A 36-year-old Thai man presented to the hospital after a motorcycle accident where he collided with a dog and fell off his bike 3 hours prior. He complains of left shoulder and chest pain. Imaging shows a closed fracture of the mid-shaft left clavicle with a left scapula neck fracture. The patient is admitted and managed conservatively with sling immobilization.

1. Orthopaedic department 22/2/18
TELECONFERENCE

2. EXT. PIYANGKUL
LORCHARASSRIWONG
6th year medical student Ramathibodi hospital

3. Patient profile :
ผู้ป่ วยชายไทยคู่อายุ 36 ปี
นับถือ พุทธ
อาศัย จ.นครราชสีมา
ภูมิลาเนา จ.นครราชสีมา
ระดับการศึกษา ปริญญาตรี
อาชีพ รับจ ้าง
CASE PRESENTATION

4. มาโรงพยาบาลด ้วย ขี่รถจักรยานยนต์ชนสุนัข ล ้มเอง 3 ชั่วโมง ก่อนมา
โรงพยาบาล
เหตุเกิดเมื่อ 14 กุมภาพันธ์ พ.ศ. 2561 เวลาประมาณ 11.00 น.
CHIEF COMPLAINT

5. A : can talk fluently, spontaneous neck movement, full ROM of neck,
can active elevate neck, not tender along C-spine
B : CCT positive at left chest wall, clear and equal breathsound both
lungs, no external wound at chest wall
C : BP 165/86 mmHg, HR 95 bpm, no external bleeding, PCT negative,
abdomen – not distend, soft, not tender, FAST negative at o1.oo pm
D : E4V5M6, full EOM, pupils 3 mm RTLBE
E : Ecchymosis with stepping at mid shaft of left clavicle
PRIMARY SURVEY

6. - 3 hr. PTA ขี่รถจักรยานยนต์ชนสุนัขเสียหลักล ้มเอง สวมหมวกนิรภัย
ปฏิเสธประวัติดื่มแอลกอฮอล์ก่อนขับขี่ ล ้มหน้าอกด ้านซ ้ายกระแทกพื้น ไม่มี
ศีรษะกระแทกพื้น ไม่สลบ จาเหตุการณ์ได ้ ลุกขึ้นได ้เอง มีเจ็บบริเวณอก และ
ไหล่ข ้างซ ้าย ขยับแขนซ ้ายได ้น้อยเนื่องจากเจ็บ ไม่ชา ไม่อ่อนแรง หายใจได ้
ไม่หอบเหนื่อย ไม่มีปวดคอ หรือปวดศีรษะ ไม่ปวดท ้อง มีแผลถลอกตาม
ร่างกาย แต่ไม่มีแผลฉีกขาก ไม่มีเลือดออกมาก รถกู้ชีพนาส่งที่รพช.โนนสูง
จากนั้นจึงส่งตัวต่อมาที่รพศ.มหาราช นม.
PRESENT ILLNESS

7. • ปฏิเสธประวัติโรคประจาตัว การผ่าตัด และนอนโรงพยาบาลมาก่อนหน้านี้
• ปฏิเสธยาที่ใช ้ประจา
• ปฏิเสธประวัติยาต ้ม ยาหม ้อ ยาสมุนไพร และยาลูกกลอน
• ปฏิเสธประวัติแพ ้ยา หรือแพ ้อาหาร
• ดื่มแอลกอฮอล์ตามงานสังสรรค์นานๆครั้ง ปฏิเสธประวัติสูบบุหรี่
PAST HISTORY

8. • ปฏิเสธโรคประจาตัวในครอบครัว
• ปฏิเสธโรคทางพันธุกรรม โรคมะเร็ง และโรคเลือดในครอบครัว
FAMILY HISTORY

9. Vital signs : BP 129/68 mmHg, PR 96 bpm, RR 26 /min BT 36.5oC
GA : A male, alert, good conciousness, obesity, BW 120 kg.,
Ht. 1.75 m. BMI 39.18 kg/m2
HEENT : not pale conjunctivae, anicteric sclerae, no subconjunctival
hemorrhage
Chest : CCT positive left upper chest esp. at left clavicle,
ecchymosis and stepping at mid shaft of left clavicle, no
external wound, clear and equal breathsound both lungs
CVS : full and regular pulse, normal s1s2, no murmur
Abdomen : not distend, no scar, soft, not tender, no guarding,
PCT negative
PHYSICAL EXAMINATION

