CLAVICLE FRACTURE, SC

JOINT AND AC JOINT

INJURY
TEAM III
 EPIDEMIOLOGY
Clavicle fractures account for 2.6% to
12% of all fractures and for 44% to
66% of fractures about the shoulder.
Middle third fractures account for
80% of all clavicle fractures, whereas
fractures of the lateral and medial
third of the clavicle account for 15%
and 5%, respectively.
 CLASSIFICATION
Group I: fracture of the middle third
(80%). This is the most common
fracture in both children and adults;
proximal and distal segments are
secured by ligamentous and
muscular attachments.
 CLASSIFICATION
Group II: fracture of the distal third
(15%). This is subclassified according
to the location of the
coracoclavicular ligaments relative to
the fracture:
 CLASSIFICATION
Type I: Minimal displacement: interligamentous
fracture between the conoid and trapezoid or
between the coracoclavicular and AC ligaments;
ligaments still intact
Type II: Displaced secondary to a fracture medial
to the coracoclavicular ligaments: higher incidence
of nonunion
IIA: Conoid and trapezoid attached to the distal segment
IIB: Conoid torn, trapezoid attached to the distal segment
Type III: Fracture of the articular surface of the AC
joint with no ligamentous injury: may be confused
with first-degree AC joint separation
 CLASSIFICATION
Group III: fracture of the proximal third
(5%). Minimal displacement results if the
costoclavicular ligaments remain intact. It
may represent epiphyseal injury in children
and teenagers. Subgroups include:
Type I: Minimal displacement
Type II: Displaced
Type III: Intraarticular
Type IV: Epiphyseal separation
Type V: Comminuted
 TREATMENT
Nonoperative
Most clavicle fractures can be successfully
treated nonoperatively with some form of
immobilization.
Comfort and pain relief are the main goals. A
sling has been shown to give the same results
as a figure-of-eight bandage, providing more
comfort and fewer skin problems.
In general, immobilization is used for 4 to 6
weeks.
 The surgical indications for midshaft clavicle fractures are
controversial.
The accepted indications for operative treatment of acute clavicle
fractures are open fracture, associated neurovascular compromise,
and skin tenting with the potential for progression to open fracture.
Controversy exists over management of midshaft clavicle fractures
with substantial displacement and shortening (>1 to 2 cm).
Although most displaced midshaft fractures will unite, studies have
reported shoulder dysfunction and patient dissatisfaction with the resulting
cosmetic deformity.
Controversy also exists over management of type II distal clavicle
fractures.
Some authors have indicated that all type II fractures require operative
management.
Others report that if the bone ends are in contact, healing can be expected
even if there is some degree of displacement. In this situation,
nonoperative management consists of sling immobilization and progressive
range of shoulder motion.
 COMPLICATIONS
Neurovascular compromise: This is uncommon and can result from
either the initial injury or secondary to compression of adjacent
structures by callus and/or residual deformity.
Malunion: This may cause an unsightly prominence, but operative
management may result in an unacceptable scar.
The effect of malunion on functional outcomes remains controversial.
Nonunion: The incidence of nonunion following clavicle fractures
ranges from 0.1% to 13.0%, with 85% of all nonunions occurring in
the middle third.
Factors implicated in the development of nonunions of the clavicle include
(1) severity of initial trauma, (2) extent of displacement of fracture
fragments, (3) soft tissue interposition, (4) refracture, (5) inadequate period
of immobilization, and (6) primary open reduction and internal fixation.
Posttraumatic arthritis: This may occur after intraarticular injuries to
the sternoclavicular or AC joint.
 ACROMIOCLAVICULAR (AC) JOINT
INJURY
Epidemiology
Most common in the second decade
of life, associated with contact
athletic activities
More common in males
 Classification
Type I:Sprain of the AC ligament
Type II:AC ligament tear with joint disruption,
coracoclavicular ligaments sprained
Type III: AC and coracoclavicular ligaments torn with AC joint
dislocation. The deltoid and trapezius muscles are usually
detached from the distal clavicle.
Type IV: Distal clavicle displaced posteriorly into or through
the trapezius. The deltoid and trapezius muscles are
detached from the distal clavicle.
