Clavicle and scapular fracture

Fracture in clavicle and scapula and approach to their management
clavicle fracture
scapula fracture

Dr Kuldeep Singh
AIIMS Bhopal
Ortho resident

1. CLAVICLE AND SCAPULAR NAME- Dr. KULDEEP SINGH Ortho Resident AIIMS Bhopal

2. Clavicle fracture Clavicle fractures are common injuries Account for 2.6% of all fractures Up to 44% of injuries to the shoulder girdle Easy to recognize Majority unite uneventfully

3. Incidence & Classification Group 1 (middle one third of the clavicle - the shaft) 80-85%. Group 2 (lateral one third - the acromial end)15-20%. Group 3 (medial one third - the sternal end) 0-5%.

4. Mechanism of Injury Trauma – Fall against lateral shoulder (90%) – Fall on Outstretched Hand (5%) – Direct blow to clavicle (5%) Non traumatic (in children) – Tumor – Rickets – Osteogenesis imperfecta – Physical Abuse

5. Displacement mechanism

6. Diagnosis C/F- Symptoms - Pain and swelling , decreased movement of the affected limb. Sign - Bruising, Tenderness Crepitation , Pressure on the overlying skin & palpable deformity.

7. Radiographs Different angles: AP – evaluate superior-inferior displacement 45’ cephalic tilt(Serendipity view) view » Evaluate AP displacement • Stress views useful in lateral 1/3 fractures to assess AC & CC ligaments injury. • Chest x-ray • CT

8. Classification Based on the position of the fracture:[“ Allman ”] Distal third (Group II) Middle third (Group I) Proximal (Group III). “ Neer ” divided distal clavicle fractures into three subgroups, based on their ligamentous attachments and degree of displacement.

9. Classifications Group-II: Type I : Distal clavicle fracture with the intact coracoclavicular ligaments.

10. Classifications Group II -TYPE II TYPE-IIA TYPE-IIB (Rockwood): Conoid detached from the medial fragment (Rockwood): Both conoid and trapezoid attached to the distal fragment

11. Group II: Type III: Distal clavicle fracture with extension into the AC joint. Group III: Medial clavicular fracture- subgroups are Type 1 :Minimal displacement Type 2: Displaced Type-3: Intra- articular Type-4: Epiphyseal seperation Type-5: Comminuted

12. Other Classifications AO/OTA classification scheme of clavicle fractures. Robinson classification scheme of clavicle fractures.

13. Non-operative Treatment Indications : Majority cases – Non-displaced Group I (middle third) – Stable Group II fractures – Group III (medial third) Technique – Sling or figure-of-8 – 2-4 weeks-gentle ROM exercises. – No attempt at reduction should be made.

14. Clavicle fracture rehabilitation Protocol Lädermann et al. Functional recovery following early mobilization & rehabilitation after clavicle fractures : A case-control study. Orthop Traumatol Surg Res. 2017;103(6):885–9 .

15. Operative management Stabilization techniques include – Plate fixation – Intramedullary fixation – External fixation – Coracoclavicular ligament repair or reconstruction in Group II • Postoperative rehabilitation – Sling for 2wk followed by active motion – Strengthening exercise at 6-8 weeks when pain free motion and radiographic evidence of union – Full activity including sports at ~ 3 months

16. MID CLAVICULAR FRACTURE

17. DISTAL CLAVICULAR FRACTURE

18. Direct fixation of the fracture site without coraco-clavicular stabilization 1.Plate Fixation The distal fragment is large enough to hold a minimum of two, and ideally three, bi-cortical screws

19. 2.The clavicular hook plate: If distal fragment is too small . Usually removal at 3 month post-op.

20. 3. intramedullary nailing- Completely displaced transverse fracture. Advantages- smaller, more cosmetic skin incision less soft tissue stripping at fracture site decreased hardware prominence Disadvantages- 1.inferior in resisting displacement as compare to plate fixation 2.Implant failure 3. Infection 4. nail protrusion/irritation on the medial side

21. 4.Kirschner Wire Fixation Inherent risk of wire breakage and migration. High nonunion and infection rates. So not use d now a days .