10. Ext. : no deformities, limit ROM left shoulder due to pain
Neuro. : E4V5M6, full EOM, pupils 3 mm RTLBE,
motor power gr. V all, sensory intact
PHYSICAL EXAMINATION

11. PHYSICAL EXAMINATION

12. • Chest X-ray
• Film left clavicle AP
• Film left shoulder AP/transcapular
• Film left hand AP/oblique
• Film pelvis AP
• CBC, BUN, Creatinine, Coagulogram, Electrolyte, Anti-HIV
• DTX, Hct stat
• EKG 12 leads
INVESTIGATION

13. CHEST X-RAY

14. LEFT CLAVICLE AP

15. LEFT SHOULDER AP

16. LEFT SHOULDER TRANSCAPULAR

17. LEFT HAND AP

18. LEFT HAND OBLIGUE

19. PELVIS AP

20. • WBC 16,500 cumm (N 90.8% L 4.7% M 4.4%)
• Hb 13.6 g/dl
• Hct 42.5 %
• MCV 79.2 fl
• MCH 25.4 pg
• RDW 14.2 %
COMPLETE BLOOD COUNT

21. • PT 11.3 sec
• INR 0.97
• aPTT 21.9 sec
• TT 19.7 sec
COAGULOGRAM

22. • Na 138.5 mmol/l
• K 3.99 mmol/l
• Cl 100.4 mmol/l
• HCO3 28.3 mmol/l
• Cr. 0.94 mg/dl
• BUN 14.2 mg/dl
• eGFR 104 ml/min/1.73 m2
ELECTROLYTE

23. • Anti-HIV negative
IMMUNOLOGY

24.  Closed fracture mid-shaft left clavicle with left scapula neck fracture
 Blunted chest injury
IMPRESSION

25. One day order Continuous order
- Admit ศอช. - NPO
- blood for CBC, BUN, Cr., E’lyte - Record V/S, I/O as ml
Coag., anti-HIV Meds.
- CXR, film left clavicle AP, film pelvis AP, - None
film left shoulder AP/transcapular, film
left hand AP/oblique
- RLS (1,000) IV 100 ml/h
- EKG 12 leads
- DTX stat 121 mg%, Hct stat 42%
- FAST negative at 01.30 pm.
- on O2 mask c bag 12 lpm keep SpO2 > 95%
- on arm sling left arm
MANAGEMENT AT ER

26. Mid-shaft left clavicle fracture
CLAVICLE FRACTURE

27. ANATOMY

30.  2.6% of all fractures
 80-85 % middle 1/3 segment, 15-20% distal 1/3 segment, 0-5% proximal
1/3 segment
 Most often seen in young, active person
EPIDERMIOLOGY

31.  Fall on an outstretched hand
 Falling onto shoulder
 Direct trauma
MECHANISM OF INJURY

32. MECHANISM OF INJURY

33.  Proximal segment
Sternocleidomastoid muscle  Posterosuperiorly
 Distal segmen
Pectoralis and weight of arm  Inferomedially
DISPLACEMENT

34. DISPLACEMENT

35.  Ipsilateral scapula fracture
 Scapulothoracic dissociation
 Rib fracture
 Pneumothorax
 Neurovascular injury
ASSOCIATED INJURIES

36. “The combination of ipsilateral fractures of the clavicle and
scapula neck”
FLOATING SHOULDER

37. Double disruption of the superior shoulder suspensory complex
(SSSC)
This describes the bone and soft tissue circle or ring of the
-Glenoid
-Coracoid process
-Coracoclavicular ligament
-Clavicle (especially its distal, middle part)
-AC joint
-Acromian
*** Maintained anatomical relationship between the UE and the axial
skeletal
FLOATING SHOULDER

38. SUPERIOR SHOULDER
SUSPENSORY COMPLEX

39. Long-term functional problems including
-shoulder weakness or stiffness
-impingement syndrome
-neurovascular compression
-pain
FLOATING SHOULDER

40. o Non-operative treatment
o Operative treatment
-Internal fixation of clavicle alone
-Internal fixation of clavicle and glenoid neck
TREATMENTS

41. on arm sling for 1-2 months immobilization then early physical
therapy
NON-OPERTATIVE

42. Indications
o A clavicle fracture that warrants, in isolation, fixation
o Glenoid displacement of greater than 2.5 to 3 cm.
o Displaced intra-articular glenoid fracture extension
o Patient-associated indications (i.e. polytrauma with a requirement for early
upper extremity weight bearing)
o Severe glenoid angulation, retroversion, or anteversion >40 degrees (Goss
type II)
o Documented ipsilateral coracoacromial and/or AC ligament disruption or
it equivalent (coracoid fracture, i.e., AC joint disruption)
OPERATIVE

