nullInjuries of the Clavicle, Acromioclavicular Joint and Sternoclavicular JointInjuries of the Clavicle, Acromioclavicular Joint and Sternoclavicular JointAndrew H. Schmidt, M.D.
T.J. McElroy
Created March 2004; Revised January 2007ClavicleClavicle“S”-shaped bone
Medial - sternoclavicular joint
Lateral - acromioclavicular joint and coracoclavicular ligaments
Muscle attachments:
Medial: sternocleidomastoid
Lateral: Trapezius, pectoralis majorAC JointAC JointDiarthrodial 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 importantDistal ClavicleDistal ClavicleCoracoclavicular ligaments
“Suspensory ligaments of the upper extremity”
Two components:
Trapezoid
Conoid
Stronger than AC ligaments
Provide vertical stability to AC jointMechanism of InjuryMechanism of InjuryModerate or high-energy traumatic impacts to the shoulder
Fall from height
Motor vehicle accident
Sports injury
Blow to the point of the shoulder
Rarely a direct injury to the claviclePhysical ExaminationPhysical ExaminationInspection
Evaluate deformity and/or displacement
Beware of rare inferior or posterior displacement of distal or medial ends of clavicle
Compare to opposite side.Physical ExaminationPhysical ExaminationPalpation
Evaluate pain
Look for instability with stress
Physical ExaminationPhysical ExaminationNeurovascular examination
Evaluate upper extremity motor and sensation
Measure shoulder range-of-motion
Radiographic Evaluation
of the ClavicleRadiographic Evaluation
of the ClavicleAnteroposterior View
30-degree Cephalic Tilt ViewRadiographic Evaluation of the ClavicleRadiographic Evaluation of the ClavicleQuesana View
45-degree angle superiorly and a 45-degree angle inferiorly
Provide better assessment of the extent of displacementRadiographic Evaluation
of the AC Joint Radiographic Evaluation
of the AC Joint 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 JointStress Views of the Distal Clavicle & AC JointRationale: will 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 AC joint injuries treated the same, and management of distal clavicle fractures depends on initial displacement and location of fracture.Radiographic Evaluation of the Medial One ThirdRadiographic Evaluation of the Medial One ThirdX-ray: Cephalic tilt view of 40 to 45 degrees
CT scan usually indicated to best assess degree and direction of displacementClavicle FracturesClavicle FracturesClassification of
Clavicle FracturesClassification of
Clavicle FracturesGroup 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 OptionsTreatment OptionsNonoperative
Sling
Brace
Surgical
Plate Fixation
Screw or Pin FixationNonoperative TreatmentNonoperative Treatment“Standard of Care” for most clavicle fractures.
Continued questions about the need to wear a specialized brace.
Simple Sling vs.
Figure-of-8 BandageSimple Sling vs.
Figure-of-8 BandageProspective randomized trial of 61 patients
Simple sling
Less discomfort
Functional and cosmetic results identical
Alignment of healed fractures unchanged from the initial displacement in both groupsAndersen et al., Acta Orthop Scand 58: 71-4, 1987.Nonoperative TreatmentNonoperative TreatmentIt 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 TreatmentNonoperative TreatmentThere 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.Deficits following nonoperative treatment of displaced midshaft clavicular fracturesDeficits following nonoperative treatment of displaced midshaft clavicular fracturesA patient-based outcome questionnaire and muscle-strength testing were used to evaluate 30 patients after nonoperative care of a displaced midshaft fracture of the clavicle.
At a minimum of twelve months (mean 55 mos), outcomes were measured with the Constant shoulder score and the DASH patient questionnaire. In addition, shoulder muscle-strength testing was performed with the Baltimore Therapeutic Equipment Work Simulator, with the uninjured arm serving as a control. McKee et al. J Bone Joint Surg Am 2006;88-A:35-40.Deficits following nonoperative treatment of displaced midshaft clavicular fracturesDeficits following nonoperative treatment of displaced midshaft clavicular fracturesThe strength of the injured shoulder was 81% for maximum flexion, 75% for endurance of flexion, 82% for maximum abduction, 67% for endurance of abduction, 81% for maximum external rotation, 82% for endurance of external rotation, 85% for maximum internal rotation, and 78% for endurance of internal rotation (p < 0.05 for all).
The mean Constant score was 71 points, and the mean DASH score was 24.6 points, indicating substantial residual disability. McKee et al. J Bone Joint Surg Am 2006;88-A:35-40.nullDisplaced midshaft clavicle fractures can cause significant, persistent disability, even if they heal uneventfully.Definite Indications for Surgical Treatment of Clavicle FracturesDefinite Indications for Surgical Treatment of Clavicle Fractures1) Open fractures
2) Associated neurovascular injury
Relative Indications for Acute Treatment of Clavicle FracturesRelative Indications for Acute Treatment of Clavicle Fractures1) Widely displaced fractures
2) Multiple trauma
3) Displaced distal-third fractures
Relative Indications for Acute Treatment of Clavicle FracturesRelative Indications for Acute Treatment of Clavicle Fractures4) Floating shoulder
5) Seizure disorder
6) Cosmetic deformity
7) Earlier return to work.nullClavicular DisplacementClavicular Displacement< 5 mm shortening: acceptable results at 5 years (Nordqvist et al, Acta Orthop Scand 1997;68:349-51.