22. 5.Endobutton Technique The use of two Endo-Buttons, toggled through drill-holes in the clavicle and coracoid

23. 2. Direct Fixation of the Fracture with Coracoclavicular Stabilization Indications : -Very distal fracture in a young individual. -Fractures that involve the clavicular insertion of the coracoclavicular ligaments . Bosworth screw

24. MEDIAL CLAVICULAR FRACTURES

25. TREATMENT Usually managed non-operatively. Except- fracture displacement which produces superior mediastinal compromise  require urgent attempt at closed reduction or open reduction next if this is unsuccessful.

26. Complications Complications of nonoperative treatment - Nonunion (1-5%) -Decreased shoulder strength and endurance Complications of operative treatment(10%- 30%) – Hardware complications : 30% request for plate removal. – Infection (~4.8%) – Mechanical failure (~1.4%)

27. Conclusion Completely displaced midshaft fractures: superior results with primary fracture fixation. Anteroinferior plating- may reduce risk of symptomatic hardware compared to superior plating. Outcome: No difference between regular sling & figure-of-eight bandage. Outcome: No difference between plating & intramedullary nailing of displaced midshaft fractures.

28. SCAPULAR FRACTURE

29. SCAPULA Is a flat triangular bone that lies on the posterior thorax wall between 2-7 rib. It enveloped by : supraspinatus muscle Infraspinatus muscle Subscapularis muscle Attached to clavicle at acromioclavicular . Articulate with humerus at glenohumeral joint .

30. Fracture of scapula Uncommon - location and surrounding muscles protection . R esult of high energy trauma with 60-98 % associated injuries 0.4% to 0.9% of all fractures. 3% to 5% of shoulder girdle #.

31. Associated life threatening injuries Pneumothorax Pulmonary contusion Arterial injury Abdominal injury Head injury (10% to 42% of all cases of scapula fracture.) Brachial plexus injury

32. Mechanism of injury From severe direct trauma Fall from height with direct landing on posterior aspect of trunk. Fall on shoulder Fall on outstretched hand

33. Clinical picture Brusing over scapula or chest area . Pain in movement . Swelling around back of shoulder . Tenderness at site of # . Arm is held immobile .

34. Diagnosis X – ray : Anteroposterior view \ lateral \ axillary view. Neer I projection : true AP To assess glenohumeral joint space Displacement of the glenoid in relation to the lateral border of the scapula To measure the glenopolar angle (GPA).

35. Diagnosis Neer II projection : Y-view - true lateral scapular projection. A llows- Assessment of scapular body fractures in terms of translation, angulation , and overlap of fragments Displays relationship between the acromion and the lateral clavicle To identify any avulsion of the anterior rim of the glenoid . CT scan : Useful in glenoid or body fracture.

36. Glenopolar angle (GPA) Angle b/w two lines, one connecting the most cranial & most caudal point of the glenoid one connecting the most cranial point of the glenoid with the most caudal part of the scapula . GPA of less than 20 degrees is associated with a poor functional outcome GPA of less than 20’ is one of the criteria for operative treatment.

37. Ideberg Classification Type 1a- Anterior rim Type 1b- Posterior rim Type 2- Transverse  to lateral margin Type 3- Transverse to superior margin Type 4- Transverse to medial margin Type 5a- Transverse lateromedial Type 5b- Transverse superomedial Type 5c- Transverse supero - medio -lateral Type 6- Comminuted crush- irreparable

38. Anatomic classification( Zdravkovik & Damholt ) Type-1 :Scapular body fracture Type-2: Apophyseal fracture, including the acromian and coracoid Type-3 : Fracture of supero -lateral angle, including scapular neck and glenoid .

39. Classification ( Tscherne and Christ ) 1. Fractures of processes 2. Fractures of the scapular body(~50%) 3. Fractures of the scapular neck 4. Fractures of the glenoid fossa 5. Combined and comminuted fractures.

