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orthopaedics > clavicular > Flashcards

clavicular Flashcards

1
Q

what are the different types of clavicular fractures ?

A

proximal clavicular fractures -10 -20 percent

mid shaft clavicular fractures - 80 percent

distal clavicular fractures - 5 percent

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2
Q

which is the most common type of clavicular fractures ? and why ?

A

midhsaft clavicular fractures - junction between the outer and middle part of the clavicle is the thinest part of the bone and not supported by muscle or ligamentous attachment

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3
Q

what is the cause of mid shaft clavicular fracture ?

A

fall on an outstretched arm
direct trauma to the shoulder
axial loading

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4
Q

what is the typical displacement of the of mid shaft clavicular fractures ?

A

the sternocleidomastoid muscle pulls the medial fragment postero superiorly

the lateral fragment by the weight of the arm and and pectoralis pulls it inferomedially

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5
Q

how do we classify mid shaft clavicular fractures ?

A

NEER classification

> less than 100 percent displacement =non operative

> more than 100 percent displacement= operative

also the AO classification 
A = simple 
A1 spiral
A2 oblique 
A3 transverse

B = wedge
B1 - spiral wedge
B2 - bending wedge
B3 - fragmented wedge

C = complex
C1 - complex spiral
C2 - segmented
irregular

all c is operative

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6
Q

what are the signs and symptoms of mid clavicular fracture ?

A

anterior shoulder pain

Physical exam
may have deformity
may have skin tenting (impending open fracture)
important to perform careful neurovascular exam

AC joint dislocation - piano key sign

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7
Q

what are the non operative indications mid clavicular fractions?

A

less than 2 cm shortening and displacement

less than 1 cm shortening of the superior shoulder suspensory complex 
and no neurovascular injury
open fracture 
tenting of the skin or 
floating shoulder
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8
Q

what is the superior shoulder suspensory complex ?

A

it is a ring composed of the:
coracoid process
acromion process
the glenoid flossa

coracoclavicular ligament
acromioclavicular ligament
and the distal clavicle

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9
Q

for the non operative in mid shaft clavicular fracture what is the method ?

A

immobilisation with NO ATTEMPT AT REDUCTION
ROM at 2-4 weeks and strengthening at 6-10 wks after an x ray of union

technique : SLING OR
figure-of-eight brace or figure of 8 bandage (NO SHOWN DIFFERENCE IN FUNCTIONAL OR COSMETIC OUTCOMES BETWEEN THE TWO)

when using bandage , HAND IS PLACED ON THE HIPS
first anchor it around the upper uninjured arm

(https://www.youtube.com/watch?v=VaB6Klp9KRM)

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10
Q

indications for CR and intramedullary fixation / OR and internal fixation for mid clavicular shaft fracture ?

A

open fractures

displaced fracture with skin tenting

subclavian artery or vein injury

floating shoulder (clavicle and scapular neck fracture)

symptomatic nonunion

symptomatic malunion

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11
Q

what are the operative methods for clavicular fractures ?

A

closed reduction and intrameduallary fixation -

using a cannulated screw
titanium elastic nail
for simple

or

open reduction with distractor and internal fixation
k wires and clamps if comminuted
precontoured dynamic compression plate (or reconstruction plate and locking plate)

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12
Q

when is closed reduction and intrameduallary fixation contraindicated ?

A

substantial comminution

segmental fractures

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13
Q

what is the closed reduction technique in mid clavicular fractures ?

A

Reduction:

The operator stands behind the patient, who is seated on a stool, places his knee between the shoulder blades and pulls on the patient’s shoulders.

put pads under the axilla

• Maintenance:

Figure of 8 bandage , the hands paced on the hips
tied in a knot on the back, OR PUT COTTON PAD at the back between the intrascapular area

This bandage must be re-tied every 3 or 4 days and left in place for 3 weeks. to get the traction

or use the figure 8 brace

ALWAYS feel his artery

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14
Q

in plating for open reduction and internal fixation where does the plate go in relation to the clavicle ?

A

superiorly - improved functional outcomes , faster time time
improoved cosmetic satisfaction
increased shoulder strength and endurance

compared to anteroinferior plating

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15
Q

what is one of the major advantages of operative to non operative treatmnet in midclavicular fractures

A

time to union
operative (16.4 weeks) vs. non-operative (28.4 weeks)

and GREATER FUNCTIONAL OUTCOMES

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16
Q

what is the disadvantage of intramedullary fixation ?

A

higher complication due to hardware migration , hardware breakage

17
Q

what is the advantage of open reduction and internal plate fixation ?

A

improved functional outcomes

faster time to union

18
Q

what is the post op rehabilitation for open reduction and internal fixation ?

