Scapular and Clavicle Fractures

Sternoclavicular Joint

Anatomy

Diarthrodial jt, both jt surfaces covered by fibrocartilage
Artic surface of clavicle larger than that of the sternum, jt surfaces not congruent

Ligaments

  1. intraarticular disc- fibrocartilage, divides jt into 2 cavities, rarely perforated
    - runs from synchondral junction of 1st rib + sternum to sup + post aspect of med clavicle. Ant and post it blends with the capsule.
    - acts to prevent med displacement of the med clavicle
  2. Costoclavicular lig ( = rhomboid lig) - form the upper surface of the 1st rib and synchondral junction with the sternum to the rhomboid tubercle on the inf surface of the clavicle. Has 2 laminae - run in same pattern as the int and ext oblique muscles.
    - ant fibres act to prevent upward motion of the clavicle
    - post fibres act to prevent downward motion of the clavicle
  3. Interclavicular lig - connects the superomed ends of each clavicle with the capsule and the upper sternum
    - acts to prevent upward motion of the med clavicle
  4. Capsule - thickened ant and post with the post being strongest
    - prevents upward displacement of the med clavicle

Ossification

the clavicle is the 1st long bone of the body to ossify ( 5th intrauterine wk)
the med epiphysis is the last to appear (~ 18 ) and last to close ( ~ 25)
The capsule attaches to the epiphysis and the costoclavicular lig attaches to the metaphysis.
Thus in a SH 1 injury the costoclavicular lig is detached from the metaphysis or torn while the capsule and epiphysis remain intact.
In a SH 2 injury the costoclavicular lig remains attached to the distal fragment comprising the epiphysis and a piece of metaphysis

Classification

Anterior - most common, caused by lat compression with the shoulder rolling backward
Posterior - uncommon, caused by lat compression with the shoulder rolling forward
Injuries to the jt can be
  1. sprain
  2. acute dislocation
  3. recurrent dislocation
  4. unreduced dislocation

Symptoms and signs

severe pain increased by any movement of the arm ( post more painful than ant )
the affected shoulder appears shortened and thrust forward cf the normal side

Anterior

the med clavicle can be observed and palpated ant to the sternum
med clavicle may be fixed or mobile

Posterior

the med prominence of the normal clavicle is absent
the med clavicle is not palpable
may be venous congestion
breathing or swallowing difficulties
pneumothorax
shock due to damage to great vessels

XRay

AP view difficult to interpret
Hobbs view - pt seated, leans over table with arms up and head resting in hands, cassette on table ~ under pts neck, XR beam directed vertically down
Serendipity view : pt supine, 40 deg cephalic tilt view
Tomography
CT - gold standard

Treatment

Sprain: Rest, sling, gradual return to activity

Dislocation, anterior

most ant dislocations are unstable - notwithstanding -
  1. CR - GA, pt supine, sandbag under centre of back
    assistant pushes shoulders back
    surgeon pushes clavicle back into place
  2. in most cases this will not remain reduced - pt counselled that the risks of ORIF outweigh the cosmetic benefits of reduction
  3. postreduction - if stable - clavicular rings to maintain position
    if unstable - sling, gradual return to activity
  4. NB cosmetic and functional deficit minimal if unreduced

Dislocation, posterior

once reduced are usually stable
may need to involve thoracic surgeon if mediastinal structures compromised
  1. CR - GA, pt supine, sandbag under centre of back
    gentle traction in line of clavicle, countertraction by assistant - this alone may reduce the dislocation
    if not reduced, add manipulation with a towel clip - will reduce with clunk
  2. rarely CR fails therefore ® OR
    same position, free drape arm
    involve thoracic surgeon
    incision parallel to med 7-10 cm clavicle
    reduction -
    if stable treat as for CR
    if unstable - excise the med 1- 1.5 cm clavicle and secure the remaining clavicle to the 1st rib with dacron tape
    post op - clavicular rings 6 wks

Unreduced dislocation

Anterior
functional and cosmetic deficit minimal if any - no treatment indicated
Posterior
due to risk to mediastinal structures - OR indicated ( as above)

