Injuries of the Clavicle, Injuries of the Clavicle, Acromioclavicular Joint and Acromioclavicular Joint and

Sternoclavicular JointSternoclavicular Joint

Fahad Fahad zakwanzakwan

Goals

•1) Review anatomy of clavicle, AC joint, and 1) Review anatomy of clavicle, AC joint, and sternoclavicular jointsternoclavicular joint•2) Review imaging of these areas.2) Review imaging of these areas.•3) Clavicle Fractures3) Clavicle Fractures

Nonoperative RXNonoperative RXSurgical RepairSurgical RepairNonunions and MalunionsNonunions and Malunions

•4) AC Joint Injuries4) AC Joint Injuries•5) Sternoclavicular joint injuries5) Sternoclavicular joint injuries

THE CLAVICLETHE CLAVICLE

• The clavicle is a doubly curved (S – shaped) bone The clavicle is a doubly curved (S – shaped) bone that acts as a strut btw the scapula and the that acts as a strut btw the scapula and the sternum, located directly above the first rib.sternum, located directly above the first rib.

• Medially it articulates with manubrium of the Medially it articulates with manubrium of the sternum at the sternoclavicular joint.sternum at the sternoclavicular joint.

• Laterally it articulates with the acromion of the Laterally it articulates with the acromion of the scapula at the Acromioclavicular joint.scapula at the Acromioclavicular joint.

• It has rounded medial end and a flattened lateral It has rounded medial end and a flattened lateral end.end.

ClavicleClavicle

•Muscle attachments:Muscle attachments:•Medial: Medial: sternocleidomastoidsternocleidomastoid• Lateral: Trapezius, Lateral: Trapezius, pectoralis majorpectoralis major

AC Joint

• Diarthrodial joint between medial facet of acromion and the lateral (distal) clavicle.• Contains intra-articular disk of

variable size.• Thin capsule stabilized by

ligaments on all sides:• AC ligaments control horizontal

(anteroposterior ) displacement• Superior AC ligament most important

Distal Clavicle

•Coracoclavicular ligaments• “Suspensory ligaments of the upper extremity”• Two components:• Trapezoid• Conoid

• Stronger than AC ligaments• Provide vertical stability to AC joint

Mechanism of Injury

• Direct impact to the anterior - superior shoulder of moderate – high force.

1. Fall from height2. Motor vehicle accident3. Sports injury4. Blow to the point of the shoulder5. Rarely, a direct injury to the clavicle

Physical Examination

•Inspection• Evaluate deformity and/or displacement• Beware of rare inferior or posterior displacement of distal or medial ends of clavicle• Compare to opposite side.

Physical Examination

•Palpation•Evaluate pain•Look for instability with stress

• Neurovascular examination• Must be done thoroughly

and documented!• Evaluate upper extremity

motor and sensation• Measure shoulder range-

of-motion

Radiographic Evaluationof the Clavicle

• Anteroposterior View

• 30-degree Cephalic Tilt View

Radiographic Evaluation of the Clavicle

•Quesana ViewQuesana View• 45-degree angle superiorly 45-degree angle superiorly and a 45-degree angle and a 45-degree angle inferiorly inferiorly • Provide better assessment of Provide better assessment of the extent of displacementthe extent of displacement

•Zanca View•AP view centered at AC joint with 10 degree cephalic tilt•Less voltage than used for AP shoulder

Stress Views of the Distal Clavicle & AC Joint

• Rationale: demonstrate instability and differentiate grade III AC separations from partial Grade I-II injuries.• Performed by having patient hold 10# weight with injured arm.• Rarely used today, since most Grade I-III AC joint injuries are treated the same anyway, and management of distal clavicle fractures depends on initial displacement and location of fracture.

Radiographic Evaluation of the Medial One Third

•X-ray: Cephalic tilt view of 40 to 45 degrees•CT scan usually indicated to best assess degree and direction of displacement

S=sternumC= medial clavicleE= esophagus

CLAVICLE CLAVICLE FRACTURESFRACTURES

Classification of Clavicle Fractures

•Group I : Middle third•Most common (80% of clavicle fractures)

•Group II: Distal third•10-15% of clavicle injuries

•Group III: Medial third•Least common (approx. 5%)

Treatment Options

•Nonoperative• Sling• Brace

•Surgical• Plate Fixation• Screw or Pin Fixation• Titanium elastic nails (usually inserted medial to lateral)

Nonoperative Treatment

•“Standard of Care” for most clavicle fractures.•Unclear about the need to wear a specialized brace.

