Fracture around Shoulder Girdle Dr.Kushal

Shoulder Girdle

1. Adult: Fractures around Shoulder Girdle (Clavicle, Scapula, Humerus ) Presenter: Dr. Kushal Khanal Moderator: Assoc.Prof.Dr . Rajesh B Lakhe Guide:Dr.Jayant Bhagwan Mishra

2. Relevant Anatomy Shoulder girdle: consists of clavicle, scapula and proximal humerus and their associated ligaments and muscles The shoulder girdle

3. Radiographic views for shoulder girdle

4. Clavicle fractures Clavicle Fracture: 44 % to 66% of fractures about the shoulder(middle third- 80% > lateral third-15% > medial third-5%) Young active individuals Direct blow Fall on to the affected shoulder leading to a bending force Convulsions

5. Clinical features History of fall on a shoulder Arm adducted to chest Supporting the elbow with other hand Clear deformity, skin tenting if displaced Localized tenderness Unwilling to move the shoulder Neurovascular assessment Possible pneumothorax and associated injuries like rib fractures (9%) Skin tenting

6. Radiological features Ideally taken in upright position AP clavicle 20⁰ cephalad view Chest X-ray showing B/L Shoulder joints 20⁰ Cephalad view

7. Classification:

8. Neer classification

9. Non operative treatment Sling and figure of eight bandage provide same results 4-6 weeks Active ROM of elbow,wrist and hand

10. Surgical indication

11. Shaft fractures: Initial shortening of 2 cm or more is predictive of non union Lateral end fractures Mostly are undisplaced and extra-articular Generally progress to uncomplicated healing Medial end fractures: Usually non operative Posterior displacement - significant mediastinal compromise

12. Intramedullary fixation Titanium Elastic Intramedullary Nails Advantages: Small skin incision Less periosteal stripping Relative stability to callus formation Complications: Intrathoracic migration Pin breakage Damage to underlying structures Biomechanical study: plated constructs superior in resisting displacement

13. Plate fixation Reconstruction plates: Facilitates contouring of implants Susceptible to deformation– implant failure or malunion Anatomically precontoured locking compression plate Further need of countouring to avoid hardware prominence Calvicular hook plates: If distal fragment is too small Engage posterior aspect of acromion

14. Complications Early Wound complications Numbness- injury to supraclavicular nerves Hardware prominence and irritation Refracture Late: Non union – smoking, elderly, high energy trauma Malunion -corrective osteotomy with plate fixation

15. Acromioclavicular Joint injuries Diarthrodial joint between lateral end of clavicle and acromion Accounts 9 - 10% of traumatic injuries to shoulder girdle AC ligaments: anterior, posterior, superior, inferior Horizontal stability- AC ligaments Vertical stability- CC ligaments Deltoid and Trapezius-Secondary vertical stabilizer Mechanism of injury: Direct: fall on to shoulder with arm adducted Indirect: FOOSH causing force transmitted through humerus into AC joint

16. Clinical features Examination done in sitting or standing position with upper extremity in dependent position Clinical deformity, focal tenderness and swelling Downward sag of shoulder: most characteristics anatomic deformity Apparent step off deformity Restricted range of motion Pain exacerbation on cross arm adduction

17. Radiographic evaluation Shoulder AP view, Axillary views Zanca view  X-ray beam in 10◦ to 15◦ cephalad Stress radiographs not recommended for routine evaluation Zanca view

18. Rockwood Classification

19. Treatment: Non-operative Operative Type I AC joint injury Type III AC joint injury-Younger, and Labourer using upper extremity above horizontal plane Type II AC joint injury Type IV to VI AC joint injury Type III AC joint injury- Inactive,Non - labouring or recreational athletic patient Failed non operative management

20. Key elements of Surgical management of ACJ injuries Anatomic and accurate reduction of ACJ to correct superior displacement and AP translation Direct repair or reconstruction of CC ligaments Supplementation of protection of CC ligament repair or reconstruction with synthetic material (suture or tape) Repair of deltoid or trapezial fascia Distal clavicular resection in chronic ACJ injuries with clinical and radiographical evidence of ACJ osteoarthritis

21. Operative treatment Bosworth technique of Coracoclavicular Screw with or without primary repair of ligaments

22. Hook plate fixation

23. Arthroscopic or mini open stabilization using suture tightropes or suture anchors

24. Suture or sling augmentation of CC ligaments

25. Sternoclavicular injuries Rare Motor vehicle accidents or sports-related SCJ: medial end of clavicle and manubrium Only true articulation between upper extremity and axial skeleton Saddle type joint Intra articular disc ligament, extra articular costoclavicular ligament, capsular ligament and interclavicular ligament

