The Fractures of clavicle & scapula.pptx

Fractures of clavicle and scapula Done by Dr.Islam Ali

1. FRACTURE OF CLAVICLE & SCAPULA Dr. Ibtisam Al- Ariqi Prepared By . Islam Ali

2. CLAVICLE CLAVICLE : Is an S-shape long,curved,tubular bone, lies horizontally a cross the root of neck It articulate with sternum medially to form sternoclavicular joint. Also articulate with acromion process of scapula at acromioclavicular joint and acromioclavicular ligament T he muscles inserting on clavicle are: sternocleidomastoid , And subclavius muscles The subclavian vessels and brachial plexus lie posterior to clavicle

3.   I am the first bone to ossify in the body. I ossify from two primary centers. I am the only long bone in the body lying horizontal . I am the only long bone ossifying from a membrane. I am the only link between the appendicular and the axial skeleton . I am the most common bone to be fractured in children. I invariably end up maluniting after the fracture. THE clavicle speak :

4. Functions of Clavicle It increases the arm strength mechanism. It protects the neurovascular bundle consisting of subclavian vessels and brachial plexus. It gives attachments to important muscles around the shoulder. It braces the shoulder back during rest and motion (Strut function).

5. Mechanism of Injury Direct Due to fall on the point of the shoulder. This is the most common mode of injury accounting for 91 % of the cases Direct trauma over the clavicle due to RTAccidents Direct injury, etc. Accounts for 8 percent of the cases Indirect fall on the outstretched hands accounts fo 1 % of the cases.

6. • 80% of the fracture clavicle occurs in the middle part of the clavicle • 5% at the medial end of the clavicle . • 15% at the Lateral end of the clavicle. Sites of Fracture Q Why is common in the middle ?

7. Classification of Fracture Clavicle (Allman’s) Group I is fractures involving middle one-third of the shaft. Group II is fractures involving the lateral third distal to the attachment of the coracoclavicular ligament. This is further subdivided into two subgroups (Proposed by Neer): • Type A: Coracoclavicular ligament intact. • Type B: Coracoclavicular ligament ruptured. • Type C: Intra-articular extension into ACM joint. Group III are medial third fractures.

8. Clinical Features The patient presents with : pain & swelling deformity inability to raise the shoulder Rarely, the patient may present with pseudo-paralysis of the affected arm.

9. Diagnosis The following views are recommended: Clinical picture \ examination. investigation : x-ray [AP view]: is usually in middle third, > outer fragment below of the inner . Distal clavicle requires special radiography
technique. CT scan: useful for non union assessment. A rteriography : if vascular injury suspected

10. Principles of Treatment Conservative Methods In MIDDLE-THIRD FRACTURES Simple silng for comfort the pain(1-3weaks) than Encouraged to mobilize the limb as pain allows. In LATERAL-THIRD FRACTURES Sling for 2–3 weeks until the pain subsides, followed by mobilization within the limits of pain. This is the treatment of choice in fracture clavicleand consists of the following methods: Cuff and collar sling for undisplaced fractures (Fig. 11.5A). Strapping of the fracture site after reduction of the fracture by elevating the arm and bracing the shoulder upwards and backwards gives good resultsin both children and adults (Fig. 11.5B).

11. Sabre method consists of rigid dressing over the fracture. This is no longer used. Billington Yoke method uses a plaster of Paris over a well-padded figure of ‘8’ dressing. Figure of ‘8’ is popularly used and it acts by retracting the shoulder girdle , minimizes the overlap and allows more anatomical healing . It does not immobilize the fracture but acts by serving as a reminder to the patient to hold the shoulder up and back neutralizing the forces mentioned above. If they allow the shoulder to slump forward, then the support cuts into the anterior axilla and reminds them to hold the shoulders back (Fig. 11.5C).

12. Treatment Plan according to age Newborn to perambulatory children: Treated symptomatically, bind arm to the chest. Ambulatory stage (2-12 yr): Figure of ‘8’ bandages, tightened after three days and later one week. Twelve years to maturity (above 12yr) : Commercially available figure of ‘8’ harness.

