This document discusses injuries to the acromioclavicular joint, sternoclavicular joint, and scapula. It describes the anatomy, mechanisms of injury, classifications, clinical and radiographic evaluation, treatment options including non-operative and operative management, and potential complications for each type of injury. Surgical procedures are outlined for repair or reconstruction depending on the severity of the injury.

1. Acromioclavicular joint
injury, Sternoclavicular
joint injury and Scapula
fracture
Presenter
Dr. Prakash Singh JR1
Department of orthopaedic surgery
KMCTH

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

4. Acromioclavicular ligaments
• Anterior
• Posterior
• Superior
• Inferior
Coracoclavicular ligaments
• Conoid
• Trapezoid

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)

6. Mechanism of injury
Direct
• Fall onto the shoulder with arm adducted
Indirect

7. Associated Fractures and Injuries
Fractures
• Clavicle
• Acromion process
• Coracoid process
Injuries
• Pneumothorax
• Pulmonary contusion

8. Rockwood classification

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

17. Type lll
Non operative
• Sling
• Early range of motion
Operative
• Stabilization

18. Types IV–VI
• Open reduction and surgical repair or
reconstruction of the coracoclavicular ligaments

19. Procedures for surgical treatment
• Acromioclavicular reduction and fixation
• Acromioclavicular reduction, coracoclavicular
ligament repair and coracoclavicular fixation
• Combination of first two categories
• Distal clavicle excision
• Muscle transfers
• Arthroscopic Treatment

20. Bosworth screw suspension
technique

21. Acromioclavicular hook plates
fixation technique

22. Transfer of acromial attachment of
coracoacromial ligament (Modified
Weaver and Dunn technique)

23. Mazzocca anatomic coracoclavicular
reconstruction

24. Complications
• Coracoclavicular ossification
• Distal clavicle osteolysis
• Acromioclavicular arthritis

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

29. Radiographic Evaluation
• Anteroposterior chest radiograph
• Hobbs view
• Serendipity view

30. • Computed Tomography
• Magnetic Resonance Imaging
• Ultrasonography
• CT Angiography

31. Classification
Anatomic
• Anterior dislocation
• Posterior dislocation
• Physeal inury

32. Etiologic
• Sprain or subluxation
• Acute dislocation
• Recurrent dislocation
• Unreduced dislocation
• Atraumatic

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

37. Adduction Traction Technique
(Buckerfield–Castle Technique)

38. Direct Reduction with Towel Clip

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

41. Semi-tendinosus figure-of-eight
reconstruction

42. Complications
• Poor cosmesis
• Tracheal compression
• Pneumothorax
• Laceration/compression of great vessels
• Brachial plexus injury/compression
• Esophageal rupture
• Voice changes

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

44. Anatomy of scapula

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

52. Fractures of scapular neck

53. Types of glenoid fractures

54. Fractures of scapular processes

55. Ideberg Classification of Intra-
Articular Glenoid Fractures

56. Classification of Acromion
Fractures (Kuhn et al.)

57. Classification of Coracoid
Fractures (Ogawa et al.)
• Type I: Proximal to the coraco clavicular
ligament
• Type II: Distal to the coraco clavicular
ligament

58. Treatment

59. Nonoperative treatment
Indications:-
• Undisplaced or minimally displaced fractures
• Displaced fractures in patients with poor local soft
tissue or general condition

60. • Sling immobilization for 2 weeks
• Passive range of motion exercises
• Active range of motion from 2nd month
• Strengthening exercises from 3rd month

61. Indications of operative treatment

62. Surgical approach
• Judet posterior approach
• Dupont–Evrard posterolateral approach
• Deltopectoral Approach

63. Judet posterior approach

64. Deltopectoral approach

65. Glenoid fractures treatment

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

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

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

72. Complications
• Associated injuries
• Malunion
• Delayed union
• Nonunion
• Suprascapular nerve injury
• Rib nonunion

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

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

82. Thank you