Clavicle FractureSling and Swathe

Clavicle FractureVelpeau

Figure of eight bandage

Nonoperative Treatment

• It is difficult to reduce clavicle fractures by closed means.•Most clavicle fractures unite rapidly despite displacement.•Significantly displaced mid-shaft and distal-third injuries have a higher incidence of nonunion.

Nonoperative Treatment

•There is new evidence that the outcome of nonoperative management of displaced middle-third clavicle fractures is not as good as traditionally thought, with many patients having significant functional problems.

Definite Indications for Surgical Treatment of Clavicle Fractures

•1) Open fractures•2) Associated neurovascular injury

Relative Indications for Acute Treatment of Clavicle Fractures

1. Widely displaced fractures2. Multiple trauma3. Displaced distal-third

fractures4. Floating shoulder5. Seizure disorder6. Cosmetic deformity7. Earlier return to work.

Plate Fixation

•Traditional means of ORIF•Plate applied superiorly or inferiorly• Inferior plating associated with lower risk of hardware prominence.

•Used for acute displaced fractures and nonunion.

Intramedullary Fixation

•Large threaded cannulated screws

•Flexible elastic nails

•K-wiresAssociated with risk of migration

•Useful when plate fixation contra-indicated

Bad skinSevere osteopenia

•Fixation less secure

Titanium Elastic Nails

•Same as used in pediatric femur fractures.

•Accommodate three-dimensional anatomy of the clavicle.

•Typically inserted “retrograde” (from medial to lateral)

•Best in fractures without comminution

•Small incision at fracture site may be needed.

Comparison of Techniques

•No studies available that compare one operative technique to another. •Both elastic nails and plates seem equivalent in stable fractures; benefits of minimally invasive approach used in elastic nailing awaiting study. •Plate fixation best in comminuted fractures, but again no evidence.

Complications of Clavicular Fractures and its Treatment

•Nonunion•Malunion •Neurovascular Sequelae•Post-Traumatic Arthritis

Risk Factors for the Development of Clavicular Nonunions

•Location of Fracture • (outer third)

•Degree of Displacement • (marked displacement)

•Primary Open Reduction

Principles for the Treatment of Clavicular Nonunions

•Restore length of clavicle•May need intercalary bone graft

•Rigid internal fixation, usually with a plate• Iliac crest bone graft• Role of bone-graft substitutes not yet defined.

Correction of symptomatic nonunion with IM screw

Clavicular Malunion

• Symptoms of pain, fatigue, cosmetic deformity.• Initially treat with strengthening, especially of scapulothoracic stabilizers.• Consider osteotomy, internal fixation in rare cases in which nonoperative treatment fails.

Correction of malunion with thoracic outlet sx

Neurologic Sequelae

•Occasionally, fracture fragments or abundant callus can cause brachial plexus symptoms.•Treatment is reduction and fixation of the fracture, or resection of callus with or without osteotomy and fixation for malunions.

DISTAL THIRD CLAVICLE DISTAL THIRD CLAVICLE FRACTURESFRACTURES

Classification of Distal Clavicular Fractures(Group II Clavicle Fractures)

•Type I-Type I-nondisplacednondisplaced

•Between the CC and AC ligaments with ligament still intact

Type II

•Typically displaced secondary to a fracture medial to the coracoclavicular ligaments, keeping the distal fragment reduced while allowing the medial fragment to displace superiorly•Highest rate of nonunion (up to 30%)•Two Types

Type IIA

A. Conoid and trapezoid attached to distal fragment

Type IIB

B: Conoid torn, trapezoid attached

Type III:

• articular fractures

From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

Treatment of Distal-Third (Type II) Clavicle Fractures

• Nonoperative treatment• 22 to 33% failed to unite• 45 to 67% took more than three months to heal

• Operative treatment• 100% of fractures healed within 6 to 10 weeks

after surgery

•Displaced Type II fractures of the distal clavicle are often treated more aggressively because of the increased risk of nonunion with nonoperative treatment

Techniques for Acute Operative Treatment of Distal Clavicle Fractures

•Kirschner wires inserted into the distal fragment•Dorsal plate fixation•CC screw fixation •Tension-band wire or suture•Transfer of coracoid process to the clavicle•Clavicular Hook Plate

•For most techniques of clavicular fixation, coracoclavicular fixation is also needed to prevent redisplacement of the medial clavicle.