13. Methods of Internal Fixation • Intramedullary fixation with K-wires. • Rigid plate and screw fixation with AO semi- tubular or pelvic reconstruction plate Indications of surgery 1- Open fractures , 2- injury to neurovascular bundle , 3- if the fracture is threatening to penetrate the skin , 4- non-union , 5- fracture near acromioclavicular joint , 6- floating shoulder , 7- soft tissue interposition and displaced epiphysis in children . 2- Surgery is rarely indicated and consists of open reduction and rigid internal fixation.

14. More Specific Indications for Open Reduction and Internal Fixation of Fracture Clavicle • Shortening or distraction of fragments for more than 2 cm. • More than 100 percent displacement or fragmentation. • Bilateral fractures. What is new in the treatment of fracture clavicle? Intramedullary compression clavicular nail 👉 Mckeever’s threaded IM pin (C) • External fixators in open clavicular fractures (D)

15. Complications of Fracture Clavicle EARLY Despite the close proximity of the clavicle to vital structures, a pneumothorax , damage to the subclavian vessels and brachial plexus injuries are all very rare . LATE Non-union : treated by internal fixation and bone grafting Malunion : It causes only a cosmetic problem and does not usually impair function. Neurovascular injury Stiffness of the shoulder This is common but usually temporary.

16. FRACTURE OF THE SCAPULA

17. Scapula Scapula : Is a flat triangular bone that lies on the posterior thorax wall between 2-7 rib. It envelope by: supraspinatus muscle infraspinatus muscle subscapularis muscle Attached to clavicle at acromioclavicular joint,secured by acromioclavicular ligament. Articulate with humerus at glenohumeral joint... Attached to thorax in scapulothoraxic joint.

18. FRACTURE OF THE SCAPULA Incidence It is a rare injury. • 3 to 5 % of all shoulder girdle injuries. • 0.4 to 1 % of all fractures. • Mean age is 35 to 45 years.

19. Functions of scapula • Stabilizes the upper extremity against the thorax. • Links the upper extremity to the glenoid. Mechanism of Injury s • Direct blow—fall of a heavy object on the shoulder blade . Common causes include direct blunt trauma , crushing injuries , falls and seizures . • Axial loading on the outstretched hands. There associated injuries such as rib fractures and other intra-thoracic injuries are common.

20. Mechanism of injury : Injury of body : from sever direct trauma - fall from height with direct landing on posterior aspect of trunk. - motor vehicle crush of neck : direct blow to shoulder - fall shoulder - fall on outstretched hand of glenoid : direct blow to lateral aspect of shoulder or impaction of humeral head in to glenoid fossa, may dislocation of the shoulder Of coracoid process :direct blow or shoulder dislocation of acromion : direct down ward blow to shoulder.

21. Classification (Thompson’s) Type I: Coracoid, acromion and small fractures of the body. Type II: The glenoid and neck fractures. Type III: Body fractures major Note: • Neck fractures —10 to 60 % • Body fractures—49 to 89 % • Glenoid fractures—9 %

22. Fractures of the scapular body Fractures of the glenoid neck Intra-articular glenoid fossa fractures (Ideberg modified by Goss) • Type I Fractures of the glenoid rim • Type II Fractures through the glenoid fossa, inferior fragment displaced with subluxed humeral head • Type III Oblique fracture through glenoid exiting superiorly (may be associated with acromioclavicular dislocation or fracture) • Type IV Horizontal fracture exiting through the medial border of the scapula • Type V Combination of type IV and a fracture separating the inferior half of the glenoid • Type VI Severe comminution of the glenoid surface

23. Fractures of the acromion • Type I Minimally displaced • Type II Displaced but not reducing subacromial space • Type III Inferior displacement and reduced subacromial space Fractures of the coracoid process • Type I Proximal to attachment of the coracoclavicular ligaments and usually associated with acromioclavicular separation • Type II Distal to the coracoacromial ligaments

24. Clinical Features The patient complains of : pain and swelling , Severe bruising over the scapula or the chest wall. arm is held adducted to the sides of the chest , all movements of the shoulder, especially abductions,are painful , may be associated rarely with pneumothorax and inability to elevate the arms may give a feeling of pseudo-rupture of the rotator cuff.

