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Extern conference ortho
- 1. EXTERN CONFERENCE D E PA R T M E N T O F O R T H O PA E D I C S M A H A R AT N A KO R N R ATC H A S R I M A H O S P.
- 2. CASE ชาย 54 ปี C C : M C ช น วั ว 2 H P TA
- 3. HISTORY • primary survey – A : speak fluently, move neck freely, no tender C-spine – B : no dyspnea, -ve CCT, tender Rt. clavicle with stepping – C : BP 143/78 mmHg, HR 106 bpm, no JVP engorged, -ve PCT – D : E4V5M6, pupils 3mm RTLBE – E : no life-threatening wound
- 4. HISTORY • secondary survey – A : no allergy – M : amlodipine, simvastatin, no antiplatelet/anticoagulant – P : HT, DLP F/U MNRH – L : last meal 16.30 9/2/61 – E : MC ชนวัว ใส่หมวกกันน็อค ล้มลาตัวด้านขวาลงพื้น เจ็บหัวไหล่ขวา แขนขวาแรงดี ไม่ชา ไม่ศีรษะกระแทก ไม่สลบ จาเหตุการณ์ได้ ไม่คลื่นไส้ อาเจียน
- 5. PHYSICAL EXAMINATIONS • v/s : BP 143/76 mmHg, HR 106 bpm, T 36oC, SpO2 98% • GA : A Thai man, alert, well cooperated • HEENT : not pale, no jaundice, no bleeding per nose/ear, no raccoon eye, no Battle’s sign • Chest & Lungs : tender Rt. clavicle with stepping, equal chest expansion and clear breath sound, -ve CCT • CVS : no JVP engorged, normal S1S2, no murmur • ABD : soft, not tender, -ve PCT • Ext : no edema, no external wound, full ROM both arms • Neuro : E4V5M6, pupils 3mmRTLBE, motor power gr.V all, intact PPS, CR<2 sec
- 10. DIAGNOSIS • 1. Displaced Rt. midshaft clavicule fracture • 2. U/D : HT, DLP
- 12. T R E A T M E N T 1. Figure of Eight 2. F/U 3wk 3. HM : paracetamol
- 14. MIDSHAFT CLAVICLE FXM C K E E , M . D . ( 2 0 1 4 ) . C L A V I C L E F R A C T U R E S . I N R O C K W O O D A N D G R E E N ' S F R A C T U R E S I N A D U L T S ( 8 T H E D . , V O L . 1 , P P . 1 4 2 7 - 1 4 7 0 ) . L I P P I N C O T T W I L L I A M S & W I L K I N S
- 15. CLAVICLE ANATOMY
- 16. CLAVICLE ANATOMY
- 17. CLAVICLE ANATOMY
- 18. M E C H A N I S M 1. direct blow at lateral aspect of shoulder 2. FOOSA 3. direct trauma 4. if minor pathologic Fx
- 20. CLAVICLE ANATOMY
- 21. ASSOCIATED INJURY • Ribs Fx • Scapular Fx • Glenoid Fx • Hemo/Pneumothorax • Scapulothoracic dissociation (closed traumatic forequarter amputation)
- 24. PHYSICAL EXAMS • shoulder ptosis • shortened clavicle • scapular protraction• skin tenting
- 25. IMAGING • CXR • clavicle AP film at suspected side
- 26. C L A S S I F I C AT I O N Allman 1. Middle third 2. Distal third - Neer classification (type I-V) - Neer type II : Rockwood 3. Proximal third
- 27. TREATMENT • Operative – Plating – IM Pinning • Non-operative – Arm sling – Figure of Eight
- 28. NON-OP VS OP Zlowodzki, M., Zelle, B. A., Cole, P. A., Jeray, K., & McKee, M. D. (2005). Treatment of acute midshaft clavicle fractures: systematic review of 2144 fractures: on behalf of the Evidence-Based Orthopaedic Trauma Working Group. Journal of orthopaedic trauma, 19(7), 504-507.
- 29. NON-OP VS OP McKee, R. C., Whelan, D. B., Schemitsch, E. H., & McKee, M. D. (2012). Operative versus nonoperative care of displaced midshaft clavicular fractures: a meta-analysis of randomized clinical trials. JBJS, 94(8), 675-684.
- 30. COSMETIC ISSUE Canadian, O. T. S. (2007). Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. The Journal of bone and joint surgery. American volume, 89(1), 1.
- 32. ARM SLING VS FIGURE OF EIGHT • No difference in primary outcome • “The application of the figure of eight bandage is more difficult than of the broad arm sling, and patients experience more pain during the first day when treated with this option. ” Ersen, A., Atalar, A. C., Birisik, F., Saglam, Y., & Demirhan, M. (2015). Comparison of simple arm sling and figure of eight clavicular bandage for midshaft clavicular fractures: a randomised controlled study. Bone Joint J, 97(11), 1562-1565.
- 34. COMPLICATIONS
- 35. THANK YOU
Editor's Notes
- in displaced fractures, the sternocleidomastoid muscle pulls the medial fragment posterosuperiorly, while pectoralis and weight of arm pull the lateral fragment inferomedially
- Acromioclavicular Joint Anatomy AC joint stability acromioclavicular ligament provides anterior/posterior stability has superior, inferior, anterior, and posterior components superior ligament is strongest, followed by posterior coracoclavicular ligaments (trapezoid and conoid) provides superior/inferior stability trapezoid ligament inserts 3 cm from end of clavicle conoid ligament inserts 4.5 cm from end of clavicle in the posterior border conoid ligament is strongest capsule, deltoid and trapezius act as additional stabilizers
- If the clavicular fracture has occurred with minimal trauma, one must be alert to the possibility of a pathologic fracture (Fig. 38-7). Metabolic processes that weaken bone (i.e., renal disease, hyperparathyroidism), benign or malignant tumors (i.e., myeloma, metastases), or pre-existing lesions (i.e., congenital pseudarthrosis of the clavicle) can result in pathologic fracture.
- as it has been reported in multiple studies to be of prognostic significance (greater shortening, especially more than 1.5 to 2 cm, is associated with a worse prognosis)
- Ideally, a classification scheme should be reproducible with a low rate of inter- and intra-observer variability, should help direct treatment, can be used to predict outcome, should be useful in both the clinical and research realms, and should be simple enough to be practically useful yet robust enough to include all fracture patterns
- In a meta-analysis of the literature from FIGURE 38-1 The epidemiology of clavicle fractures in Edinburgh, Scotland. (Adapted from Robinson CM, Court-Brown CM, McQueen MM, et al. Estimating the risk of nonunion following nonoperative treatment of a clavicle fracture. J Bone Joint Surg Am. 2004;86-A(7):1359–1365.) 1975 to 2005, Zlowodzki et al.209 found that the nonunion rate for nonoperatively treated displaced midshaft clavicle fractures was 15.1%, exponentially higher than that previously described