The Hook Plate (Synthes USA, Paoli, PA) was The Hook Plate (Synthes USA, Paoli, PA) was specifically designed to avoid this problem of specifically designed to avoid this problem of redisplacement.redisplacement.

Hook Plate - Results

•Recent series of distal clavicle fractures treated with the Hook Plate document high union rates of 88% - 100%. •Complications are rare but potentially significant, including new fracture about the implant, rotator cuff tear, and frequent subacromial impingement.

Preferred technique for fixation of acute distal third clavicle fractures

•Horizontal incision•Manual reduction of fracture•Dorsal tension band suture and reconstruction/augmentation of coracoclavicular ligaments.

Look for avulsion fracture of CC ligament attachment

• If present, this fragment can be sutured to proximal (eg. medial) clavicle to restore stability, without need for hardware.

• Jackson WFM, et al. J Trauma 2006;61:222-225

Indications For Late Surgery For Distal Clavicle Fractures

•Pain•Weakness•Deformity

Techniques For Late Surgery For Distal Clavicle Fractures

•Excision of distal clavicle•With or without reconstruction of coracoclavicular ligaments (Modified Weaver-Dunn procedure)

•Reduction and fixation of fracture

Case Example Case Example 11

Case Example 1Case Example 1

Distal Clavicle

Medial Clavicle

Case Example Case Example 11

Coracoclavicular fixation not visible

Fixation to Acromion

Case Example 2Case Example 2

This fragment likely has CC ligament attached; need to reduce and hold clavicle shaft to this piece.

Case Example 2Case Example 2

This fragment likely has CC ligament attached; need to reduce and hold clavicle shaft to this piece.

Sutures passed into this fragment (not visible)

Case Example 2

This fragment likely has CC ligament attached; need to reduce and hold clavicle shaft to this piece.

Sutures passed into this fragment (not visible)

4 months

Acromioclavicular Joint

Mechanism

•Sports injury or trauma.Sports injury or trauma.•Impact to superior acromion, driving Impact to superior acromion, driving the arm down and rupturing the AC the arm down and rupturing the AC joint capsule (first) and then the the joint capsule (first) and then the the coracoclavicular ligaments (second).coracoclavicular ligaments (second).

Physical Findings

•Pain over lateral clavicle / AC joint•May have prominent distal clavicle•May have skin abrasions•Unwilling to lift arm.•Should have full passive ROM of the shoulder.

Radiographic Evaluation of the Acromioclavicular Joint

• Proper exposure of the AC joint requires one-third to one-half the x-ray penetration of routine shoulder views• Initial Views:• Anteroposterior view• Zanca view (15 degree cephalic tilt)

•Other views:• Axillary: demonstrates anterior-posterior displacement• Stress views: not generally relevant for treatment decisions.

Classification For Acromioclavicular Joint Injuries

•Initially classified by both Allman and Tossy et al. into three types (I, II, and III). •Rockwood later added types IV, V, and VI, so that now six types are recognized.•Classified depending on the degree and direction of displacement of the distal clavicle.

Type I Type I •Sprain of acromioclavicular ligament•AC joint intact •Coracoclavicular ligaments intact•Deltoid and trapezius muscles intact

• AC joint disrupted•< 50% Vertical displacement• Sprain of the coracoclavicular ligaments• CC ligaments intact•Deltoid and trapezius muscles intact

Type II Type II

Type III Type III • AC ligaments and CC

ligaments all disrupted• AC joint dislocated and the

shoulder complex displaced inferiorly• CC interspace greater than

the normal shoulder(25-100%)• Deltoid and trapezius

muscles usually detached from the distal clavicle

Type III Type III Variants Variants • “Pseudo-dislocation” through an intact

periosteal sleeve

• Physeal injury

• Coracoid process fracture

Type IV Type IV • AC and CC ligaments disrupted • AC joint dislocated and clavicle displaced posteriorly into or through the trapezius muscle•Deltoid and trapezius muscles detached from the distal clavicle

Type V Type V • AC ligaments disrupted • CC ligaments disrupted• AC joint dislocated and

gross disparity between the clavicle and the scapula (100-300%)• Deltoid and trapezius

muscles detached from the distal half of clavicle

Type VI Type VI • AC joint dislocated and

clavicle displaced inferior to the acromion or the coracoid process• AC and CC ligaments

disrupted• Deltoid and trapezius

muscles detached from the distal clavicle

Treatment Options For Types I - II Acromioclavicular Joint Injuries

Nonoperative: Nonoperative: •Ice and protection until pain subsides (7 to 10 days).Ice and protection until pain subsides (7 to 10 days).•Return to sports as pain allows (1-2 weeks)Return to sports as pain allows (1-2 weeks)•No apparent benefit to the use of specialized braces.No apparent benefit to the use of specialized braces.

operative treatmentoperative treatment• Generally reserved only for the patient with chronic pain.Generally reserved only for the patient with chronic pain.• Treatment is resection of the distal clavicle and reconstruction of Treatment is resection of the distal clavicle and reconstruction of

the coracoclavicular ligaments.the coracoclavicular ligaments.

