2. Acromioclavicular joint
• Diarthrodial joint
• Formed by articulation of facets at lateral end of
clavicle and on the medial margin of acromion
process of scapula
• Facets are covered with fibrocartilage
5. Epidemiology
• Most common in second decade of life associated
with contact athletic activities
• Represent 9% to 10% of acute traumatic injuries to
shoulder girdle
• M:F(approximately 5:1)
9. Clinical Evaluation
• Pain
• Swelling
• Downward sag of shoulder and arm
• Step-off deformity of injured AC joint
• Skin tenting overlying distal clavicle
• Tenderness over AC joint
• Range of shoulder motion may be limited
10. Radiographic Evaluation
Standard trauma series of shoulder
• Anteroposterior
• Scapular-Y
• Axillary view
Zanca view
Stress radiograph
Magnetic resonance imaging
11. Type III Injury
• Coracoclavicular interspace is significantly (25% to
100%) greater than in the normal shoulder
12. Type IV Injury
• Posterior displacement of distal clavicle seen on
axillary lateral radiograph
13. Type V Injury
• Marked increase (100% to 300%) in
coracoclavicular distance
14. Type VI Injury
Inferior acromioclavicular dislocation
• Subacromial:- Decreased Coracoclavicular distance
and distal clavicle in subacromial location
• Subcoracoid:- Reversed coraco clavicular
distance and clavicle displaced inferior to
coracoid process
15. Treatment
Type I
• Rest for 7 to 10 days
• Ice packs
• Sling
• Refrain from full activity until painless
• Full range of motion in 2 weeks
16. Type ll
• Sling for 1 to 2 weeks
• Gentle range of motion as soon as possible.
• Refrain from heavy activity for 6 weeks
25. Sternoclavicular joint injury
• Diarthrodial joint
• Both articular surface are covered with
fibrocartilage
• True articulation between upper
extremity and axial skeleton
26. Epidemiology
• Rare
• Cave et al. reported that of 1,603 shoulder girdle
dislocations, only 3% were sternoclavicular , with
85% glenohumeral and 12% acromioclavicular
dislocations
• Approximately 80% of dislocations caused by either
motor vehicle accident (47%) or sports related
(31%)
27. Mechanism of injury
Direct
• Force applied to the anteromedial aspect of clavicle
forces the clavicle posteriorly into mediastinum to
produce posterior dislocation
Indirect
28. Clinical Evaluation
• Patient typically presents supporting affected
extremity across the trunk with contralateral
uninjured arm
• Swelling
• Tenderness
• Painfull range of shoulder motion
• Neurovascular status
33. Treatment
Mild sprain
• Ice
• Sling immobilization for 3 to 4 days and agradual
return to normal activities as tolerated
Moderate sprain or subluxation
• Ice
• clavicle strap, sling and swathe, or figure of eight
bandage for 1 week
• Sling immobilization for 4 to 6 weeks
34. Severe sprain or dislocation
Anterior dislocation
• Closed reduction
• Postreduction:- Clavicle strap, sling and swathe, or
figure-of-eight bandage for 4 to 6 weeks
• Bulky anterior dressing with elastic tape
35. Posterior dislocation
• Closed or open reduction
• Postreduction:- Clavicle strap, sling and swathe, or
figure-of-eight bandage for 4 to 6 weeks
36. Technique for closed reduction of
Sternoclavicular joint
• Abduction Traction Technique
39. Posterior Physeal Injuries of
Medial Clavicle
• Closed reduction
• Postreduction:- Clavicle strap, sling and swathe, or
figure-of-eight bandage for 4 to 6 weeks
• Open reduction in cases of redislocation
40. Operative management
Fixation of the medial clavicle to the sternum
• Using fascia lata, subclavius tendon or suture
• Osteotomy of the medial clavicle
• Resection of the medial clavicle
43. Scapula fracture
Flat triangular bone that lies on the posterior thorax
wall between 2-7 rib
Enveloped by
• Supraspinatus muscle
• Infraspinatus muscle
• Subscapularis muscle
Attached to clavicle at acromioclavicular joint
Articulate with humerus at glenohumeral joint
45. Epidemiology
• Represent 3% to 5% of shoulder fractures and 0.4%
to 1% of all fractures
• Mean age:- 35 to 45 years
46. Mechanism of injury
• Direct blow to scapula
• Impact of humeral head on Part of Scapula
• Dislocation of humeral head