> 20 mm shortening associated with increased risk of nonunion and poor functional outcome at 3 years (Hill et al, JBJS 1997;79B: 537-9)
Plate FixationPlate FixationTraditional means of ORIF
Plate applied superiorly or inferiorly
Inferior plating associated with lower risk of hardware prominence
Used for acute displaced fractures and nonunions.nullnullnullnullnullnullIntramedullary FixationIntramedullary FixationLarge threaded cannulated screws
Flexible elastic nails
K-wires
Associated with risk of migration
Useful when plate fixation contra-indicated
Bad skin
Severe osteopenia
Fixation less secure
Complications of Clavicular Fractures and its TreatmentComplications of Clavicular Fractures and its TreatmentNonunion
Malunion
Neurovascular Sequelae
Post-Traumatic Arthritis Risk Factors for the Development of Clavicular NonunionsRisk Factors for the Development of Clavicular NonunionsLocation of Fracture
(outer third)
Degree of Displacement
(marked displacement)
Primary Open ReductionPrinciples for the Treatment of Clavicular NonunionsPrinciples for the Treatment of Clavicular NonunionsRestore 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.nullCorrection of symptomatic nonunion with IM screwnullnullnullClavicular MalunionClavicular MalunionSymptoms 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 sxNeurologic SequelaeNeurologic SequelaeOccasionally, 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.Osteotomy for Clavicular MalunionOsteotomy for Clavicular Malunion15 patients with malunion after nonoperative treatment of a displaced midshaft clavicle fracture of the clavicle. Average clavicular shortening was 2.9 cm (range, 1.6 to 4.0 cm).
Mean time from the injury to presentation was three years (range, 1 to 15 years).
Outcome scores revealed major functional deficits.
All patients underwent corrective osteotomy of the malunion through the original fracture line and internal fixation. McKee MD, et al. J Bone Joint Surg Am 2003;85-A(5):790-7Osteotomy for
Clavicular MalunionOsteotomy for
Clavicular MalunionAt follow-up (mean 20 months postoperatively) the osteotomy site had united in 14 of 15 patients.
All 14 patients satisfied with the result.
Mean DASH score for all 15 patients improved from 32 points preoperatively to 12 points at the time of follow-up (p = 0.001).
Mean shortening of the clavicle improved from 2.9 to 0.4 cm (p = 0.01).
There was 1 nonunion, and 2 patients had elective removal of the plate.
McKee MD, et al. J Bone Joint Surg Am 2003;85-A(5):790-7Distal Third Clavicle FracturesDistal Third Clavicle FracturesClassification of Distal Clavicular Fractures
(Group II Clavicle Fractures)Classification of Distal Clavicular Fractures
(Group II Clavicle Fractures)Type I-nondisplaced
Between the CC and AC ligaments with ligament still intactFrom Nuber GW and Bowen MK, JAAOS, 5:11, 1997Classification of Distal Clavicular FracturesClassification of Distal Clavicular FracturesType II
Typically displaced secondary to a fracture medial to the coracoclavicular ligaments, keeping the distal fragment reduced while allowing the medial fragmetn to displace superiorly
Highest rate of nonunion (up to 30%)
Two TypesType IIAType IIAA. Conoid and trapezoid attached to distal fragmentFrom Nuber GW and Bowen MK, JAAOS, 5:11, 1997Type IIBType IIBType IIB: Conoid torn, trapezoid attached From Nuber GW and Bowen MK, JAAOS, 5:11, 1997Classification of Distal Clavicular FracturesClassification of Distal Clavicular FracturesType III:articular fracturesFrom Nuber GW and Bowen MK, JAAOS, 5:11, 1997Treatment of Distal-Third (Type II) Clavicle FracturesTreatment of Distal-Third (Type II) Clavicle FracturesNonoperative 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
nullDisplaced Type II fractures of the distal clavicle are often treated more aggressively because of the increased risk of nonunion with nonoperative treatmentTechniques for Acute Operative Treatment of Distal Clavicle FracturesTechniques for Acute Operative Treatment of Distal Clavicle FracturesKirschner 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
nullFor most techniques of clavicular fixation, coracoclavicular fixation is also needed to prevent redisplacement of the medial clavicle.
nullThe Hook Plate (Synthes USA, Paoli, PA) was specifically designed to avoid this problem of redisplacement.nullHook Plate - ResultsHook Plate - ResultsRecent series of distal clavicle fractuers 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 FracturesPreferred Technique for Fixation of Acute Distal Third
Clavicle FracturesHorizontal incision
Manual reduction of fracture
Dorsal tension band suture and reconstruction/augmentation of coracoclavicular ligaments.