40. Fractures of processes A1—fractures of the superior border and the superior angle A2—fractures of the acromion and the lateral part of the scapular spine A3—fractures of the coracoid process A2 A3

41. Fracture of body : B1—anatomical body ( fracture lines pass from the supraspinous fossa-scapular spine- infraspinous fossa) B2—biomechanical bod y(only infraspinous fossa)

42. Fracture of neck : Separating the glenoid from the scapular body. C1—Anatomical neck # C2—Surgical neck #- line passes through the suprascapular notch. C3 — T rans spinous neck #. line passes medial to the suprascapular notch. C3

43. Glenoid Fossa Fractures D1—superior glenoid #- d/t avulsion of the coracoid base. D2—avulsion of the anteroinferior rim of the glenoid + anterior dislocation of the humeral head. D3—fractures of the inferior glenoid

44. Treatment Reduction is usually unnecessary . Sling for comfort and from start movement. Check repeatedly for dislocation of the shoulder.

45. Indications for operative treatment Scapular body and neck #- 100% translation or 30’ to 40’ degree angulation of fragments of the lateral border. Mediolateral displacement of the glenoid in relation to the lateral border of the scapular body of >1-2 cm. GPA less than 20 degrees. Acromion or Coracoid # - Displacement of fragments of >1 cm Glenoid fractures - if displacement is, a gap/step off of ≥3 to 10 mm, with 20% to 30% involvement of the articular surface.

46. Surgical approach Judet posterior Anterior deltopectoral Judet approach provides an excellent exposure to Infraspinous fossa, Lateral and medial borders of the scapula Scapular spine Scapular neck Posterior and inferior rims of the glenoid.

47. Judet approach Skin incision along the scapular spine and the medial border of the scapula. A skin flap is then raised and the posterior border of the deltoid identified. Posterior deltoid is detached from the scapular spine and turned back laterally and distally. Infraspinatus is mobilized and retracted proximally.

48. Complication Malunion –M/c Non-union : rare Glenohumeral arthritis . Limitation in range of motion. Post-op : Limited range of motion of the shoulder- quite common Infection Failure of internal fixation frequently requires reoperation Post traumatic arthritis Rotator cuff dysfunction

49. Associated injuries

50. Floating Shoulder I psilateral clavicle + scapular neck fracture. Unstable injury-may require operative fixation . Subgroup/ commonest type of the “double disruption of the superior shoulder suspensory complex (SSSC).

51. Superior shoulder suspensory complex (SSSC) Maintains anatomic relationship b/w upper extremity & axial skeleton. Clavicle-only bony connection b/w the two Scapula is suspended from it by coracoclavicular and AC ligaments.

52. Classification Williams GR et al. The floating shoulder: a biomechanical basis for classification and management. J Bone Joint Surg Am. 2001 Aug;83(8):1182–7.

53. Classification Williams GR et al. The floating shoulder: a biomechanical basis for classification and management. J Bone Joint Surg Am. 2001 Aug;83(8):1182–7.

54. Classification Williams GR et al. The floating shoulder: a biomechanical basis for classification and management. J Bone Joint Surg Am. 2001 Aug;83(8):1182–7.

55. Treatment Indications for operative management- C lavicle fracture that warrants, in isolation, fixation Glenoid displacement > 2.5 to 3 cm Patient-associated ( R equirement for early upper extremity wt bearing) Severe glenoid angulation(retroversion/ anteversion >40’) Documented ipsilateral coracoacromial and/or AC ligament disruption

56. Treatment If operative intervention is chosen; anatomic reduction and internal fixation of the clavicle Shoulder reimaged to see alignment of glenoid Alignment is acceptable No further intervention is required “ Unacceptable "position fixation of the glenoid neck

57. Scapulothoracic Dissociation Separation of scapula from the thorax along with the upper extremity. Characterized by a wide range of concomitant injuries including- Clavicle fracture Sterno -clavicular dislocation Acromio -clavicular dislocation Tears of the levator scapulae, rhomboids,trapezius , latissimus dorsi , pectoralis minor and deltoid muscles. Partial or complete avulsion of brachial plexus Vascular injuries to subclavian or axillary artery

58. Caused by- violent lateral distraction of the shoulder girdle rotational displacement of the shoulder girdle

59. Treatment scapulo -thoracic dissociation requires Internal fixation of clavicular fractures + Stabilization of disrupted AC or SC joints. To prevent brachial plexus, Subclavian , and Axillary vessels injury. To restore stability to the shoulder girdle.

60. Take Home Message Scapular fracture should alert the surgeon to presence of other injuries . Sever chest injury should also raise suspicion of possible scapular injury .

61. THANK-YOU