with Neer’s modification

6. Group I (Middle third) 80%
Non-Displaced :-
Less than 100% displacement
Non-operative
displaced :-
Greater than 100% displacement
Nonunion rate of 4.5%
operative

7. Group II -Lateral third (10-15%)

8. Type 1 minimal
displacement
(interligamentus)
• Stable because conoid
and trapezoid
ligaments remain
intact
• Nonoperative

9. Type II displaced 2ndry to
a fracture line medial to
the CC ligament
Type II A :-
conoid and trapezoid
attached (fracture medial to
CC ligaments)
Medial clavicle unstable
Up to 56% nonunion rate with
nonoperative management
Operative

10. Type II B :-
conoid torn, trapezoid attached (fracture
between the CC ligaments)
Medial clavicle unstable
Up to 30-45% nonunion rate with
nonoperative management
Operative

11. Type III
fracture of the articular surface
Conoid and trapezoid intact therefore stable
injury
Non-operative

12. Type IV
periosteal sleeve fracture (children)
Conoid and trapezoid ligaments remain
attached to periosteum and overall the
fracture pattern is stable
Non-operative

13. Type V
Comminuted fracture
Conoid and trapezoid ligaments remain
attached to comminuted fragment
Medial clavicle unstable
Operative

14. Presentation:-
Symptoms
anterior shoulder pain
Physical exam
Deformity
perform careful neurovascular exam
tenting of skin (impending open fracture)
Associated injury
ipsilateral scapular fracture
scapulothoracic dissociation
rib fracture
pneumothorax
neurovascular injury

17. deformity forces on
clavicular fracture
•the sternocleidomastoid
muscle pulls the medial
fragment posterosuperiorly
•pectoralis and weight of
arm pull the lateral
fragment inferomedially

18. Diagnosis
plain X-ray:-
• standard AP view of bilateral shoulders to measure clavicular
shortening
• 15° cephalic tilt (ZANCA view) determine superior/inferior
displacement
CT scan
• may help evaluate displacement, shortening, comminution, articular
extension, and nonunion
• useful for medial physeal fractures and sternoclavicular injuries

20. Treatment
Non-operative
sling immobilization with gentle
ROM exercises at 2-4 weeks and
strengthening at 6-10 weeks.
Operative
• Closed Reduction,
Intramedullary Fixation
• Open Reduction, Plate and
Screw Fixation

21. Indications:
• minimally displaced.
• shortening and displacement <2cm
• no neurologic deficit
Indications:
absolute
• open fxs
• displaced fracture with skin tenting
• subclavian artery or vein injury
• floating shoulder (clavicle and scapula neck fx)
• symptomatic nonunion
• symptomatic malunion
• unstable fracture patterns (Type IIA, Type IIB, Type
V)
relative and controversial indications
• displaced Group I (middle third) with >2cm
shortening
• bilateral, displaced clavicle fractures
• brachial plexus injury (questionable b/c 66% have
spontaneous return)
• closed head injury
• seizure disorder
• polytrauma patient

23. Close reduction and intramedullary fixation
(titanium elastic nail)
Advantage:-
1. Small incision and less soft tissue disruption
2. Less prominent
3. Avoid supraclavicular cutaneous nerve injury
Disadvantage:-
1. Hardware migration
2. Biomechanically inferior to plating

27. Open Reduction, Plate and Screw Fixation
Superior of anteroinferior plating
Hook plate

31. complications

32. Non-operative complication
1-non-union
Risk factor:-
• Fracture comminution
• Fracture displacement
• Smoker
• Advancing age

34. 2-mal-union
shortening >3cm, angulation >30 degrees, translation >1cm
Complains:-
• increased fatigue with overhead activities
• thoracic outlet syndrome
• dissatisfaction with appearance
• difficulty with shoulder straps, backpacks

37. Operative complication

38. 1-infection

39. 2-hardware prominence

40. 3-Mechanical failure

43. 4-neurovascular injury
superior plates associated with increased risk of subclavian artery or vein penetration.
5-pneumothorax.
6-non-union.
7-adhesive capsulitis.

44. Acromioclavicular joint injuries
(A.C separation)

45. Anatomy
• AC joint is a synovial joint with a fibrocartilaginous disk.
• It has thin capsule that is stabilized by sup. Inf. Ant. and post.
Ligaments.
• superior and posterior ligaments are most important.
• Vertical stability is provided by the CC ligaments:-
• Trapezoid insert 3cm from end of clavicle.
• Conoid insert 4,5cm from end of clavicle.
• Normal AC joint are 5 to 6 mm in width.
• Normal CC distance is 1,1 cm to 1,3 cm.

47. Mechanism of injury
• Fall on shoulder or
direct blow to the
acromion with arm
adducted. (most
common)
• Fall on outstretched
arm transmitted to AC
joint.
• Rugby and hockey
players frequently
sustained this injury.

48. The Rockwood classification

49. Type 1
Sprain of the A.C joint
only

50. Type 2
A.C joint and capsule are
disrupted.
C.C ligaments are intact.
Less than or equal to 50%
vertical subluxation of the
clavicle.
The C.C interval is slightly
increase (<25%).
reducible.

51. Type 3
Rupture of both ACJ and
CC ligaments.
Complete loss of contact
between clavicle and
acromion.
CC interval is increased
from 25-100%.
Reducible.

52. Type 4
Rupture of ACJ and CC
ligaments with
displacement of clavicle
posteriorly through
trapezoid.
not reducible.

53. Type 5
Rupture of both ACJ and
CC ligaments with gross
displacement of the ACJ
and detachment of
deltoid and trapezius.
not reducible.

54. Type 6
Subcoracoid
displacement of the
clavicle.
Rare.
not reducible.

55. • Symptoms
pain
• Physical exam
palpate for lateral clavicle or AC joint tenderness.
observe for abnormal contour of the shoulder compared to
contralateral side.
prominence of the distal calvicle

57. Imaging
• bilateral AP view (compare displacement to contralateral side).
• 15 cephalic tilt (zanca view) to evaluate joint displacement and intra-
articular fracture.
• Axillary view is mandatory to determine AP displacement

62. Treatment:-
Non-operative:-
ice, rest and sling for 3 weeks.
regain functional motion by 6 weeks.
return to normal activity at 12 weeks.
• Indication:-
type 1, 2, and type 3 if displacement less than 2cm.

63. Operative:-
Indication:-
• Type 4, 5, 6
• Type 3 in athletes, and those with cosmetic concern.
rehabilitation
• sling immobilization without abduction for 6 weeks
• no shoulder ROM for 6 weeks
• generally return to full activity after 6 months

64. ORIF with Bosworth CC
screw fixation
Advantage:
Provide rigid fixation.
Disadvantage
1. Hardware irritation
2. Hardware failure
3. routine screw removal at 8-12wk is
advised to prevent screw breakage

65. ORIF with CC suture
fixation
Advantage:-
ORIF with CC suture fixation.
Disadvantage:-
• suture not as stronger as screw fixation.
• suture erosion causing distal third clavicle
fracture.

66. ORIF with hook plate
Advantage:-
rigid fixation
Disadvantage:-
acromial erosion.
hook pullout.
require second surgery for plate
removal.

67. CC ligament reconstruction
(Modified Weaver-Dunn)

68. Endobutton (minimal invasive)

69. CC ligament reconstruction
with free tendon graft
Advantage:-
graft reconstruction more closely
recreates strength of native CC
ligament

70. Complications:-
1. Residual pain at AC joint in 30-50%
2. AC arthritis:- more common with surgical management than with
nonop.
3. CC screw breakage/pullout