26. Mechanism of injury Direct force on anteromedial aspect of clavicle-posterior SC joint dislocation Indirect: anterolateral force– anterior SC joint dislocation, posterolateral force– posterior SC joint dislocation Associated injuries: Tracheal compression Pneumothorax Laceration/compression of great vessels Esophageal perforation

27. Clinical features Supporting the affected limb across the trunk with unaffected limb Unwilling to place the affected clavicle flat on table Swelling,tenderness and painful range of shoulder motion Corner of sternum is easily palpated Shortness of breath and dysphagia Neurovascular injury

28. Radiographic evaluation Hobbs view Serendipity view CT: Distinguishes injuries of the joint from fractures and minor subluxations Substantial asymmetry in joints Hobbs view Serendipity view

29. Non operative treatment of SCJ injuries For most acute and chronic anterior subluxations and dislocations Acute traumatic posterior subluxations and some dislocations Most physeal injuries (usually in <25 yrs ) heal without surgery Collar and cuff sling for anterior SCJ disruption

30. Closed reduction techniques for posterior SCJ dislocation: Abduction traction technique Adduction traction technique Direct reduction with towel clip

31. Abduction traction technique Buckerfield and Castle Technique(Adduction traction technique) Direct reduction with towel clip

32. Surgical management Open reduction and stabilization in conjunction with vascular surgery Fixation of medial clavicle to sternum using fascia lata , subclavius tendon or suture, osteotomy of medial clavicle or resection of medial clavicle

33. Scapula Consists of Blade: triangular flattened region Spine: horizontal projection posteriorly Acromion: highest and most lateral point Coracoid process Glenoid: oriented anteriorly around 30◦

34. Lateral and spinal pillar: load bearing part of scapula Spinomedial angle: weakest area in circumference Anatomy of the scapula. (a) Anterior view, (b) posterior view. LP, lateral pillar; SGN, spino-glenoidal notch; SMA, spino -medial angle; SP, spinous pillar.

35. Mechanism of injury Direct blow to the scapula Impact of humeral head on part of scapula Dislocation of humeral head Muscle contracture Associated injuries: rib fractures most common, thoracic cavity and lungs, shoulder girdle

36. Clinical features Masked by concomitant injuries Upper extremity in contralateral hand in adducted and immobile position, painful ROM especially shoulder abduction Suprascapular nerve risk at # of scapular neck Brachial plexus and axillary artery injury

37. Angle between line connecting the superior and inferior poles of glenoid and line connecting the superior pole of the glenoid and center of inferior angle of scapula GPA <20⁰ one criteria for operative treatment

38. Radiographic evaluation AP view of entire shoulder girdle Neer I projection True AP radiograph of scapula Glenohumeral joint space, displacement of glenoid in relation to lateral border of scapula Measure glenopolar angle (GPA) Neer II projection True lateral radiograph of scapula translation, angulation and overlap of fragments CT

39. Classification of scapular fractures Anatomic Classification Type I: scapula body Type II: apophyseal fractures, including the acromion and coracoid Type III: Fractures of superolateral angle, including scapular neck and glenoid

40. Ideberg classification of intra articular glenoid fractures

41. Classification of acromial fractures

42. Non operative treatment three phases: Immobilization (2-3 weeks) Passive/assisted range of motion Progressive resistance exercises (at 6 weeks)

43. Surgical indications INDICATION CRITERION INTRAARTICULAR FRACTURES Articular step off ≥ 5 mm Percentage of glenoid affected >20% Glenohumeral articulation Unstable despite closed reduction EXTRAARTICULAR FRACTURES Glenopolar angle ≤ 20⁰ Angulation ≥ 45⁰ Translation ≥ 100%

44. Implant selection Glenoid rim: 4.0 mm cancellous screws Scapular body: reconstruction plate 3.5mm Acromion, acromial spine, coracoid: mini fragment plates

45. Fixation in scapular fractures The standard plate for this fixation is the 2.7 or a 3.5 reconstruction plate. Fixation with lag screw

46. Complications Shoulder Stiffness: Restricted internal rotation-most common Infection: deep infection rare Hematoma Suprascapular nerve palsy: decrease the range and strength of shoulder external rotation

47. Floating shoulder Double disruptions of the Superior Shoulder Suspensory Complex Failure of the SSSC complex and its multiple disruptions and strut fractures

