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
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
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
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
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
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
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
47.
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
50.
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
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
56. o Nondisplaced
Less than 100% displacement Non-operative
o Displaced
Greater than 100% displacement Operative
(Rate of nonunion 4.5%)
NEER’S CLASSIFICATION
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
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
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
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