The document describes the anatomy and classification of injuries to the clavicle, acromioclavicular joint, and sternoclavicular joint. It discusses the clavicle bone, its joints, ligaments, muscle attachments, mechanisms of injury, physical exam, radiographic evaluation, classification of fractures, and treatment options for fractures and dislocations which can include nonoperative treatment, plate fixation, intramedullary fixation, coracoclavicular screw fixation, and distal clavicle excision.

2. Clavicle
 “S”-shaped bone
 Medial - sternoclavicular joint
 Lateral - acromioclavicular joint and
coracoclavicular ligaments
 Muscle attachments:
 Medial: sternocleidomastoid
 Lateral: Trapezius, pectoralis major

3. AC Joint
 Diarthrodial joint between medial facet of acromion
and the lateral (distal) clavicle.
 Contains intra-articular disk of variable size.
 Thin capsule stabilized by ligaments on all sides:
 AC ligaments control horizontal (anteroposterior )
displacement
 Superior AC ligament most important

4. Distal Clavicle
 Coracoclavicular ligaments
 “Suspensory ligaments of the upper
extremity”
 Two components:
 Trapezoid
 Conoid
 Stronger than AC ligaments
 Provide vertical stability to AC joint

5. Mechanism of Injury
Moderate or high-energy traumatic impacts to the
shoulder
1. Fall from height
2. Motor vehicle accident
3. Sports injury
4. Blow to the point of the shoulder
5. Rarely a direct injury to the clavicle

6. Physical Examination
 Inspection
 Evaluate deformity and/or
displacement
 Beware of rare inferior or
posterior displacement of distal
or medial ends of clavicle
 Compare to opposite side.

7. Physical Examination
 Palpation
 Evaluate pain
 Look for instability with stress

8. Physical Examination
 Neurovascular examination
 Evaluate upper extremity motor and sensation
 Measure shoulder range-of-motion

9. Radiographic Evaluation
of the Clavicle
 Anteroposterior
View
 30-degree Cephalic
Tilt View

10. Clavicle Fractures

11. Classification of
Clavicle Fractures
 Group I : Middle third
 Most common (80% of clavicle fractures)
 Group II: Distal third
 10-15% of clavicle injuries
 Group III: Medial third
 Least common (approx. 5%)

12. Treatment Options
 Nonoperative
 Sling
 Brace
 Surgical
 Plate Fixation
 Screw or Pin Fixation

13. Nonoperative Treatment
 “Standard of Care” for most clavicle fractures.
 Continued questions about the need to wear a
specialized brace.

14. Simple Sling vs.
Figure-of-8 Bandage
 Prospective randomized trial of 61 patients
 Simple sling
 Less discomfort
 Functional and cosmetic results identical
 Alignment of healed fractures unchanged from the
initial displacement in both groups
Andersen et al., Acta Orthop Scand 58: 71-4, 1987.

15. Nonoperative Treatment
 It is difficult to reduce clavicle fractures by closed
means.
 Most clavicle fractures unite rapidly despite
displacement
 Significantly displaced mid-shaft and distal-third
injuries have a higher incidence of nonunion.

16. Nonoperative Treatment
 There is new evidence that the outcome of
nonoperative management of displaced middle-third
clavicle fractures is not as good as traditionally
thought, with many patients having significant
functional problems.

17. Deficits following nonoperative treatment of
displaced midshaft clavicular fractures
 A patient-based outcome questionnaire and muscle-
strength testing were used to evaluate 30 patients after
nonoperative care of a displaced midshaft fracture of
the clavicle.
 At a minimum of twelve months (mean 55 mos),
outcomes were measured with the Constant shoulder
score and the DASH patient questionnaire. In addition,
shoulder muscle-strength testing was performed with
the Baltimore Therapeutic Equipment Work Simulator,
with the uninjured arm serving as a control.
McKee et al. J Bone Joint Surg Am 2006;88-A:35-40.

18. Deficits following nonoperative treatment of
displaced midshaft clavicular fractures
 The strength of the injured shoulder was 81%
for maximum flexion, 75% for endurance of
flexion, 82% for maximum abduction, 67% for
endurance of abduction, 81% for maximum
external rotation, 82% for endurance of external
rotation, 85% for maximum internal rotation,
and 78% for endurance of internal rotation (p <
0.05 for all).
 The mean Constant score was 71 points, and the
mean DASH score was 24.6 points, indicating
substantial residual disability.
McKee et al. J Bone Joint Surg Am 2006;88-A:35-40.

19.  Displaced midshaft clavicle fractures can cause
significant, persistent disability, even if they heal
uneventfully.

20. Definite Indications for Surgical
Treatment of Clavicle Fractures
 1) Open fractures
 2) Associated neurovascular injury

21. Relative Indications for Acute
Treatment of Clavicle Fractures
 1) Widely displaced fractures
 2) Multiple trauma
 3) Displaced distal-third fractures

22. Relative Indications for Acute
Treatment of Clavicle Fractures
 4) Floating shoulder
 5) Seizure disorder
 6) Cosmetic deformity
 7) Earlier return to work.