• Muscle contracture
• Other injury mechanisms
• Intensity of trauma energy
47. Associated injuries
• Occurs in 35% to 98%
• Fractures of ribs :- 27% to 65%
• Injuries to thoracic cavity and lungs:- 16% to 67%
• Injuries to shoulder girdle:- 8% to 47%
• Injuries to major blood vessels :- 10% to 15%
• Head injuries:- 10% to 42%
• Pelvic njuries:- 15% to 20%
• Spine injuries :- 4% to 70%
48. Clinical Evaluation
• Patient typically presents with upper extremity
supported by contralateral hand in an adducted
and immobile position
• Painfull range of motion especially shoulder
abduction
• Careful examination for associated injures
• Neurovascular assessment
• Compartment syndrome :- Comolli sign
49. Radiographic Evaluation
Chest x-ray anteroposterior view
Standard trauma series of shoulder
• Anteroposterior
• Scapular-Y
• Axillary view
Stryker notch radiograph
Computed tomography
50. Anatomic alphanumeric
classification
Fractures of processes
• IA-Acromion fractures
• IB-Scapular spine fractures
• IC-Coracoid process fractures
Fractures of the neck
• IIA-Fracture of surgical neck
• IIB-Trans-spinous fractures of neck
• IIC-Fractures of neck, inferior to scapular spine
Fractures of the glenoid
Fractures of the body
51. Anatomic 3D CT Classification
• Fractures of scapular body
57. Classification of Coracoid
Fractures (Ogawa et al.)
• Type I: Proximal to the coraco clavicular
ligament
• Type II: Distal to the coraco clavicular
ligament
60. • Sling immobilization for 2 weeks
• Passive range of motion exercises
• Active range of motion from 2nd month
• Strengthening exercises from 3rd month
66. Type IV
• Open reduction for displaced fractures especially in
uperior fragment of glenoid displaces laterally
Type V
• Nonoperative treatment with early motion
• Operative management for articular step-off >5
mm
67.
68. Scapular body fracture
Nonoperative:-
• Immobilize the shoulder for 2 to 3 weeks
• Active-assisted range-of-motion protocol
• Active range-of-motion program
• Strengthening exercises
Operative fixation when neurovascular compromise
and significant displacement
69.
70. Glenoid neck fracture
• Nonoperative and early range-of-motion exercises
• Operative for associated displaced clavicle fracture
71. Acromion fracture
• Dorsal tension banding for displaced fracture
causes subacromial impingement
Coracoid fracture
• Open reduction and internal fixation
73. Floating shoulder
• Traumatic disruption of two or more components
of superior shoulder suspensory complex
• Operative management because of potential
instability and displacement of glenoid
• Glenopolar angle <30 degrees may predispose to
poorer results
74.
75. Scapulothoracic Dissociation
• Traumatic disruption of scapula from posterior
chest wall
• Rare
• life-threatening injury
• Associated with fracture or dislocation of
shoulder or without obvious bone
injury
76. Neurovascular injury:- Common
• Complete brachial plexopathy: 80%
• Partial plexopathy: 15%
• Subclavian or axillary artery: 88%
77. Diagnosis
• Massive swelling of shoulder region
• Pulseless arm
• Complete or partial neurologic deficit
• Lateral displacement of the scapula on nonrotated
chest radiograph
78. Classification
• Type I: Musculoskeletal injury alone
• Type IIA: Musculoskeletal injury with vascular
disruption
• Type IIB: Musculoskeletal injury with neurologic
impairment
• Type III: Musculoskeletal injury with both
neurologic and vascular injury
79. Initial Treatment
• Advanced trauma life support protocols
• Angiography of the limb with vascular repair and
exploration of brachial plexus
• Stabilization of associated bone or joint injuries
80. Later treatment
Neurologic
• At 3 weeks:- Electromyography
• At 6 weeks:- Cervical myelography or magnetic
resonance imaging (MRI)
Osseous
• Shoulder arthrodesis and/or above elbow
amputation if limb is flail
81. Intrathoracic dislocation of
scapula
• Inferior angle of scapula locked in intercostal space
• Extremely rare
• Chest computed tomography
• Treatment:- Closed reduction and immobilization
with sling and swathe for 2 weeks, followed by
progressive functional use of shoulder and arm