Type V: Distal clavicle grossly and severely displaced
superiorly (>100%). The deltoid and trapezius muscles are
detached from the distal clavicle.
Type VI: The AC joint is dislocated, with the clavicle displaced
inferior to the acromion or the coracoid; the coracoclavicular
interspace is decreased compared with normal. The deltoid
and trapezius muscles are detached from the distal clavicle.
 Treatment
Type I: Rest for 7 to 10 days, ice packs, sling. Refrain from
full activity until painless, full range of motion (2 weeks).
Type II: Sling for 1 to 2 weeks, gentle range of motion as
soon as possible. Refrain from heavy activity for 6 weeks.
More than 50% of patients with type I and II injuries remain
symptomatic at long-term follow-up.
Type III: For inactive, nonlaboring, or recreational athletic
patients, especially for the nondominant arm, nonoperative
treatment is indicated: sling, early range of motion,
strengthening, and acceptance of deformity. Younger, more
active patients with more severe degrees of displacement
and laborers who use their upper extremity above the
horizontal plane may benefit from operative stabilization.
Repair is generally avoided in contact athletes because of
the risk of reinjury.
Type IV: Open reduction and surgical repair of the
coracoclavicular ligaments are performed for vertical
stability.
 Complications
Coracoclavicular ossification: not
associated with increased disability
Distal clavicle osteolysis: associated
with chronic dull ache and weakness
AC arthritis
 STERNOCLAVICULAR (SC) JOINT
INJURY
Epidemiology
Injuries to the SC joint are rare; Cave
et al. reported that of 1,603 shoulder
girdle dislocations, only 3% were SC,
with 85% glenohumeral and 12% AC
dislocations
 Classification
Anterior dislocation: more common
Posterior dislocation
Sprain or subluxation
Mild: joint stable, ligamentous integrity maintained
Moderate: subluxation, with partial ligamentous disruption
Severe: unstable joint, with complete ligamentous compromise
Acute dislocation: complete ligamentous disruption with frank
translation of the medial clavicle
Recurrent dislocation: rare
Unreduced dislocation
Atraumatic: may occur with spontaneous dislocation,
developmental (congenital) dislocation, osteoarthritis,
condensing osteitis of the medial clavicle, SC hyperostosis, or
infection
 Treatment
Mild sprain: Ice is indicated for the first 24 hours with
sling immobilization for 3 to 4 days and a gradual
return to normal activities as tolerated.
Moderate sprain or subluxation: Ice is indicated for the
first 24 hours with a clavicle strap, sling and swathe,
or figure-of-eight bandage for 1 week, then sling
immobilization for 4 to 6 weeks.
Severe sprain or dislocation
Anterior: As for nonoperative treatment, it is controversial
whether one should attempt closed reduction because it is
usually unstable; a sling is used for comfort. Closed
reduction may be accomplished using general anesthesia, or
narcotics and muscle relaxants for the stoic patient.
 Treatment
Posterior: A careful history and physical examination are necessary to
rule out associated pulmonary or neurovascular problems. Prompt
closed or open reduction is indicated, usually under general
anesthesia. Closed reduction is often successful and remains stable.
Medial physeal injury: Closed reduction is usually successful,
with postreduction care consisting of a clavicle strap, sling and
swathe, or figure-of-eight bandage immobilization for 4 to 6
weeks.
Operative management of SC dislocation may include fixation
of the medial clavicle to the sternum using fascia lata,
subclavius tendon, or suture, osteotomy of the medial clavicle,
or resection of the medial clavicle. The use of Kirschner wires
or Steinmann pins is discouraged, because migration of
hardware may occur.
 Complications
Poor cosmesis is the most common complication with patients
complaining of an enlarged medial prominence.
Complications are more common with posterior dislocations and
reflect the proximity of the medial clavicle to mediastinal and
neurovascular structures. The complication rate has been
reported to be as high as 25% with posterior dislocation.
Complications include the following:
Pneumothorax
Laceration of the superior vena cava
Venous congestion in the neck
Esophageal rupture
Subclavian artery compression
Carotid artery compression
Voice changes
Severe thoracic outlet syndrome
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