clavicle fractures and ACJ

Question 1

How do you manage lateral clavicle fractures?

Answer 1

Imaging
- AP Zanca view - 10deg cephalad

Stable
- lateral to CC ligaments - medial part stable
- intra-articular minimally displaced
- physeal

Unstable
- medial to CC ligaments
- bwn the cc ligaments
- lateral to CC ligaments - but both ligaments are torn
- comminuted
- 30% risk of non-union - with non-op
- 1% non-union with op

Management
- stable fractures - non-op
- unstable - operative

Procedures
- Hook plate - if comminuted fracture - needs removing
- lateral clavicle looking plate/ distal clavicle plate - if sufficient lateral fragment
- +/- CC stabilisation

Question 2

management of a midshaft clavicle fracture?

Answer 2

Displacing forces
- pec major - inferolateral
- sternoclamastoid - superomedial

Indications for surgery
Absolute:
- open fracture
- neurovascular injury
- floating shoulder - scapulothoracic dissociation - clavicle easiest to fix

Relative:
- polytrauma
- 100% displaced
- > 2cm shortening
- comminuted, displaced in an appropriate patient - athlete

Shortening
consideration in athletes, leads to:
- medial scapular pain
- fatigue
- pseudo winging

Exam answer for clavicle fractures:
- ORIF improves union rates
- ORIF doesnt speed up return to work
- debatable if operative improves function
- if you heal with non-op you do well, if you don’t unite, function isnt as good

Question 3

What is the evidence for middle clavicle fractures?

Answer 3

COTS trial - 2007
- ORIF (plating) vs non-op (sling)
- 132 patients
- better function and union with operative

Robinson
- ORIF plate vs non op sling
- multicentre RCT - 200 patients
- no difference in return to work or sport
- higher rate of non-union in non-op group
- patients who united - no difference in function
- high complication rates in surgery

Woltz - 2017
- surgery improves union but not function

Question 4

what is the management and outcomes of clavicle fracture non-union?

Answer 4

Assess:
address cause of non-union
- patient factors
- fracture factors

Conservative management:
- low demand
- good shoulder rom
- pain controlled
likely fibrous union - no restrictions

Operative management:
- active patient
- tender
- movement at fracture site
- no callus
plate fixation +/- graft

procedure:
adrenaline and local anaesthesia
superior approach centred on fracture
platysma and clavipectoral fascia inline with incision
danger = supraclavicular nerve
excise fibrous tissue and freshen bone ends - may need a burr
+/- structural graft - depends on defect
contoured clavicle place - compress fracture

Question 5

what are the stabilisers of the ACJ?

Answer 5

static stabilisers:
- capsule
- AC ligaments - prevents AP translation
- CC ligaments - prevents superoinferior translation
conoid - more medial
trapezoid

Question 6

Rockwood classification of ACJ injuries

Answer 6

I - sprain of AC ligament
II - AC ligament torn <25% displaced
III - AC and CC torn <100% displaced
IV - lateral clavicle displaced posteriorly through trapezius - AXILLARY view
V - > 100% displacement
VI - inferior dislocation - subcoracoid or subacromium

Question 7

ACJ injury management

Answer 7

Conservative
- types I and II
- sling, early ROM, functional motion by 6 weeks

Controversial
- type III
- trial of conservative treatment for 6 weeks to 3 months - if difficulty with forward flexion or abduction then ACJ reconstruction
- young athletes keen to go back to sport - early operative

Operative
- types IV, V and VI - irreducible

Procedures:
ACUTE
Ligament repair
- tightrope or dogbone
- Complications - CC distance increases due to stretching and clavicle tunnel diameter increases
Hook plate

CHRONIC
LARS reconstruction

Question 8

how do you perform a LARS reconstruction?

Answer 8

• Bra strap incision - prox to distal clavicle to coracoid
• superficial - clavipectoral fascia
• deep - muscle window in anterior deltoid
• dangers - musculocutaneous nerve in conjoined tendon and coracoid fracture/ lysis from ligament
• ligament passed under the coracoid and secured to clavicle via 2 bone tunnels and interference screw

Question 9

what is the superior suspensory shoulder complex?

Answer 9

Definition: ring shaped structure composed of bones and soft tissue essential for maintaining shoulder stability
- consists of: clavicle, acromium, coracoid, glenoid fossa, acromioclavicular joint, coracoclavicular and coracoacromial ligaments
- disruptions leads to floating shoulder - discontinuity between scapula and axial skeleton