25. Radiographs Scapular fractures can be difficult to define on plain X-rays because of the surrounding soft tissues. A true scapular AP view and a true lateral view (axillary view) helps to make the diagnosis. CT and 3D reconstruction are useful for demonstrating glenoid fractures or body fractures Treatment Nonoperative Methods: Undisplaced scapular fractures may be treated conservatively with rest, sling, strap, etc. Operative Methods: Displaced fractures need open reduction and internal fixation with K-wires,screws, etc.

26. Body fractures Surgery is not usually necessary. The patient wears a sling for comfort , and from the start practises active exercises to the shoulder, elbow and fingers. Isolated glenoid neck fractures This is the second most common fracture of the scapula. A CT scan is usually required to confirm that it is extra-articular. The fractures are often displaced, but further dis placement is uncommon as long as the clavicle is not fractured. The fracture is frequently impacted and the glenoid surface is intact. A sling is worn for comfort and early exercises are begun. Intra-articular fractures . Type I glenoid fractures, if displaced , may result in instability of the shoulder. If the fragment involves more than a quarter of the glenoid surface and is displaced by More than 5 mm , surgical fixation should be considered. Anterior rim fractures are approached through a deltopectoral incision and posterior rim fractures through the posterior approach.

27. Type II fractures are associated with inferior subluxation of the head of the humerus and require open reduction and internal fixation. Type III, IV, V and VI fractures have poorly defined indications for surgery, but indications include excessive medialization of the glenoid or intra-articular steps of more than 5 mm. Generally speaking , if the head is centred on the major portion of the glenoid and the shoulder is stable, a non-operative approach is adopted. Comminuted fractures of the glenoid fossa are likely to lead to osteoarthritis in the longer term.

28. Fractures of the acromion Undisplaced fractures are treated non-operatively . Only type III acromial fractures, in which the subacromial space is reduced, require operative intervention to restore the anatomy. Fractures of the coracoid process Fractures distal to the coracoacromial ligaments do not result in serious anatomical displacement ; those proximal to the ligaments are usually associated with acromioclavicular separations and may need operative treatment. Combined fractures Whereas an isolated fracture of the glenoid neck is stable, if there is an associated fracture of the clavicle or disruption of the acromioclavicular ligament, the glenoid mass may become markedly displaced, giving rise to a ‘floa t ing shoulder’. Diagnosis can be difficult and may require advanced imaging and 3D reconstructions. At least one of the injuries (and sometimes both) will need operative fixation before the fragments are stabilized .

29. Reduction is usually unnecessary. Patient wears a sling for comfort and from start movement. Check repeatedly for dislocation of the shoulder . of body by : conservatively by analgesics and simple sling to rest shoulder for 2-3 weeks. of acromion process Undisplaced : sling for 3-4 weeks for rest shoulder. displaced acromion should be reduced and fixed. Of coracoid : conservatively in major, using a sling for 2-3 weeks. Vigorous exercises should be prohibited for 2 m. If there is marked displacement > open reduction of neck and glenoid: - sling for 2-3 weeks if there is displacement > shoulder space after reduction open reduction > indicated if there is isolated glenoid rim fractures associated with dislocation or subluxation of shoulder.

30. Complications Osteoarthrosis stiffness of shoulder joint Associated chest injury is common After surgery: local dyscomfort infection nerve injuries post traumatic arthritis rotator cuff dysfunction

31. References Apley and Solomon's System of Orthopaedics and Trauma Textbook of Orthopedics

32. Thank You Islam Ali