Clavicle fracture, basal skull fracture.pptx

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1. TUGAS MCR CLAVICLE FRACTURE

2. Anatomy Clavicle The clavicle (collar bone) connects the upper limb to the trunk The shaft of the clavicle has a double curve in a horizontal plane. Its medial half is convex anteriorly, and its sternal end is enlarged and triangular where it articulates with the manubrium of the sternum at the sternoclavicular (SC) joint.

3. The clavicle is easily fractured because of its subcutaneous, relatively anterior location and frequent exposure to trans-mitted forces. The subclavian groove (groove for the subclavius) in the medial third of the shaft of the clavicle is the site of attachment of the subclavius muscle. More medially is the impression for the costoclavicular ligament, a rough, often depressed, oval area that gives attachment to the ligament binding the 1st rib (L. costa) to the clavicle, limiting elevation of the shoulder

4. The clavicle has many important functions: it connects the axial skeleton to the upper extremity contributes to the motion and stability of the upper extremity with the subclavius muscle, it provides protection to the underlying neurovascular structures (i.e., subclavian vessels and bra- chial plexus). Malunion may impair these functions. In addition, callus formation or displacement can lead to thoracic outlet compression.

5. Insertion The coracoclavicular ligament is trapezoidal (more lateral) and conoid (more medial) is a thick ligament that originates at the base of the coracoid and inserts into the small bulge inferior to the clavicle (trapezoid) and the conoid tubercle of the clavicle ( conoid ). The insertion of the muscles plays a significant role in the deformity after fracture: the medial fragment of the clavicle is lifted by the pull of the sternocleidomastoid muscle, while the distal fragment is pulled down by the deltoid, and medially by the pectoralis major. On the underside of the clavicle is the insertion of the subclavius muscle, which functions little, but is a soft tissue buffer in the superior subclavicular space of the brachial plexus and subclavian vessels.

6. Origin On the medial side, the pectoralis major muscle originates on the anteroinferior clavicle shaft, and the sternocleidomastoid muscle originates superiorly. The pectoral and anterior deltoid origins join laterally, while the trapezius insertion joins the deltoid origin.

7. CLASSIFICATION Classification Clavicle fractures are usually classified on the basis of their location: Group I (middle third fractures), Group II (lateral third fractures) and Group III (medial third fractures). Lateral third fractures can be further sub-classified into those with the coracoclavicular ligaments intact, those where the coracoclavicular ligaments are torn or detached from the medial segment but the trapezoid ligament remains intact to the distal segment, and factures which are intra-articular.

8. Xray for Clavicle

9. Stress View

10. Chepalad View

11. Serendipity View

12. Zanca View

13. Clavicle X-ray Parameter

14. Thorax X-ray Confirm detail  patient detail name, date and time the film was taken, previous imaging Assess image quality Rotation : The medial aspect of each clavicle should be equidistant from the spinous processes.The spinous processes should also be in vertically orientated against the vertebral bodies. Inspiration: The 5-6 anterior ribs, lung apices, both costophrenic angles and the lateral rib edges should be visible. Projection: Note if the film is AP or PA: if there is no label, then assume it’s a PA film (if the scapulae are not projected within the chest, it’s PA). Exposure: The left hemidiaphragm should be visible to the spine and the vertebrae should be visible behind the heart.

15. The  ABCDE approach  can be used to carry out a  structured interpretation of a chest X-ray : A irway: trachea, carina, bronchi and hilar structures. B reathing: lungs and pleura. C ardiac: heart size and borders. D iaphragm: including assessment of costophrenic angles. E verything else: mediastinal contours, bones, soft tissues, tubes, valves, pacemakers and review areas.

16. Pelvic X-ray Radiographic interpretation is systematized with ABCS approach: Alignment Bones Cartilage and joints Soft Tissues

17. Pelvic X-ray Normal findings AP view interpretation A Adequacy and quality Alignment B Bone: check each the following: Pubic sacrum Acetabulum Femoral heads Iliac crest Lumbar vertebrae

18. Pelvic X-ray C Cartilage and joints Check the pubic symohisis Check the sacroiliac joints Check the acetabulum S Soft tissues Check the disruption of fat planes inside the pelvis Check for soft tissue shadows outside the pelvis

19. A In this step, focus the three circles enclosed by the pelvis. One is created by the pelvic brim (A) and the other two by the obturator foramina (B)

20. B Examine the outer edges of the pelvis and its bony structure for evidence of fractures. These may present as areas of increased density, lucency , or alteration of the internal trabecular pattern. Pubic symphysis. Progress to the right or left side. Focus on the posterior and anterior joint margin, the ilioischial line (posterior column), and the iliopectineal line (anterior column). Look for “teardrop sign” (acetabular floor)

21. B 5. Focus on the anterior inferior iliac spine, anterior superior iliac spine and look for the iliac crest to the sacrum. The sacrum should also be examined for symmetry of its foramina

22. C Check for either widening or overlapping of bones at the level of the symphysis pubis (A) Sacroiliac joints (B) at the right and left sides must also be checked for widening, defects in the cortical surface, overlapping of bone, and lack of congruity of the joint margin

23. S Check for soft tissue shadowing both inside and outside the pelvis because hematoma and tissue edema can produce swellings which are visible on the anteroposterior radiograph.

