Superior Shoulder Suspensory Complex injuries

1. Zonal CME
conducted at GSLMC
DR.S.JAGANMOHAN
M.S,D.N.B. ORTHO, FELLOW ARTHROPLASTY
ASSISTANT PROFESSOR , DEPT. OF ORTHOPAEDICS
GSL MEDICAL COLLEGE AND HOSPITAL

2.  Introduction
 Definition
 Related anatomy
 Pathoanatomy
 Investigations
 Treatment options
 Conclusion

3.  Ganz and Noesberger 1975 -The Floating
Shoulder - the ipsilateral glenoid surgical
neck and midshaft clavicle fracture
 Goss 1993 introduced the concept Superior
shoulder suspensory complex

4.  Described as a bony / soft tissue
ring at the end of a superior and
inferior bony strut
 Bony struts :
The superior strut
The inferior strut
 The ring is composed of the
glenoid fossa, coracoid process,
coracoclavicular ligaments, distal
clavicle, acromioclavicular joint
and the acromial process.
 Function: This complex maintains a
normal stable relationship
between the scapula and the axial
skeleton

5.  Double disruption:
There should be injury to any two
structures
 Depending on the structure
injured in SSSC that could lead to
instability it is subdivided into
1. Clavicular - acromio clavicular
joint - acromion strut
2. Clavicular – coraco clavicular
ligament- coracoid C4 linkage
3. The three processes scapular
body junction
clavicular-acromioclavicular
joint-acromial strut
C4
The three-process-scapular body junction

6.  Fractures of the surgical neck
of the scapula produce
 D. Distal fragment consisting
of the glenoid and the
coracoid process and
 P. Proximal fragment
consisting of the acromion,
scapular spine and scapular
body.
D
P
P
Anterior view Posterior view

7.  The distal fragment is
attached to the proximal
fragment by coracoacromial
ligament and to the axial
skeleton, through the
clavicular shaft, by the
coracoclavicular ligament.
 To produce a floating shoulder
(scapula) - damage to these
attachments is needed.
D
P
P
P

8. Surgical neck
Lateral Clavicle acromial strut
C4 coracoid , coraco clavicular lig and
Its attachment to clavicle
Surgical neck of scapula

9. AC joint C4
Acromion
C4

10.  The scapular neck fracture is displaced inferiorly
as well as anteromedially by the altered muscle
forces and the weight of the upper extremity.
 And If significant displacement occurs at either
or both sites, there may be problems with
healing, such as delayed union, malunion and
nonunion
 Malunion is common

11.  Drooping of shoulder- deformity
 Brachial plexus pressure
 Relationship of the glenohumeral joint
with the acromion is altered, creating
a functional imbalance
 Decreased range of motion
 Loss of normal lever arm of the rotator
cuff (length)
 Results in weakness on abduction and
subacromial pain are common
Drooping of shoulder

12.  Most are following Road traffic injuries
 High energy injuries
 Polytrauma associated with chest injuries
pneumo/ haemo thorax, rib fractures

13.  Recommended views of shoulder
1. Anteroposterior view ( weight bearing)
2. Lateral view
3. Axillary view or trauma axillary view

16. Standard axillary Alternative axillary views

19. In ring structure concept, like the pelvis, it is
more reasonable to think if the ring is broken in
one area and the fragments displaced, then
there must be a fracture or dislocation in another
portion of the ring.

21.  Conservative treatment : supported by recent papers
 Edwards (jbjs2000) : Reported excellent results in 20 treated
nonoperatively by a shoulder immobilizer.They recommend
conservative treatment, especially in patients with less than 5-mm
displacement.
 Van Noort et al ( injury and octa ortopaedica 2005, 2006) In a
retrospective study, reported fair to good results in 28 patients treated
conservatively with a well-aligned glenoid.
The authors concluded conservative treatment leads to a good functional
outcome in the absence of caudal displacement of the glenoid.
Caudal displacement was defined as an inferior angulation of the glenoid
of at least 20 degrees

22.  Surgical management:
 Goss 1993, recommended stabilisation of both sides and stated that
conservative treatment causes drooping of the shoulder
 Ada and Miller reported a high incidence of rotator cuff dysfunction in
patients with displaced clavicular and scapular fractures resulting in loss
of the normal lever arm of the rotator cuff, and they recommended that
the fractures be treated by open reduction
 Romeo et al. reported a poor outcome after scapular neck fractures with
malalignment; they measured the glenopolar angle to assess the
rotational malalignment of fractures involving the glenoid . In their
series patients with scapular fractures, which were displaced by more
than 1 cm, had poorer results than those with undisplaced fractures.

23.  B.D.Owens &T.P. Goss jbjs2006 Surgical
stabilisation of the clavicle alone could reduce
the scapular fracture indirectly, and fixation
of the scapular fracture was only required
with displaced fractures

24. Case example quoted in wheeles textbook for conservative management
With glenoid not much displaced

25. Case of SSSC with clavicle plate fixation with undisplaced scapula neck treated
With clavicle plate alone

26. Case of Failure with clavicle plate fixation with displaced scapula
neck treated With calvicle plate alone resulted in decreased ROM

27. Protocol to be followed clavicle plate fixation still scapula neck is
displaced . scapula fixation is done

28. Double Plating done at the same time

29. Fixation of lateral clavicle (acromio clavicular ) and coracoid (c4)

30.  less than 5-mm
displacement
 No Caudal displacement
Conservative
management
• Clavicle plating first
• Scapula still unreduced
• Scapula fixation
SSSC
yes
No
Operative management