43. 1. Anatomical reduction and internal fixation of the clavicle
2. +/- Fixation of the Glenoid neck (in “unacceptable” position of Glenoid
fracture  displacement, that is, a gap, or step-off, ≥3 to 10 mm, with the
simultaneous involvement of 20% to 30% of the articular surface and/or
persisting subluxation of the humeral head.)
OPERATIVE

44. A traumatic disruption of the scapulothoracic articulation often
associated with
- severe neurologic injury
- vascular injury
- orthopaedic injury
- Mechanism
- lateral traction injury to the shoulder girdle
- involved significant trauma to heart, chest wall and lungs
SCAPULOTHORACIC
DISSOCIATION

45. - Associated conditions
- orthopaedic
- scapular fracture
- clavicle fracture
- AC dislocation/separation
- sternoclavicular dislocation
- flail extremity (52%)
complete loss of sensory and function
- vascular injury
- subclavian artery most commonly injured
- axillary artery
SCAPULOTHORACIC
DISSOCIATION

46. - Associated conditions
- neurologic injury (up to 90%)
- ipsilateral brachial plexus injury (often complete)
- neurologic injury more common than vascular injury
- Prognosis
- mortality rate 10%
- functional outcome is dependent on neurologic injury
if return of neurological function is unlikely, early
amputation is recommended
SCAPULOTHORACIC
DISSOCIATION

48. - Presentation
- History : high energy trauma
- Symptoms : pain in involved upper extremity, numbness/tingling
- Physical examinations :
- inspection
- significant swelling in shoulder region
- bruising around shoulder
- vascular examination
- decrease or absent pulse
- neurological examination
- neurological deficit
SCAPULOTHORACIC
DISSOCIATION

49. - Imaging
- Radiograph
- required view (AP chest)
- recommended views (shoulder AP/lat., appropiate fx. Site)
Findings
- laterally displaced scapular (edge of scapular displaced >1 cm.
from spinous process as compared to contralateral side
- widely displaced clavicle fracture
- AC separation
- sternoclavicular dislocation
- Angiogram
- indicated to detect injury to subclavian and axillary artery
SCAPULOTHORACIC
DISSOCIATION

51. - Treatment
- non operative
- immobilization/supportive care
- patients without significant vascular injury who
are hemodynamically stable (patient may have
adequate collateral flow to UE)
- operative
- high lateral thoracotomy with vascular repair
- axillary artery injury in unstable hemodynamic
- median sternotomy with vascular repair
- more proximal artery injury in unstable
hemodynamic
SCAPULOTHORACIC
DISSOCIATION

52. - Treatment
- operative
- ORIF of the clavicle or AC joint
- associated clavicle and AC injuries
- Forequarter amputation
- complete brachial plexus injury
SCAPULOTHORACIC
DISSOCIATION

53. FOREQUARTER AMPUTATION

54.  Static stabilizer
Acromioclavicular ligament
Provides anterior/posterior stability
Has superior, inferior, anterior and posterior components
Superior ligament is strongest followed by posterior
Coracoclavicular ligament (trapezoid and coronoid)
Provides superior/inferior stability
coronoid ligament is strongest
Capsule
 Dynamic stabilizer
Deltoid and Trapezius muscle
ACROMIOCLAVICULAR JOINT

55. ANATOMY

56. o Nondisplaced
Less than 100% displacement  Non-operative
o Displaced
Greater than 100% displacement  Operative
(Rate of nonunion 4.5%)
NEER’S CLASSIFICATION

60.  Symptoms
Anterior shoulder pain
 Physical examinations
Deformity
Tenting (impending open fracture)
Ecchymosis, external wound
Tender at clavicle
Perform careful neurovascular examination
PRESENTATION

61. TENTING

62. • Radiographs
Views
sitting/standing upright, standard AP view of bilat. Shoulder
Additional views
15o cephalic tilt, (ZANCA view), determine superior/inferior
displacement
• CT
View
coronal, sagittal, axial
3D reconstruction view
Finding
evaluate displacement, shortening, comminution, articular extension
and nonunion
vascular injury
IMAGING

