PowerPoint Presentation

FRACTURES OF THE CLAVICLEIn adults clavicle fractures are common, accounting for 2.64 per cent of fractures and approximately 35 percent of all shoulder girdle injuries. Fractures of the midshaft account for 6982 per cent, lateral fractures for 2128 per cent and medial fractures for 23 per cent.Mechanism of injuryA fall on the shoulder or the outstretched hand may break the clavicle. In the common mid-shaft fracture, the outer fragment is pulled down by the weight of the arm and the inner half is held up by the sternomastoid muscle. In fractures of the outer end, if the ligaments are intact there is little displacement; but if the coracoclavicular ligaments are torn, or if the fracture is just medial to these ligaments, displacement may be severe and closed reduction impossible.Clinical featuresThe arm is clasped to the chest to prevent movement.A subcutaneous lump may be obvious and occasionally a sharp fragment threatens the skin. Though vascular complications are rare, it is prudent to feel the pulse and gently to palpate the root of the neck.Outer third fractures are easily missed or mistaken for acromioclavicular joint injuries.ImagingRadiographic analysis requires at least an anteroposterior view and another taken with a 30 degree cephalic tilt. The fracture is usually in the middle third of the bone, and the outer fragment usually lies below the inner. Fractures of the outer third may be missed, or the degree of displacement underestimated, unless additional views of the shoulder are obtained. With medial third fractures it is also wise to obtain x-rays of the sterno-clavicular joint. In assessing clinical progress, remember that clinical union usually precedes radiological union by several weeks.CT scanning with three-dimensional reconstructions may be needed to determine accurately the degree of shortening or for diagnosing a sternoclavicular fracture-dislocation, and also to establish whether a fracture has united.ClassificationClavicle fractures are usually classified on the basis of their location: Group I (middle third fractures),Group II (lateral third fractures) Group III(medial third fractures). Lateral third fractures can be further sub-classified into (a) those with the coracoclavicular ligaments intact, (b) those where the coracoclavicular ligaments are torn or detached from the medial segment but the trapezoid ligament remains intact to the distal segment, and (c) factures which are intra-articular. An even more detailed classification proposed by Robinson (1998) is useful for managing data and comparing clinical outcomes.TreatmentMIDDLE THIRD FRACTURESThere is general agreement that undisplaced fractures should be treated non- operatively. Most will go on to unite uneventfully with a non-union rate below 5 percent and a return to normal function.Non-operative management consists of applying a simple sling for comfort. It is discarded once the pain subsides (between 13 weeks) and the patient is then encouraged to mobilize the limb as pain allows. There is no evidence that the traditional figure-of-eight bandage confers any advantage and it carries the risk of increasing the incidence of pressures sores over the fracture site and causing harm to neurological structures; it may even increase the risk of non-union.There is less agreement about the management of displaced middle third fractures. Treating those with shortening of more than 2 cm by simple splintage is now believed to incur a considerable risk of symptomatic mal-union mainly pain and lack of power during shoulder movements (McKee et al., 2006) and an increased incidence of non-union. There is, therefore, a growing trend towards internal fixation of acute clavicular fractures associated with severe displacement.Methods include plating (specifically contoured locking plates are available) and intramedullary fixation.

LATERAL THIRD FRACTURESMost lateral clavicle fractures are minimally displaced and extra-articular.The fact that the coracoclavicular ligaments are intact prevents further displacement and non-operative management is usually appropriate.Treatment consists of a sling for 23 weeks until the pain subsides, followed by mobilization within the limits of pain.Displaced lateral third fractures are associated with disruption of the coracoclavicular ligaments and are therefore unstable injuries.A number of studies have shown that these particular fractures have a higher than usual rate of non-union if treated non-operatively.Surgery to stabilize the fracture is often recommended. However the converse argument is that many of the fractures that develop non-union do not cause any symptoms and surgery can therefore be reserved for patients with symptomatic non-union.Operations for these fractures have a high complication rate and no single procedure has been shown to be better than the others. Techniques include the use of a coracoclavicular screw, plate and hook plate fixation and suture and sling techniques with Dacron graft ligaments.