24. Clavicular Displacement
 < 5 mm shortening: acceptable results at 5 years (Nordqvist et
al, Acta Orthop Scand 1997;68:349-51.
 > 20 mm shortening associated with increased risk of nonunion
and poor functional outcome at 3 years (Hill et al, JBJS
1997;79B: 537-9)

25. Plate Fixation
 Traditional means of ORIF
 Plate applied superiorly or inferiorly
 Inferior plating associated with lower risk of hardware
prominence
 Used for acute displaced fractures and nonunions.

27. Intramedullary Fixation
 Large threaded cannulated screws
 Flexible elastic nails
 K-wires
 Associated with risk of migration
 Useful when plate fixation contra-
indicated
 Bad skin
 Severe osteopenia
 Fixation less secure

28. Complications of Clavicular
Fractures and its Treatment
 Nonunion
 Malunion
 Neurovascular Sequelae
 Post-Traumatic Arthritis

29. Risk Factors for the Development
of Clavicular Nonunions
 Location of Fracture
 (outer third)
 Degree of Displacement
 (marked displacement)
 Primary Open Reduction

30. Principles for the Treatment of
Clavicular Nonunions
 Restore length of clavicle
 May need intercalary bone graft
 Rigid internal fixation, usually with a plate
 Iliac crest bone graft
 Role of bone-graft substitutes not yet defined.

31. Clavicular Malunion
 Symptoms of pain, fatigue, cosmetic deformity.
 Initially treat with strengthening, especially of
scapulothoracic stabilizers.
 Consider osteotomy, internal fixation in rare
cases in which nonoperative treatment fails.
Correction of malunion with thoracic outlet sx

32. Neurologic Sequelae
 Occasionally, fracture fragments or abundant callus
can cause brachial plexus symptoms.
 Treatment is reduction and fixation of the fracture, or
resection of callus with or without osteotomy and
fixation for malunions.

34. Classification of Distal Clavicular
Fractures
(Group II Clavicle Fractures)
 Type I-nondisplaced
 Between the CC and AC
ligaments with ligament
still intact
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

35. Classification of Distal Clavicular
Fractures
 Type II
 Typically displaced secondary to a
fracture medial to the coracoclavicular
ligaments, keeping the distal fragment
reduced while allowing the medial
fragmetn to displace superiorly
 Highest rate of nonunion (up to 30%)
 Two Types

36. •A. Conoid and trapezoid
attached to distal
fragment
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

37. •Type IIB: Conoid
torn, trapezoid
attached
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

38. Classification of Distal Clavicular
Fractures
 Type III:articular
fractures
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

39. Treatment of Distal-Third (Type II)
Clavicle Fractures
 Nonoperative treatment
 22 to 33% failed to unite
 45 to 67% took more than three months to heal
 Operative treatment
 100% of fractures healed within 6 to 10 weeks after
surgery

40.  Displaced Type II fractures of the distal clavicle are
often treated more aggressively because of the
increased risk of nonunion with nonoperative
treatment

41. Techniques for Acute Operative
Treatment of Distal Clavicle Fractures
 Kirschner wires inserted into the distal
fragment
 Dorsal plate fixation
 CC screw fixation
 Tension-band wire or suture
 Transfer of coracoid process to the clavicle
 Clavicular Hook Plate

42.  For most techniques of clavicular fixation,
coracoclavicular fixation is also needed to prevent
redisplacement of the medial clavicle.

43. • The Hook Plate (Synthes USA, Paoli, PA)
was specifically designed to avoid this
problem of redisplacement.

45. Hook Plate - Results
 Recent series of distal clavicle fractuers treated with
the Hook Plate document high union rates of 88% -
100%. Complications are rare but potentially
significant, including new fracture about the implant,
rotator cuff tear, and frequent subacromial
impingement.

46. Indications for Late Surgery for
Distal Clavicle Fractures
 Pain
 Weakness
 Deformity

47. Radiographic Evaluation of the
Acromioclavicular Joint
 Proper exposure of the AC joint requires one-third
to one-half the x-ray penetration of routine
shoulder views
 Initial Views:
 Anteroposterior view
 Other views:
 Axillary: demonstrates anterior-posterior displacement
 Stress views: not generally relevant for treatment
decisions.

48. Type I
 Sprain of
acromioclavicular
ligament
 AC joint intact
 Coracoclavicular
ligaments intact
 Deltoid and trapezius
muscles intact
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

49. Type II
 AC joint disrupted
 < 50% Vertical
displacement
 Sprain of the
coracoclavicular
ligaments
 CC ligaments intact
 Deltoid and trapezius
muscles intact
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

50. Type III
 AC ligaments and CC
ligaments all disrupted
 AC joint dislocated and
the shoulder complex
displaced inferiorly
 CC interspace greater
than the normal
shoulder(25-100%)
 Deltoid and trapezius
muscles usually detached
from the distal clavicle
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

51. Type III Variants
 “Pseudodislocation” through an intact
periosteal sleeve
 Physeal injury
 Coracoid process fracture