48. Superior Shoulder Suspensory Complex

49. Treatment Internal fixation of clavicle alone failed to reduce the scapula Simultaneous fixation good results - early rehabilitation

50. Proximal Humerus Fractures Most common humerus fracture Low energy injuries in elderly population: fragility fracture Mostly- non displaced Mechanism: Elderly: fall from standing height onto an outstretched arm Young: high energy trauma, more soft tissue injury Seizures or electric shock

51. Proximal humerus Anatomical head: retroversion 35-40 ◦ Greater tuberosity: ¾ rotator cuff muscle insertion Lesser tuberosity: insertion of subscapularis Surgical head: anatomical head and tuberosities Surgical neck : junction of surgical head and shaft

52. Blood supply Blood supply of head of humerus

53. Clinical Examination Arm held close to the chest by contralateral hand Swelling and bruising Bruising may spread to dependent areas Restricted range of motion Motor and sensory function of axillary nerve

54. Radiographic evaluation AP, Lateral and axillary view of shoulder joint Axillary view may be impossible Velpeau view AP view of shoulder joint

55. AP Grashey View Neer View(lateral Y View)

56. Axillary view Velpeau view

57. Neers classification Based on anatomical parts of the proximal humerus and their displacement from each other Malposition of >1 cm or angulation of >45⁰:considered as displacement

58. Classification of proximal humerus fractures Neer classification

59. Risk of AVN -Four part fractures and fracture dislocations- highest risk forAVN of Humeral Head Hertel’s Criteria : -Metaphyseal extension of humeral head<8 mm -Medial hinge disruption of >2 mm -Fracture through anatomical head The combination above factors had 97% positive predictive value for humeral head ischaemia .

60. Non operative management Indications: Stable non displaced or minimally displaced Elderly frail patients Patients not fit for surgery Treatment: Sling immobilization for 2-3 weeks Early pendulum exercises or codman exercises then active ROM

61. Surgical indications Displaced fractures Head splitting fractures Neurovascular injury Open fractures Unstable fractures with disrupted medial hinge Floating shoulder Polytrauma Irreducible fracture dislocations

62. Implant selection Sutures, tension bands, screws: 2 part tuberosity fractures with good bone quality Locking plates: displaced fractures MIPO: closed reduction maintained during surgery Arthroplasty: complex fractures in elderly osteoporotic bone

63. Surgical approaches Delto pectoral approach Deltoid Splitting approach

64. Reduction and fixation Traction sutures Isolated 2 part fractures: suture more reliable Complex 3-4 part fractures: restoration of neck shaft angle using joystick technique Temporary k wires- hold reduction Lag screws: isolated tuberosity fractures with good bone quality Traction sutures on tendon bone junction of rotator cuff

65. Locking plates Correct plate position: 5-8 mm distal to top of greater tuberosity Aligned properly along the axis of the humeral shaft Slightly posterior to bicipital groove Calcar screws maintain medial support

66. MIPO Decrease chain of non union and infection Proximal: deltoid split Distal: at deltoid insertion Arthroplasty or reverse shoulder arthroplasty Shoulder arthroplasty Reverse Shoulder Arthroplasty

67. Type of fixation BEST Closed reduction and percutaneous pinning Simple # patterns in younger patients with good bone Isolated fracture of greater tuberosity Valgus impacted fracture pattern IM Nailing Proximal ring structure intact, head complex unstable relative to shaft Completely displaced 2 part surgical neck # in elderly ORIF with locking plates Both 2 and 3 part # with displacement and articular incongruity Excessive varus or valgus deformity

68. Type of fixation BEST Hemiarthroplasty Middle aged patient with severe 3-4 part fracture dislocation Reverse shoulder arthroplasty Elderly patient with severe fracture dislocation Concurrent rotator cuff deficiency

69. Complications Screw penetration Avascular necrosis: Length of dorsomedial metaphyseal extension Integrity of medial hinge Fracture type Malunion and non union: more frequently due to loss of medial cortical buttress Nerve injuries

70. Summary Fractures of shoulder girdle can be associated with other serious cardiothoracic and vascular injuries A simple trauma series of shoulder girdle to screen them all Most fractures of shoulder girdle can be managed non operatively Surgical indications dependent on fracture displacement and patient’s physical demand Shoulder stiffness -a frequent complication Must not miss and must document neurovascular status

71. References Rockwood and Green’s fractures in adults Campbell’s operative orthopaedics AO principles of fracture management Mc Rae orthopaedic trauma management

72. NEXT PRESENTATION Journal Club(Related to Paediatric Fracture)- Dr.Arun Upreti THANK YOU