Clavicular Fractures

Classification

Type 1

middle 1/3 fractures ~ 80%

Type 2

distal 1/3 fractures ~ 15%
  1. minimal displacement bw conoid and trapezoid ligs
    ie both ligs intact
  2. (a). fracture med to coracoclavicular ligs - displaced
  3. (b). fracture bw conoid and trapezoid lig - displaced - ie conoid lig ruptured, trapezoid lig intact
  4. intraartic fracture of AC jt - no lig disruption or displacement
  5. Paediatric: ligaments intact attached to periosteum while prox frag displaces up through the disrupted periosteal sleeve
  6. Comminuted with ligaments not attached prox or dist, but an inferior, comminuted fragment
Type 3 prox 1/3 fractures ~ 5%
  1. minimal displacement
  2. signif displacement ie ligs ruptured
  3. intraarticular
  4. epiphyseal separation - children and young adults
  5. comminuted

Assoc injuries

Skeletal AC and SC dislocations
head and neck injuries
fracture 1st rib
Scapulothoracic dissociation
Lung and pleura PTX or haemothorax
tears of trachea or main bronchi
Brachial Plexus ulnar n most often involved in direct trauma
Vascular unusual - vessels protected by subclavius and deep cervical fascia

Mechanisms of injury

birth trauma clavicle compressed against maternal symphysis in a cephalic presentation or direct traction in a breech delivery
~ 5/1000 live births
assoc with : birth wght, forceps delivery, prolonged 2nd stage in primip
R more than L due to LOA position
Trauma fall on outstretched hand or on point of shoulder
direct blow
seizures
Non- traumatic fracture: pathological - tumour, infection, A-V malformation

Treatment

Children
sling until comfortable
Adults
support in a sling - no advantage with fig 8 bandage
Indications for OR
  1. NV injury that fails to reverse with nonop management
  2. severe displacement threatening the integrity of the skin
  3. compound fracture
  4. multiple trauma
  5. a floating shoulder with a displaced clavicular fracture and an unstable scapular fracture
  6. Type 2 distal clavicular fracture
  7. unable to tolerate closed management - rare- eg Parkinsons, seizures
  8. unacceptable cosmesis
Techniques of OR
  1. plating with either DC or pelvic reconstruction plates
  2. intramedullary - use heavy Knowles pin to prevent migration

Complications

Nonunion

rare ~ .9-4%
due to
inadequate immobilisation
severity of trauma
refracture
distal 1/3 fracture
marked displacement
primary ORIF
~ 75% of pts with nonunions are symptomatic
Treatment of Nonunion:
  1. plating with either DC or pelvic reconstruction plates
  2. intramedullary - use heavy Knowles pin to prevent migration
  3. Always use BG
  4. try not to shorten the clavicle - better to insert an intercalary BG to maintain length

Malunion

children remodel
adults do not remodel - can get shortening or angulation
if more than 15 mm shortening have statistically signif more pain
Treatment
swap bump etc for a scar
shaving or bevelling bone
osteotomy - risk nonunion
Neurovascular - may get compression or direct trauma to vessels or plexus
Post traumatic Arthritis - following intra articular fracture at either end
treat by excision arthroplasty

Acromio-clavicular Joint Dislocation

Classification

Types
  1. Intra-articular damage of the acromio-clavicular joint alone without ligamentous instability either of the joint capsule or of the coraco-clavicular ligaments
  2. Dislocation of the acromio-clavicular joint and disruption of its capsule and ligaments without disruption of the coraco-clavicular ligaments
  3. Acromio-clavicular separation with disruption of the coraco-clavicular ligaments as well as the AC ligaments leaving the clavicle grossly unstable
    - coracoclavicular interspace 25- 100% greater than normal side
  4. a type 3 with the distal clavicle displaced posteriorly into or through the trapezius
  5. a type 3 but with exaggeration of the vertical displacement of the clavicle from the scapula
    - coracoclavicular interspace 100- 300% greater than the normal side
  6. a type 3 with the clavicle dislocated inferiorly either subcoracoid or subacromial

XRays

Normal jt
normal width is 1-3mm
more than 7mm in men and 6mm in women is abnormal
AP view
pt standing with arms hanging unsupported, both AC jts on one film
Zanca view
10-15 deg cephalic tilt view
Axillary view
to see any post displacement of the clavicle
Stress view
AP XR with 10- 15 lb wghts hanging from both hands