63. ZANCA VIEW

64. o Non operative
o Operative
TREATMENT

65. Indications : Sling immobilization with gentle ROM exercises at 2-4 weeks and
strengthening at 6-10 weeks
- minimally displaced Group 1 (middle third)
- shortening and displaced < 2 cm.
- no neurologic deficit
- no significant displacement to the superior shoulder
suspensory complex (<10 mm displacement)
Outcomes :
- nonunion (1-5%)
risk factor (comminution, 100% displacement & shortening
(>2 cm.), advanced age and female
- poorer cosmetic
- decrease shoulder strength and endurance
NON OPERATIVE

66. Sling immobilization
-sling or figure of eight
TECHNIQUES

67. OPERATIVE INDICATIONS

68. Outcomes :
Advantages
- improved result with ORIF for clavicle fractures with 2 cm.
shortening and 100% displaced
- improved functional outcome and less pain with overhead
activity
- faster time to union
- decrease symptomatic mal-union rate
- improved cosmetic satisfaction
- increase shoulder strength and endurance
Disadvantages
- increase risk of need for future procedures (implant removal,
infection)
OPERATIVE

69. Closed reduction, intramedullary fixation
- equipment option
- cannulated screw
- specialize screw system (eg. Dual Trak)
- titanium elastic nail
- Hagle pin
- approach
- beach chair or supine
- posterolateral incision
- contraindications
- substantial comminution
- segmental fracture
TECHNIQUES

70. Closed reduction, intramedullary fixation
- 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
- biomechanically inferior to plating
TECHNIQUES

71. Open reduction, Plate and Screw fixation
- equipment
- most common
- limited contact precontroured, dynamic
compression plate
- k-wires for preliminary fixation
- others
- 3.5 mm. reconstruction plate
- locking plates
TECHNIQUES

72. Open reduction, Plate and Screw fixation
- approach
- beach chair or supine
- direct superior vs inferior incision
- biomechanics
- superior vs anteroinferior plating
- higher load to failure (S > A)
- plate strength with inferior bone comminurion
(A > S)
- lower risk of neurovascular injury (A > S)
- lower removal of deltoid attachment (S > A)
TECHNIQUES

73. Open reduction, Plate and Screw fixation
- outcomes
- time to union
- operative 16.4 weeks
- non operative 28.4 weeks
TECHNIQUES

74. FIXATIONS

75. PITFALLS

76. o Early
- sling for 7-10 days followed by active motion
o Late
- strengthening at 6 weeks when pain free motion and radiographic
evidence of union
- full activity including sports at 3 months
POST OP. REHABILITATION

77. Non operative
- non union (1-5%)
- risk factors
- fracture comminutions
- fracture displacement
- female
- advancing age
- smoking
- treatment
- asymptomatic  no treatment necessary
- symptomatic  ORIF with plate and bone graft
COMPLICATIONS

78. Non operative
- malunion : shortening > 3 cm., angulation > 30 degrees,
translation > 1 cm.
- symptoms
- increased fatigue with overhead activities
- thoracic outlet syndrome
- dissatisfaction with appearance
- difficulty with shoulder straps, backpacks
- treatment
- clavicle osteotomy with bone grafting
COMPLICATIONS

79. Operative
- hardware prominence
- 30% of patient request plate removal
- superior plates associated with increased irritation
- neurovascular injury (3%)
- superior plates associated with risk of subclavian artery or
vein penetration
- subclavian thrombosis
- nonunion (1-5%)
- infection (4.8%)
- risk factors (illicit drug use, diabetes and previous
shoulder surgery
COMPLICATIONS

80. Operative
- mechanical failure (1-4%)
- pneumothorax
- adhesive capsulitis
- 4% in surgical group develop adhesive capsulitis requiring
surgical intervention
COMPLICATIONS

81. COMPLICATIONS

82. • ออร์โธปิดิกส์ ฉบับเรียบเรียงใหม่ครั้งที่ 3. - - กรุงเทพฯ : ภาควิชาออร์โธปิ
ดิกส์ คณะแพทยศาสตร์โรงพยาบาลรามาธิบดี, 2554
• Orthopaedic trauma / ธีรชัย อภิวรรธกกุล, บรรณาธิการ. - - เชียงใหม่ : โรง
พิมพ์แสงศิลป์ , 2547
• Rockwood and Green’s fractures in adults / [edited by] Charles M. Court-
Brown, James D. Heckman, Margaret M. McQueen, William Ricci, Paul
Tornetta III; associate editor, Michael McKee. – Eighth edition.
• https://www.orthobullets.com
• https://orthoinfo.aaos.org
• https://emedicine.medscape.com
REFERENCES

83. THANK YOU
For your attentions