Indications for Late Surgery for Distal Clavicle FracturesIndications for Late Surgery for Distal Clavicle FracturesPain
Weakness
DeformityTechniques for Late Surgery for Distal Clavicle FracturesTechniques for Late Surgery for Distal Clavicle FracturesExcision of distal clavicle
With or without reconstruction of coracoclavicular ligaments (Modified Weaver-Dunn procedure)
Reduction and fixation of fracture
Case ExampleCase ExampleCase ExampleCase ExampleDistal ClavicleMedial ClavicleCase ExampleCase ExampleFixation to AcromionAcromioclavicular JointAcromioclavicular JointRadiographic Evaluation of the Acromioclavicular JointRadiographic Evaluation of the Acromioclavicular JointProper 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 InjuriesClassification for Acromioclavicular Joint InjuriesInitially 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.Allman FL Jr. Fractures and ligamentous injuries of the clavicle and its articulation. JBJS 49A: 774-784, 1967.
Rockwood CA Jr and Young DC. Disorders of the acromioclavicular joint, In Rockwood CA, Matsen FA III: The Shoulder, Philadelphia, WB Saunders, 1990, pp. 413-476.Type I Type I Sprain of acromioclavicular ligament
AC joint intact
Coracoclavicular ligaments intact
Deltoid and trapezius muscles intact
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997Type II AC joint disrupted
< 50% Vertical displacement
Sprain of the coracoclavicular ligaments
CC ligaments intact
Deltoid and trapezius muscles intactType II From Nuber GW and Bowen MK, JAAOS, 5:11, 1997Type 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 From Nuber GW and Bowen MK, JAAOS, 5:11, 1997Type III Variants Type III Variants “Pseudodislocation” through an intact periosteal sleeve
Physeal injury
Coracoid process fractureType 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 From Nuber GW and Bowen MK, JAAOS, 5:11, 1997Type 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 clavicleFrom Nuber GW and Bowen MK, JAAOS, 5:11, 1997Type 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
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997Treatment Options for Types I - II Acromioclavicular Joint InjuriesTreatment Options for Types I - II Acromioclavicular Joint InjuriesNonoperative: Ice and protection until pain subsides (7 to 10 days).
Return to sports as pain allows (1-2 weeks)
No apparent benefit to the use of specialized braces.nullType II operative treatment
Generally reserved only for the patient with chronic pain.
Treatment is resection of the distal clavicle and reconstruction of the coracoclavicular ligaments.Treatment Options for Type III-VI Acromioclavicular Joint InjuriesTreatment Options for Type III-VI Acromioclavicular Joint InjuriesNonoperative 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 fixation
Excision of the distal clavicle
Dynamic muscle transfersnullType 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 InjuriesIndications for Acute Surgical Treatment of Acromioclavicular InjuriesType III injuries in highly active patients
Type IV, V, and VI injuries Surgical Options for AC Joint InstabilitySurgical Options for AC Joint InstabilityCoracoid process transfer to distal transfer (Dynamic muscle transfer)
Primary AC joint fixation
Primary Coracoclavicular Fixation
Distal Clavicle Excision with CC ligament reconstruction.Weaver-Dunn ProcedureWeaver-Dunn ProcedureThe 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, 1997Indications for Late Surgical Treatment of Acromioclavicular InjuriesIndications for Late Surgical Treatment of Acromioclavicular InjuriesPain
Weakness
DeformityTechniques for Late Surgical Treatment of Acromioclavicular InjuriesTechniques for Late Surgical Treatment of Acromioclavicular InjuriesReduction of AC joint and repair of AC and CC ligaments
Resection of distal clavicle and reconstruction of CC ligaments (Weaver-Dunn Procedure)Case ExampleCase ExampleAP ViewZanca ViewCase ExampleCase ExampleAfter Weaver-Dunn
procedureSternoclavicular JointSternoclavicular JointFrom Wirth MA and Rockwood CA, JAAOS, 4:268, 1996The Anatomy of the Sternoclavicular JointThe Anatomy of the Sternoclavicular JointDiarthrodial 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
nullInterclavicular 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 ClavicleEpiphysis of the Medial ClavicleMedial Physis- Last of the ossification centers to appear in the body and the last epiphysis to close.
Does not ossify until 18th to 20th year
Does not unite with the clavicle until the 23rd to 25th year
Radiographic Techniques for Assessing Sternoclavicular InjuriesRadiographic Techniques for Assessing Sternoclavicular Injuries40-degree cephalic tilt view
CT scan- Best technique for sternoclavicular joint problemsFrom Wirth MA and Rockwood CA, JAAOS, 4:268, 1996Injuries Associated with Sternoclavicular Joint DislocationsInjuries Associated with Sternoclavicular Joint DislocationsMediastinal Compression
Pneumothorax
Laceration of the superior vena cava
Tracheal erosion
From Wirth MA and Rockwood CA, JAAOS, 4:268, 1996Treatment of Anterior Sternoclavicular DislocationsTreatment of Anterior Sternoclavicular DislocationsNonoperative 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 jointTreatment of Posterior Sternoclavicular DislocationsTreatment of Posterior Sternoclavicular DislocationsCareful 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 TechniquesClosed Reduction TechniquesAbduction traction
Adduction traction