Treatment Options For Type III-VI Acromioclavicular Joint Injuries

• Nonoperative treatment• Closed reduction and application of a sling and harness to

maintain reduction of the clavicle• Short-term sling and early range of motion

• Operative treatment• Primary AC joint fixation• Primary CC ligament reconstruction (usually with allograft,

often with augmentation)• Excision of the distal clavicle • Dynamic muscle transfers

• Type III Injuries: Need for acute surgical treatment remains very controversial.

• Most surgeons recommend conservative treatment except in the throwing athlete or overhead worker.

• Repair generally avoided in contact athletes because of the risk of reinjury.

Indications for Acute Surgical Treatment of Acromioclavicular Injuries

• Type III injuries in highly active patients

• Type IV, V, and VI injuries

Surgical Options for AC Joint Instability

• Coracoid process transfer to distal transfer (Dynamic muscle transfer)

• Primary AC joint fixation

• Primary Coracoclavicular Fixation

• CC ligament reconstruction +/- distal clavicle excision.

Weaver-Dunn Procedure

• The distal clavicle is excised.• The CA ligament is

transferred to the distal clavicle.

• The CC ligaments are repaired and/or augmented with a coracoclavicular screw or suture.

• Repair of deltotrapezial fascia

•

From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

Indications for Late Surgical Treatment of Acromioclavicular Injuries

• Pain

• Weakness

• Deformity

Techniques for Late Surgical Treatment of Acromioclavicular Injuries

• Reduction of AC joint and repair of AC and CC ligaments

• Resection of distal clavicle and reconstruction of CC ligaments (Weaver-Dunn Procedure)

Case Example

AP View

Zanca View

Case Example

After Weaver-Dunnprocedure

STERNOCLAVICULAR JOINTSTERNOCLAVICULAR JOINT

The Anatomy of the Sternoclavicular Joint

• Diarthrodial Joint• “Saddle shaped”• Poor congruence• Intra-articular disc

ligament. Divides SC joint into two separate joint spaces.• Costoclavicular ligament-

(rhomboid ligament) Short and strong and consist of an anterior and posterior fasciculus

• Interclavicular ligament- Connects the superomedial aspects of each clavicle with the capsular ligaments and the upper sternum• Capsular ligament- Covers the anterior and posterior aspects of the joint and represents thickenings of the joint capsule. The anterior portion of the ligament is heavier and stronger than the posterior portion.

Epiphysis of the Medial Clavicle

•Medial Physis- Last of the ossification Medial Physis- Last of the ossification centers to appear in the body and the centers to appear in the body and the last epiphysis to close. last epiphysis to close. •Does not ossify until 18th to 20th Does not ossify until 18th to 20th yearyear•Does not unite with the clavicle until Does not unite with the clavicle until the 23rd to 25th yearthe 23rd to 25th year

Radiographic Techniques for Assessing Sternoclavicular Injuries

•40-degree cephalic tilt view•CT scan- Best technique for sternoclavicular joint problems

Injuries Associated with Sternoclavicular Joint Dislocations

•Mediastinal Compression•Pneumothorax •Laceration of the superior vena cava•Tracheal erosion

Treatment of Anterior Sternoclavicular Dislocations

• Nonoperative treatment

• Analgesics and immobilization• Functional outcome usually good

• Closed reduction

•Often not successful•Direct pressure over the medial end of the clavicle may reduce the joint

Treatment of Posterior Sternoclavicular Dislocations

•Careful examination of the patient is extremely important to rule out vascular compromise.•Consider CT to rule out mediastinal compression•Attempt closed reduction - it is often successful and remains stable.

Closed Reduction Techniques

• Abduction traction

• Adduction traction

• “Towel Clip” - anterior force applied to clavicle by percutaneously applied towel clip

Operative techniques

• Resection arthroplasty

•May result in instability of remaining clavicle unless stabilization is done.• Suggest minimal resection of bone and fixation of medial clavicle to first rib.

• Sternoclavicular reconstruction with suture, tendon graft.