MEDIAL THIRD FRACTURESMost of these rare fractures are extra-articular. They are mainly managed non-operatively unless the fracture displacement threatens the mediastinal structures.Initial fixation is associated with significant complications, including migration of the implants into the mediastinum, particularly when K-wires are used. Other methods of stabilization include suture and graft techniques and the newer locking plates.Complications

EARLYDespite the close proximity of the clavicle to vital structures, a pneumothorax, damage to the subclavian vessels and brachial plexus injuries are all very rare.stiff and take months to regain movement.LATENon-union In displaced fractures of the shaft nonunion occurs in 115 per cent. Risk factors include increasing age, displacement, comminution and female sex.However accurate prediction of those fractures most likely to go on to non-union remains difficult.Symptomatic non-unions are generally treated with plate fixation and bone grafting if necessary. This procedure usually produces a high rate of union and satisfaction.Lateral clavicle fractures have a higher rate of nonunion (11.540 per cent). Treatment options for symptomatic non-unions are excision of the lateral part of the clavicle (if the fragment is small and the coracoclavicular ligaments are intact) or open reduction, internal fixation and bone grafting if the fragment is large. Locking plates and hooked plates are used.

Malunion All displaced fractures heal in a nonanatomical position with some shortening and angulation, however most do not produce symptoms.Some may go on to develop periscapular pain and this is more likely with shortening of more than 1.5cm. In these circumstances the difficult operation of corrective osteotomy and plating can be considered.Stiffness of the shoulder This is common but temporary; it results from fear of moving the fracture.Unless the fingers are exercised, they also may become

FRACTURES OF THE SCAPULAMechanisms of injuryThe body of the scapula is fractured by a crushing force, which usually also fractures ribs and may dislocate the sternoclavicular joint. The neck of the scapula may be fractured by a blow or by a fall on the shoulder; the attached long head of triceps may drag the glenoid downwards and laterally. The coracoid process may fracture across its base or be avulsed at the tip. Fracture of the acromion is due to direct force.Fracture of the glenoid fossa usually suggests a medially directed force (impaction of the joint) but may occur with dislocation of the shoulder.Clinical featuresThe arm is held immobile and there may be severe bruising over the scapula or the chest wall. Because of the energy required to damage the scapula, fractures of the body of the scapula are often associated with severe injuries to the chest, brachial plexus, spine, abdomen and head. Careful neurological and vascular examinations are essential.ClassificationFractures of the scapula are divided anatomically into scapular body, glenoid neck, glenoid fossa, acromion and coracoid processes.Fractures of the scapular bodyFractures of the glenoid neckIntra-articular glenoid fossa fractures (Ideberg modifiedby Goss)Type I Fractures of the glenoid rimType II Fractures through the glenoid fossa, inferior fragment displaced with subluxed humeral headType III Oblique fracture through glenoid exiting superiorly (may be associated with acromioclavicular dislocation or fracture)Type IV Horizontal fracture exiting through the medial border of the scapulaType V Combination of Type IV and a fracture separating the inferior half of the glenoidType VI Severe comminution of the glenoid surfaceFractures of acromion processType I Minimally displacedType II Displaced but not reducing subacromial spaceType III Inferior displacement and reduced subacromial spaceFractures of coracoid processType I Proximal to attachment of the coracoclavicular ligamentsand usually associated with acromioclavicular separationType II Distal to the coraco-acromial ligaments

Intra-articular fractures Type I glenoid fractures, if displaced, may result in instability of the shoulder. If the fragment involves more than a third of the glenoid surface and is displaced by more than 5 mm surgical fixation should be considered. Anterior rim fractures are approached through a delto-pectoral incision and posterior rim fractures through the posterior approach.Type II fractures are associated with inferior subluxation of the head of the humerus and require open reduction and internal fixation. Types III, IV, V and VI fractures have poorly defined indications for surgery. Generally speaking, if the head is centred on the major portion of the glenoid and the shoulder isstable a non-operative approach is adopted.Comminuted fractures of the glenoid fossa are likely to lead to osteoarthritis in the longer term.Fractures of the acromion Undisplaced fractures are treated non-operatively. Only Type III acromial fractures, in which the subacromial space is reduced,require operative intervention to restore the anatomy.