24. Non Operative Management

25. Operative Management

26. Clavicle Fracture Anatomy: The clavicle is an S-shaped structure, which changes from a prismatic shape medially to a flattened shape laterally. It is anchored to the scapula via the AC and CC ligaments. Mechanism of Injury: Approximately 87% of clavicle fractures occur as a result of a fall onto the shoulder. Another 6% fracture secondary to a direct blow, and the remainder occur via indirect injury with force being transmitted up the humerus.

27. FIGURE 38-5 Muscular and gravitational forces acting on the fractured clavicle with resultant deformity. The distal fragment is translated anteriorly, medially, and inferiorly, and rotated anteriorly. This Results in the scapula being protracted. Rockwood and GReen’s Fractures in Adults Eighth Edition, page 1430 medial fragment: sternocleidomastoid muscle pulls the medial fragment  posterosuperiorly lateral fragment: pectoralis and weight of arm pull the lateral fragment  inferomedially

28. Nonoperative Treatment

29. NON OPERATIVE

30. OPERATIVE

31. Recon Plate Locking plate

32. ORIF Plate and screw Clavicle Patient preparation This procedure is normally performed with the patient either in a  beach chair  or a  supine position in 30 o Rockwood and Matsens - The Shoulder, 5th Ed

33. An oblique 8-10 cm incision is made just inferiorly to the clavicle centered over the fracture site Anterior Approach

34. Anterior Approach The platysma is incised transversely and tagged with sutures. Identify the supraclavicular nerves and make every effort to preserve them. Next incise the clavipectoral fascia. This will expose the underlying clavicle and the attached pectoralis major anteriorly, and trapezius posteriorly. Minimal soft tissue dissection of underlying clavipectoral fascia is performed to expose the fracture. This can be performed bluntly with a periosteal elevator or sharply with a blade.

35. Reduction Fracture fragments should not be devitalized or stripped from their soft tissue attachments. Achieve reduction by indirect means where possible. The aim is to restore normal alignment and rotation as well as length

36. Plate application The plate can often assist as a reduction tool A properly contoured plate is usually fixed first to the medial side as medial side malalignment is less well tolerated. The lateral fragment is then reduced by manipulation involving traction and rotation and is aligned with the lateral side of the plate. A push-pull device is often helpful in obtaining the appropriate clavicular length when manual distraction is unsuccessful. Once the fracture alignment, length, and rotation are satisfactory, the remaining screws can be inserted.

37. PLATING POSITION anterior vs superior

38. SAFE ZONE FOR DRILLING

39. Aftercare Wound care Two days post-surgery the main surgical dressing may be removed and showers are permitted and a light dry dressing may be applied. Soaking in baths, hot tubs and swimming pools are not permitted until minimum two weeks after surgery when the wound is completely healed and the sutures and staples have been removed. Implant removal Plate removal from the clavicle is not routinely required or recommended. Symptomatic prominence and impingement of the clavicle plate can occur. After the fracture has completely healed, removal of the implant may be a consideration. Athletes who return to contact sports should only have the plate removed if absolutely necessary and if so, done at the end of the season to allow maximal healing prior to return to sport. Many patients who request hardware removal from local symptomatology 6-12 months after implantation find that symptoms diminish significantly by 2 years postoperatively and defer hardware removal indefinitely.

40. Aftercare Sleeping The patient should sleep wearing the sling on his/her back or on the non-injured side. When sleeping on the side, a pillow can be placed across the chest to support the injured side.

41. Aftercare Phase I: Day one after surgery After clavicular surgery, it is important to maintain full mobility of the unaffected joints to reduce arm swelling and to preserve joint motion. The following exercises are recommended: Straightening and flexion of the elbow Open and closure of the hand Squeezing of a soft ball Bending of the wrist forward, backwards and in a circular motion Movement of an open hand from side to side Squeezing the shoulder blades together, while shoulders remain relaxed

42. Aftercare Phase II: Two to six weeks after surgery Pendular exercises can be started when pain starts to subside. Gradual progression to passive and assisted range of motion exercises are started as tolerated. Scapular stabilization must be observed to restore normal kinetics to shoulder motion. Activated assisted range of motion exercises are started with: External rotation Internal rotation Flexion with arms on table Flexion with ball on wall Sub-maximal isometric exercises with: Internal rotation External rotation (1) Abduction (2) Extension Note: Timing and progression of exercises are ultimately directed by the operating surgeon as factors such as bone quality, type of fracture and fixation may vary in individuals.

43. Aftercare Note: Timing and progression of exercises are ultimately directed by the operating surgeon as factors such as bone quality, type of fracture and fixation may vary in individuals.

44. Aftercare Phase III: Six to twelve weeks after surgery Pending clinical and radiographic review by the operating surgeon, weight-bearing may now be permitted and gradual resisted/strengthening exercises can begin. Return to full activities and/or contact sports is permitted once the fracture is united and the extremity has regained full strength. Typically this takes around 6 months post injury. It may be sooner or later depending on the patient factors, progress of fracture healing and response to rehabilitation. If there has been no progress on serial radiographs of fracture healing, at 3 months, then delayed or impaired healing may be present. If the fracture has not united after 9 months surgical intervention should be considered.

45. Skull Base Fracture

46. Classification

47. Skull base fracture, anterior

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