Treatment

Type I and Type II injuries are treated conservatively and if ® acromio-clavicular arthritis should be treated by excision arthroplasty
- Supportive sling for 3 - 4 weeks ® mobilisation of the shoulder

Type III injuries ® also conservative treatment initially unless considered to be an at risk patient ® surgical repair (+/- excision outer end of clavicle)

Type IV, V and VI : surgical repair

Weaver and Dunn operation equally effective for both early and late cases therefore no indication to operate in the acute stage except in selected cases, patients who do heavy work and those whose daily work or recreational activities requires that the shoulder be held in an abducted position
ref: Weaver and Dunn " Treatment of AC injuries, especially complete AC separation"
JBJS 54A: 1187-1197, 1972

Late resection of the distal part of the clavicle ( = Mumford procedure) reliably produces significant clinical improvement if patients develop problems

Other options
screw fixation clavicle to coracoid ( Bosworth)
direct repair of coracoclavicular ligs
use of a sling to hold the clavicle down
imbrication of the deltoid and trapezius over the distal clavicle

Complications

1. of the acute injury

skeletal: fracture clavicle, acromion or coracoid
coracoclavicular calcification or ossification - common - does not affect late results
osteolysis of the distal clavicle - can follow acute injury or may occur in those that have recurrent stress on the shoulder eg weight lifters

2. of operative treatment

Early
infection
loss of reduction with recurrence of deformity
unsightly scar
Late
soft tissue calcification
AC OA
Implant - failure, erosion of bone, migration
necessity to remove

Scapular Fractures

rare: 3-5% of shoulder girdle injuries
requires high energy trauma eg MVA

Ossification

forms in cartilage - 6th wk
primary ossification centre at glenoid angle - 8th wk - by birth blade and spine are ossified
secondary centres
3/12-18/12 - midcoracoid
~ 10 yo - base of coracoid + upper 1/3 glenoid - fuses to rest of coracoid at ~ puberty
~ puberty:
-tip of coracoid
-acromion
-medial border
-inferior angle
-lower margin glenoid
these fuse at ~ 25 yo
failure of the acromial secondary centres to fuse to the body = an os acromiale

Classification

Type

  1. fracture of the body
  2. fracture of the apophysis, including the coracoid and acromion
  3. fracture of the superolat angle, including the neck and glenoid

Glenoid fracture ( intraartic) classified into ( Ideberg)

  1. an anterior avulsion fracture
  2. transverse fracture through the gleniod with an inferior triangular fragment displaced with the humeral head
  3. oblique fracture through the glenoid exiting at the midsuperior border of the scapula
  4. horizontal fracture - exiting through the medial border of the blade
  5. combines type 4 with a fracture separating the inf part of the glenoid

Associated injuries

common - 35-98% of cases - reflects the high energy to fracture the scapula
Skeletal
ipsilat upper limb fracture
fracture ribs
Visceral
PTX
lung contusion
Brachial plexus
Head injuries

XRay

AP/ True lat / axillary views
35-60 deg cephalic tilt views to see coracoid
CT - allows evaluation of a glenoid fracture

Treatment

Type 1

support and symptomatic relief
early ROM exercises to maintain function

Type 2

fracture acromion
undisplaced fracture: symptomatic relief, sling for short period
displaced fracture may require ORIF if causing impingement or if needing to reduce the AC jt
otherwise treat nonoperatively
fracture coracoid
treat nonoperatively unless grossly displaced or causing NV compromise
can ORIF or can excise the fragment and reattach muscles to the base of the process without causing problems

Type 3

Glenoid neck ( extraarticular fracture)
reduction not necessary
symptomatic relief, support, early ROM exs
- if in assoc with a floating shoulder - ORIF of the clavicle = faster rehab
Glenoid ( intraarticular)
Type 1. if fragment more than 25% of glenoid - ORIF
less than 25% - nonop
Types 2-5. aim for nonop treatment with early ROM exs
ORIF only if major incongruity or shoulder instability

Scapulothoracic Dissociation

Violent lat displacement of the scapula with clavicular disruption and soft tissue disruption
eg to brachial plexus or vessels
significant risk of death

XRays

on a nonrotated AP view the ratio of the medial border to spine distances is 1.5 or greater

Treatment

resuscitation
assessment of neurological loss
vascular injury - arteriography
reconstruction of vascular damage
exploration of plexus for diagnosis +/- repair/ reconstruction