52. Type IV
 AC and CC ligaments
disrupted
 AC joint dislocated and
clavicle displaced
posteriorly into or
through the trapezius
muscle
 Deltoid and trapezius
muscles detached from
the distal clavicle
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

53. Type V
 AC ligaments disrupted
 CC ligaments disrupted
 AC joint dislocated and
gross disparity between
the clavicle and the
scapula (100-300%)
 Deltoid and trapezius
muscles detached from
the distal half of clavicle
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

54. Type VI
 AC joint dislocated and
clavicle displaced inferior
to the acromion or the
coracoid process
 AC and CC ligaments
disrupted
 Deltoid and trapezius
muscles detached from
the distal clavicle
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

55. Treatment Options for Types I - II
Acromioclavicular Joint Injuries
 Nonoperative: Ice and protection until pain
subsides (7 to 10 days).
 Return to sports as pain allows (1-2 weeks)
 No apparent benefit to the use of specialized
braces.

56.  Type II operative treatment
 Generally reserved only for the patient with chronic
pain.
 Treatment is resection of the distal clavicle and
reconstruction of the coracoclavicular ligaments.

57. Treatment Options for Type III-VI
Acromioclavicular Joint Injuries
 Nonoperative treatment
 Closed reduction and application of a sling and harness
to maintain reduction of the clavicle
 Short-term sling and early range of motion
 Operative treatment
 Primary AC joint fixation
 Primary CC ligament fixation
 Excision of the distal clavicle
 Dynamic muscle transfers

58.  Type III Injuries: Need for acute surgical treatment
remains very controversial.
 Most surgeons recommend conservative treatment
except in the throwing athlete or overhead worker.
 Repair generally avoided in contact athletes because of
the risk of reinjury.

59. Indications for Acute Surgical
Treatment of Acromioclavicular
Injuries
 Type III injuries in highly
active patients
 Type IV, V, and VI injuries

60. Surgical Options for AC Joint
Instability
 Coracoid process transfer to distal transfer (Dynamic
muscle transfer)
 Primary AC joint fixation
 Primary Coracoclavicular Fixation
 Distal Clavicle Excision with CC ligament
reconstruction.

61. Weaver-Dunn Procedure
 The distal clavicle is excised.
 The CA ligament is transferred
to the distal clavicle.
 The CC ligaments are repaired
and/or augmented with a
coracoclavicular screw or suture.
 Repair of deltotrapezial fascia
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

62. Indications for Late Surgical
Treatment of Acromioclavicular
Injuries
 Pain
 Weakness
 Deformity

63. Techniques for Late Surgical
Treatment of Acromioclavicular
Injuries
 Reduction of AC joint and repair of AC and CC
ligaments
 Resection of distal clavicle and reconstruction of
CC ligaments (Weaver-Dunn Procedure)

65. The Anatomy of the Sternoclavicular Joint
 Diarthrodial Joint
 “Saddle shaped”
 Poor congruence
 Intra-articular disc
ligament. Divides SC joint
into two separate joint
spaces.
 Costoclavicular ligament-
(rhomboid ligament) Short
and strong and consist of
an anterior and posterior
fasciculus

66.  Interclavicular ligament- Connects the
superomedial aspects of each clavicle with the
capsular ligaments and the upper sternum
 Capsular ligament- Covers the anterior and
posterior aspects of the joint and represents
thickenings of the joint capsule. The anterior
portion of the ligament is heavier and stronger
than the posterior portion.

67. Epiphysis of the Medial Clavicle
 Medial Physis- Last of the ossification centers to
appear in the body and the last epiphysis to close.
 Does not ossify until 18th to 20th year
 Does not unite with the clavicle until the 23rd to 25th
year

68. Radiographic Techniques for
Assessing Sternoclavicular Injuries
 40-degree cephalic tilt
view
 CT scan- Best technique
for sternoclavicular joint
problems
From Wirth MA and Rockwood CA, JAAOS, 4:268, 1996

69. Injuries Associated with
Sternoclavicular Joint Dislocations
 Mediastinal
Compression
 Pneumothorax
 Laceration of the
superior vena cava
 Tracheal erosion
From Wirth MA and Rockwood CA, JAAOS, 4:268, 1996

70. Treatment of Anterior
Sternoclavicular Dislocations
 Nonoperative treatment
 Analgesics and immobilization
 Functional outcome usually good
 Closed reduction
 Often not successful
 Direct pressure over the medial end of
the clavicle may reduce the joint

71. Treatment of Posterior
Sternoclavicular Dislocations
 Careful examination of the patient is extremely
important to rule out vascular compromise.
 Consider CT to rule out mediastinal compression
 Attempt closed reduction - it is often successful and
remains stable.

72. Closed Reduction Techniques
 Abduction traction
 Adduction traction
 “Towel Clip” - anterior force applied to clavicle by
percutaneously applied towel clip

73. Operative Techniques
 Resection arthroplasty
 May result in instability of remaining
clavicle unless stabilization is done.
 Suggest minimal resection of bone and
fixation of medial clavicle to first rib.
 Sternoclavicular reconstruction with suture, tendon
graft.