clavicular Flashcards
what are the different types of clavicular fractures ?
proximal clavicular fractures -10 -20 percent
mid shaft clavicular fractures - 80 percent
distal clavicular fractures - 5 percent
which is the most common type of clavicular fractures ? and why ?
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
what is the cause of mid shaft clavicular fracture ?
fall on an outstretched arm
direct trauma to the shoulder
axial loading
what is the typical displacement of the of mid shaft clavicular fractures ?
the sternocleidomastoid muscle pulls the medial fragment postero superiorly
the lateral fragment by the weight of the arm and and pectoralis pulls it inferomedially
how do we classify mid shaft clavicular fractures ?
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
what are the signs and symptoms of mid clavicular fracture ?
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
what are the non operative indications mid clavicular fractions?
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
what is the superior shoulder suspensory complex ?
it is a ring composed of the:
coracoid process
acromion process
the glenoid flossa
coracoclavicular ligament
acromioclavicular ligament
and the distal clavicle
for the non operative in mid shaft clavicular fracture what is the method ?
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)
indications for CR and intramedullary fixation / OR and internal fixation for mid clavicular shaft fracture ?
open fractures
displaced fracture with skin tenting
subclavian artery or vein injury
floating shoulder (clavicle and scapular neck fracture)
symptomatic nonunion
symptomatic malunion
what are the operative methods for clavicular fractures ?
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)
when is closed reduction and intrameduallary fixation contraindicated ?
substantial comminution
segmental fractures
what is the closed reduction technique in mid clavicular fractures ?
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
in plating for open reduction and internal fixation where does the plate go in relation to the clavicle ?
superiorly - improved functional outcomes , faster time time
improoved cosmetic satisfaction
increased shoulder strength and endurance
compared to anteroinferior plating
what is one of the major advantages of operative to non operative treatmnet in midclavicular fractures
time to union
operative (16.4 weeks) vs. non-operative (28.4 weeks)
and GREATER FUNCTIONAL OUTCOMES
what is the disadvantage of intramedullary fixation ?
higher complication due to hardware migration , hardware breakage
what is the advantage of open reduction and internal plate fixation ?
improved functional outcomes
faster time to union
what is the post op rehabilitation for open reduction and internal fixation ?
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
what are the complications in non operative management of mid clavicular fractures ?
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
what are the complications in operative ?
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
what causes distal clavicular fractures ?
direct trauma by fall
more commonly in older or osteoportic patients
what is the classification of distal clavicular fracture?
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
which fracture type is the least stable and highest risk for nonunion ?
type 2
what is the treatment for non operative distal clavicular fractures ?
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
what are the indications for operative methods in distal clavicle fracture
open fractures subclavian artery or vein injury floating shoulder symptomatic nonunion closed head injury seizure disorder polytrauma patient
what is operative technique for distal clavicle fracture ?
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
what is the advantage to open reduction and internal fixation over non operative ways in distal clavicle fracture ?
higher union rates
faster time to union
improved functional outcome/less pain with overhead activity
decreased symptomatic malunion
improved cosmetic satisfaction
post operative rehabilitation for distal clavicle fracture after operation ?
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
what are the complications of non operative distal clavicular fracture ?
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
what are the complications of operative in distal clavicular fractures ?
hardware prominence
hardware removal
most common with hook plates
neuromuscular injury - the subclavian artery and vein damage and thrombosis
infection
adhesive capsulitis
acromioclavicular joint anatomy ?
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
what are the signs and symptoms of distal clavicular fracture?
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
