Apley 24

Fractures of Clavicle
• MOI
• A fall on the shoulder or the outstretched hand
• Clinical Features
• The arm is clasped to the chest to prevent movement
• A subcutaneous lump
• Imaging
• AP view
• Classification
• Clavicle 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
• Neer Classification
• Robinson Classification
• Treatment
• Middle-third Fractures
• Undisplaced fractures - non operative — simple sling
• Severe displacement, fragmentation, or shortening — plating (specific contoured locking
plates) and intramedullary fixation
• Lateral-third Fractures
• Most lateral clavicle fractures are minimally displaced and extra-articular. The
coracoclavicular ligaments are intact prevents further displacement — non-operative —
sling 2-3 weeks
• Displaced lateral-third fractures — disruption of the
coracoclavicular ligaments — unstable injuries
• Surgery — higher complication
• CC screw and plate, hook plate fixation, suture and sling
techniques with Dacron graft ligaments, lateral clavicle
locking plates
• Medial-third fractures
• Rare — mostly extra-articular — non operatively
• Complication
• Early
• Pneumothorax, damage to subclavian vessels, BPI are all very rare
• Late
• Non-union
• Malunion
• Stiffness of the shoulder
• Fractures of Scapula
Fractures of Scapula
• MOI
• High-energy trauma
• Associated injuries: rib fractures and intrathoracic injuries
• The arm is held immobile
• Severe bruising over the scapula or the chest wall
• Imaging
• AP of the scapula, axillary view and scapular Y views are the most helpful
• CT and 3D
• Classification
• Fractures of the scapular body
• Fractures of the glenoid neck
• Intra-articular glenoid fossa fractures
(Ideberg modified by Goss)
• Type I Fractures of the glenoid rim
• Type II Fractures through the glenoid fossa, inferior
fragment displaced with subluxed humeral head
• Type 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 scapula
• Type V Combination of type IV and a fracture
separating the inferior half of the glenoid
• Type VI Severe comminution of the glenoid surface
• Fractures of the acromion
• Type I Minimally displaced
• Type II Displaced but not reducing subacromial space
• Type III Inferior displacement and reduced subacromial space
• Fractures of the coracoid process
• Type I Proximal to attachment of the coracoclavicular ligaments and usually associated with
acromioclavicular separation
• Type II Distal to the coracoacromial ligaments
• Treatment
• Body fractures — Surgery is not usually necessary. The patient wears a sling for comfort and active
exercises to the shoulder,
elbow and fingers. Isolated glenoid neck fractures — A sling is worn for comfort and early exercises are
begun.
• Intra-articular fractures
• Type II – ORIF
• Type III, IV, V, VI poorly define indication for surgery
• Fractures of the acromion — Undisplaced fractures are treated non-operatively.
• Fractures of the coracoid process — Those proximal to the ligaments are usually associated with
acromioclavicular separations and may need operative treatment
Scapulothoracic Dissociation
• MOI
• High-energy injury
• The scapula and arm are wrenched away from the chest, rupturing the subclavian vessels and brachial plexus
• The limb is flail and ischemic
• Swelling above the clavicle
• High mortality rate associated with this injury
• Imaging
• Chest X-ray — lateral displacement of the scapula
• Treatment
• The patient is resuscitated.
• The outcome for the upper limb is very poor.
• Functional outcome is dependent on the neurological injury but in many cases early amputation may be the
outcome
Acromioclavicular Joint Injuries
• MOI
• A fall on the shoulder with the arm adducted causing: AC ligament
strain or tear, CC ligament tear, subluxation or dislocation of clavicle
• The patient can usually point to the site of injury and the area may be bruised.
• Imaging
• Anteroposterior, cephalic tilt and axillary views
• A stress view — an AP X-ray the patient standing upright, arms
by the side and holding a 5 kg weight in each hand. A difference of
more than 50% is diagnostic of acromioclavicular dislocation
• Classification
• Rockwood grade
• I. AC ligament sprain
• II. AC tear, CC intact
• III. AC & CC ligament tears 100% superior
displacement
other types are less common
• IV. Grade III w /posterior displacement
• V. Grade III 300% superior displacement
• VI. Grade III w/ inferior displacement
• Treatment
• Sprains and subluxations — the arm is rested in a sling until pain
subsides
• Type III — Accurate reduction should be the goal
• No convincing evidence that surgery provides a better functional result than
conservative.
• The modified Weaver–Dunn procedure
• The lateral end of the clavicle is excised

• the coracoacromial ligament is transferred to the outer end of the clavicle and attached
by transosseous sutures
• Tension on the repair can be reduced either by anchoring the clavicle to the coracoid
with various techniques such as anchors or slings around the coracoid and clavicle.
• Complication
• Rotator cuff problems
• Unreduced dislocation
• Ossification of the ligaments
• Secondary osteoarthritis
Sternoclavicular Dislocation
MOI
Lateral compression of the shoulders
Clinical Features
Anterior dislocation of medial end of the clavicle forms a prominent
bump over the sternoclavicular joint
Painful
Imaging
X-rays — Oblique views
CT Scan
Treatment
Anterior dislocation can be reduced by exerting
pressure over the clavicle and pulling on the arm with the
shoulder abducted
Internal fixation is usually unnecessary
Posterior dislocation should be reduced by lying the patient supine
with a sandbag between the scapulae and then pulling on the arm
with the shoulder abducted and extended. The joint reduces with a
snap and stays reduced.
If this manoeuvre fails, the medial end of the clavicle is grasped
with bone forceps and pulled forwards
If fails — open reduction is justified

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Fractures of Clavicle

• The lateral end of the clavicle is excised

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