u01 clavicle ac_sc_joints1
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ClavicleClavicle“S”-shaped bone Medial - sternoclavicular jointLateral - acromioclavicular joint and
coracoclavicular ligamentsMuscle attachments:
Medial: sternocleidomastoidLateral: Trapezius, pectoralis major
AC JointDiarthrodial 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 )
displacementSuperior AC ligament most important
Distal Clavicle
Coracoclavicular ligaments“Suspensory ligaments of the
upper extremity”Two components:
Trapezoid Conoid
Stronger than AC ligamentsProvide vertical stability to AC
joint
Mechanism of InjuryModerate or high-energy traumatic impacts
to the shoulder1. Fall from height2. Motor vehicle accident3. Sports injury4. Blow to the point of the shoulder5. Rarely a direct injury to the clavicle
Physical ExaminationInspection
Evaluate deformity and/or displacement
Beware of rare inferior or posterior displacement of distal or medial ends of clavicle
Compare to opposite side.
Physical Examination
PalpationEvaluate painLook for instability with stress
Physical Examination
Neurovascular examinationEvaluate upper extremity motor and
sensationMeasure shoulder range-of-motion
Radiographic Evaluationof the Clavicle
Anteroposterior View
30-degree Cephalic Tilt View
Clavicle Fractures
Classification ofClavicle Fractures
Group I : Middle thirdMost common (80% of clavicle fractures)
Group II: Distal third10-15% of clavicle injuries
Group III: Medial thirdLeast common (approx. 5%)
Treatment OptionsNonoperative
SlingBrace
SurgicalPlate FixationScrew or Pin Fixation
Nonoperative Treatment“Standard of Care” for most clavicle
fractures.Continued questions about the need to wear
a specialized brace.
Simple Sling vs.Figure-of-8 Bandage
Prospective randomized trial of 61 patientsSimple sling
Less discomfortFunctional and cosmetic results identicalAlignment of healed fractures unchanged
from the initial displacement in both groups
Andersen et al., Acta Orthop Scand 58: 71-4, 1987.
Nonoperative TreatmentIt is difficult to reduce clavicle fractures by
closed means.Most clavicle fractures unite rapidly despite
displacementSignificantly displaced mid-shaft and distal-
third injuries have a higher incidence of nonunion.
Nonoperative TreatmentThere 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.
Deficits following nonoperative treatment of displaced midshaft clavicular fracturesA 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.
Deficits following nonoperative treatment of displaced midshaft clavicular fracturesThe 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.
Displaced midshaft clavicle fractures can cause significant, persistent disability, even if they heal uneventfully.
Definite Indications for Surgical Treatment of Clavicle Fractures
1) Open fractures2) Associated neurovascular injury
Relative Indications for Acute Treatment of Clavicle Fractures
1) Widely displaced fractures2) Multiple trauma3) Displaced distal-third
fractures
Relative Indications for Acute Treatment of Clavicle Fractures
4) Floating shoulder5) Seizure disorder6) Cosmetic deformity7) Earlier return to work.
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)
Plate FixationTraditional means of ORIFPlate applied superiorly or inferiorly
Inferior plating associated with lower risk of hardware prominence
Used for acute displaced fractures and nonunions.
Intramedullary FixationLarge threaded cannulated screwsFlexible elastic nailsK-wires
Associated with risk of migration
Useful when plate fixation contra-indicatedBad skinSevere osteopenia
Fixation less secure
Complications of Clavicular Fractures and its Treatment
NonunionMalunion Neurovascular SequelaePost-Traumatic Arthritis
Risk Factors for the Development of Clavicular Nonunions
Location of Fracture (outer third)
Degree of Displacement (marked displacement)
Primary Open Reduction
Principles for the Treatment of Clavicular NonunionsRestore length of clavicle
May need intercalary bone graftRigid internal fixation, usually with a plateIliac crest bone graft
Role of bone-graft substitutes not yet defined.
Clavicular MalunionSymptoms 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
Neurologic SequelaeOccasionally, 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.
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
Classification of Distal Clavicular Fractures
Type IITypically 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
•A. Conoid and trapezoid attached to distal fragment
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
•Type IIB: Conoid torn, trapezoid attached
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
Classification of Distal Clavicular Fractures
Type III:articular fractures
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
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
Displaced Type II fractures of the distal clavicle are often treated more aggressively because of the increased risk of nonunion with nonoperative treatment
Techniques for Acute Operative Treatment of Distal Clavicle Fractures
Kirschner wires inserted into the distal fragment
Dorsal plate fixationCC screw fixation Tension-band wire or sutureTransfer of coracoid process to the
clavicleClavicular Hook Plate
For most techniques of clavicular fixation, coracoclavicular fixation is also needed to prevent redisplacement of the medial clavicle.
• The Hook Plate (Synthes USA, Paoli, PA) was specifically designed to avoid this problem of redisplacement.
Hook Plate - ResultsRecent 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.
Indications for Late Surgery for Distal Clavicle Fractures
PainWeaknessDeformity
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
displacementStress views: not generally relevant for
treatment decisions.
Type I Sprain of
acromioclavicular ligament
AC joint intact Coracoclavicular
ligaments intactDeltoid and trapezius
muscles intact
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
AC joint disrupted< 50% Vertical
displacementSprain of the
coracoclavicular ligaments
CC ligaments intactDeltoid and
trapezius muscles intact
Type II
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
Type III AC ligaments and CC
ligaments all disruptedAC 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
Type III Variants “Pseudodislocation” through an
intact periosteal sleevePhyseal injuryCoracoid process fracture
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
Type V AC ligaments disrupted CC ligaments disruptedAC 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
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
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.
Type II operative treatmentGenerally reserved only for the patient with
chronic pain.Treatment is resection of the distal clavicle and
reconstruction of the coracoclavicular ligaments.
Treatment Options for Type III-VI Acromioclavicular Joint InjuriesNonoperative 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 treatmentPrimary AC joint fixationPrimary CC ligament fixationExcision of the distal clavicle Dynamic muscle transfers
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.
Indications for Acute Surgical Treatment of Acromioclavicular Injuries
Type III injuries in highly active patients
Type IV, V, and VI injuries
Surgical Options for AC Joint InstabilityCoracoid process transfer to distal transfer
(Dynamic muscle transfer)Primary AC joint fixationPrimary Coracoclavicular FixationDistal Clavicle Excision with CC ligament
reconstruction.
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
Indications for Late Surgical Treatment of Acromioclavicular Injuries
PainWeaknessDeformity
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)
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
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.
Epiphysis of the Medial ClavicleMedial Physis- Last of the ossification
centers to appear in the body and the last epiphysis to close.
Does not ossify until 18th to 20th yearDoes not unite with the clavicle until the 23rd
to 25th year
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
Injuries Associated with Sternoclavicular Joint Dislocations
Mediastinal Compression
Pneumothorax Laceration of the
superior vena cavaTracheal erosion
From Wirth MA and Rockwood CA, JAAOS, 4:268, 1996
Treatment of Anterior Sternoclavicular DislocationsNonoperative treatment
Analgesics and immobilizationFunctional outcome usually good
Closed reduction Often not successfulDirect pressure over the medial end of the clavicle may reduce the joint
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.
Closed Reduction Techniques
Abduction tractionAdduction traction“Towel Clip” - anterior force applied to
clavicle by percutaneously applied towel clip
Operative TechniquesResection 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.
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