A

sling 7-10 days followed by active motion

strengthening at around 6 weeks when pain free motion and radiographic finding of union

full activity around 3 months

19
Q

what are the complications in non operative management of mid clavicular fractures ?

A

nonunion - open reduction and internal fixation with plate and bone graft
( Risk factors for non-union in non-operative management of midshaft clavicle fractures include advanced age, female gender, displacement and comminution)

poorer cosmises

!!!decreased shoulder strength and endurance esp >2cm displacement
COMPARED TO OPERATIVE

malunion - clavicle osteotomy with bone grafting

20
Q

what are the complications in operative ?

A

plate fixation :

hardware prominence

neovascular injury - esp SUPERIOIR PLATES - increased risk for subclavian artery thrombosis and damage
infection
supraclavicular nerve injury

mechanical failure

adhesive capsulitis

21
Q

what causes distal clavicular fractures ?

A

direct trauma by fall

more commonly in older or osteoportic patients

22
Q

what is the classification of distal clavicular fracture?

A

neer classification - based on the integrity
of coracoclavicular ligament (the conoid and trapezoid)

type 1 - conoid and trapezoid ligament are intact - fracture is distally to them / minimal displacement = non operative

type 2a - the fracture occurs medially to the CC lig , therefore the medial fragment not stabilised and there is displacement = operative

type 2b - fracture occurs between the two coroacocalvicular ligaments - the conoid is torn and the trapezoid is intact
or both ligaments are torn
=operative

type 3 - the fracture distal to the CC ligament and involves the AC joint
intrarticular fracture = non operative

type 4

type 5 - comminuted fracture pattern
• conoid and trapezoid ligaments remain intact
• significant medial clavicle displacement
• usually unstable
= operative

23
Q

which fracture type is the least stable and highest risk for nonunion ?

A

type 2

24
Q

what is the treatment for non operative distal clavicular fractures ?

A

sling immobilisation with or FIGURE OF EIGHT BRACE (no difference)

NO ATTEMPT AT REDUCTION

ROM at 2-4 weeks and strengthening at 6-10 wks

25
Q

what are the indications for operative methods in distal clavicle fracture

A 
open fractures  
subclavian artery or vein injury
floating shoulder 
symptomatic nonunion
closed head injury
seizure disorder
polytrauma patient
26
Q

what is operative technique for distal clavicle fracture ?

A

Open Reduction Internal Fixation

Small fragment plate fixation with possible coracoclavicular ligament reconstruction is the most appropriate treatment for a displaced distal clavicle fracture in a patient that wishes to avoid a second procedure (esp type 5 comminuted)

temporary preliminary fixation with k wires
precontoured dynamic compression plate SUPERIORLY
however there needs to be a substantial large distal fragment for multiple screws screws to be locked

========

temporary preliminary fixation with k wires
hook plates SUPERIORLY are used when there is not sufficient bone in distal fragment
hook should be placed posterior to AC joint and far lateral as possible to prevent hook escape

27
Q

what is the advantage to open reduction and internal fixation over non operative ways in distal clavicle fracture ?

A

higher union rates
faster time to union

improved functional outcome/less pain with overhead activity

decreased symptomatic malunion

improved cosmetic satisfaction

28
Q

post operative rehabilitation for distal clavicle fracture after operation ?

A

sling for 7-10 days then active range of motion

strengthening at 6 weeks when pain free and radiographic evidence of union

full activity at 3months

hardware removal considered usually after 3 months

29
Q

what are the complications of non operative distal clavicular fracture ?

A 
non union 
risk factors:
comminution
displacement
Z deformity
female
older
smoker
distal third clavicle > middle third clavicle
if symptomatic, ORIF with plate and bone graft

malunion

AC joint arthritis -treatment
distal clavicle resection

30
Q

what are the complications of operative in distal clavicular fractures ?

A

hardware prominence

hardware removal
most common with hook plates

neuromuscular injury - the subclavian artery and vein damage and thrombosis
infection

adhesive capsulitis

31
Q

acromioclavicular joint anatomy ?

A 
acromioclavicular (AC) ligament
components
superior
inferior
anterior
posterior 
superior ligament is strongest, followed by posterior
coracoclavicular (CC) ligaments (trapezoid and conoid)
provides superior/inferior stability
components:
trapezoid ligament (lateral)
conoid ligament (medial)

conoid ligament is strongest

32
Q

what are the signs and symptoms of distal clavicular fracture?

A

anterior shoulder pain

perform careful neurovascular exam
suprascapular nerve is at risk of injury
can see weakness of external rotation with the arm in adduction

orthopaedics (29 decks)

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