1. Injuries of the Clavicle, Acromioclavicular Joint and Sternoclavicular Joint Andrew H. Schmidt, M.D. T.J. McElroy Created March 2004; Revised January 2007

2. “S”-shaped bone Medial - sternoclavicular joint Lateral - acromioclavicular joint and coracoclavicular ligaments Muscle attachments: –Medial: sternocleidomastoid –Lateral: Trapezius, pectoralis major Clavicle

3. Diarthrodial 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 important AC Joint

4. Coracoclavicular ligaments –“Suspensory ligaments of the upper extremity” –Two components: Trapezoid Conoid –Stronger than AC ligaments –Provide vertical stability to AC joint Distal Clavicle

5. Mechanism of Injury Moderate or high-energy traumatic impacts to the shoulder 1.Fall from height 2.Motor vehicle accident 3.Sports injury 4.Blow to the point of the shoulder 5.Rarely a direct injury to the clavicle

6. Physical Examination Inspection –Evaluate deformity and/or displacement –Beware of rare inferior or posterior displacement of distal or medial ends of clavicle –Compare to opposite side.

7. Physical Examination Palpation –Evaluate pain –Look for instability with stress

8. Physical Examination Neurovascular examination Evaluate upper extremity motor and sensation Measure shoulder range-of-motion

9. Radiographic Evaluation of the Clavicle Anteroposterior View 30-degree Cephalic Tilt View

10. Radiographic Evaluation of the Clavicle Quesana View –45-degree angle superiorly and a 45-degree angle inferiorly –Provide better assessment of the extent of displacement

11. 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

12. Stress Views of the Distal Clavicle & AC Joint Rationale: 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.

13. Radiographic Evaluation of the Medial One Third X-ray: Cephalic tilt view of 40 to 45 degrees CT scan usually indicated to best assess degree and direction of displacement

14. Clavicle Fractures

15. Classification of Clavicle Fractures Group 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%)

16. Treatment Options Nonoperative –Sling –Brace Surgical –Plate Fixation –Screw or Pin Fixation

17. Nonoperative Treatment “Standard of Care” for most clavicle fractures. Continued questions about the need to wear a specialized brace.

18. Simple Sling vs. Figure-of-8 Bandage Prospective 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 groups Andersen et al., Acta Orthop Scand 58: 71-4, 1987.

19. Nonoperative Treatment It 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.

20. Nonoperative Treatment There 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.

21. Deficits following nonoperative treatment of displaced midshaft clavicular fractures A 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.

22. Deficits following nonoperative treatment of displaced midshaft clavicular fractures The 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.

23. Displaced midshaft clavicle fractures can cause significant, persistent disability, even if they heal uneventfully.

24. Definite Indications for Surgical Treatment of Clavicle Fractures 1) Open fractures 2) Associated neurovascular injury

25. Relative Indications for Acute Treatment of Clavicle Fractures 1) Widely displaced fractures 2) Multiple trauma 3) Displaced distal-third fractures

26. Relative Indications for Acute Treatment of Clavicle Fractures 4) Floating shoulder 5) Seizure disorder 6) Cosmetic deformity 7) Earlier return to work.

28. Clavicular 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)

29. Plate Fixation Traditional means of ORIF Plate applied superiorly or inferiorly –Inferior plating associated with lower risk of hardware prominence Used for acute displaced fractures and nonunions.

36. Intramedullary Fixation Large 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

37. Complications of Clavicular Fractures and its Treatment Nonunion Malunion Neurovascular Sequelae Post-Traumatic Arthritis

38. Risk Factors for the Development of Clavicular Nonunions Location of Fracture –(outer third) Degree of Displacement –(marked displacement) Primary Open Reduction

39. Principles for the Treatment of Clavicular Nonunions Restore 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.

40. Correction of symptomatic nonunion with IM screw

44. Clavicular Malunion Symptoms 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 sx

45. Neurologic Sequelae Occasionally, 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.

46. McKee MD, et al. J Bone Joint Surg Am 2003;85-A(5):790-7 Osteotomy for Clavicular Malunion 15 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.

47. McKee MD, et al. J Bone Joint Surg Am 2003;85-A(5):790-7 Osteotomy for Clavicular Malunion At 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.

48. Distal Third Clavicle Fractures

49. Classification of Distal Clavicular Fractures (Group II Clavicle Fractures) Type I-nondisplaced –Between the CC and AC ligaments with ligament still intact From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

50. Classification of Distal Clavicular Fractures Type 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 Types

51. Type IIA A. Conoid and trapezoid attached to distal fragment From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

52. Type IIB Type IIB: Conoid torn, trapezoid attached From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

53. Classification of Distal Clavicular Fractures Type III:articular fractures From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

54. Treatment of Distal-Third (Type II) Clavicle Fractures Nonoperative 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

55. Displaced Type II fractures of the distal clavicle are often treated more aggressively because of the increased risk of nonunion with nonoperative treatment

56. Techniques for Acute Operative Treatment of Distal Clavicle Fractures Kirschner 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

57. For most techniques of clavicular fixation, coracoclavicular fixation is also needed to prevent redisplacement of the medial clavicle.

58. The Hook Plate (Synthes USA, Paoli, PA) was specifically designed to avoid this problem of redisplacement.

60. Hook Plate - Results Recent 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.

61. Preferred Technique for Fixation of Acute Distal Third Clavicle Fractures Horizontal incision Manual reduction of fracture Dorsal tension band suture and reconstruction/augmentation of coracoclavicular ligaments.

62. Indications for Late Surgery for Distal Clavicle Fractures Pain Weakness Deformity

63. Techniques for Late Surgery for Distal Clavicle Fractures Excision of distal clavicle –With or without reconstruction of coracoclavicular ligaments (Modified Weaver-Dunn procedure) Reduction and fixation of fracture

64. Case Example

65. Distal Clavicle Medial Clavicle

66. Case Example Coracoclavicular fixation not visible Fixation to Acromion

67. Acromioclavicular Joint

68. Radiographic Evaluation of the Acromioclavicular Joint Proper 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.

69. Classification for Acromioclavicular Joint Injuries Initially 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.

70. 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, 1997

71. AC joint disrupted < 50% Vertical displacement Sprain of the coracoclavicular ligaments CC ligaments intact Deltoid and trapezius muscles intact Type II From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

72. 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 Type III From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

73. “Pseudodislocation” through an intact periosteal sleeve Physeal injury Coracoid process fracture Type III Variants

74. 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 Type IV From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

75. 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 clavicle Type V From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

76. 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 Type VI From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

77. Treatment Options for Types I - II Acromioclavicular Joint Injuries Nonoperative: 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.

78. Type 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.

79. Treatment Options for Type III-VI Acromioclavicular Joint Injuries Nonoperative 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 transfers

80. Type 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.

81. Indications for Acute Surgical Treatment of Acromioclavicular Injuries Type III injuries in highly active patients Type IV, V, and VI injuries

82. Surgical Options for AC Joint Instability Coracoid process transfer to distal transfer (Dynamic muscle transfer) Primary AC joint fixation Primary Coracoclavicular Fixation Distal Clavicle Excision with CC ligament reconstruction.

83. Weaver-Dunn Procedure The 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, 1997

84. Indications for Late Surgical Treatment of Acromioclavicular Injuries Pain Weakness Deformity

85. Techniques for Late Surgical Treatment of Acromioclavicular Injuries Reduction of AC joint and repair of AC and CC ligaments Resection of distal clavicle and reconstruction of CC ligaments (Weaver- Dunn Procedure)

86. Case Example AP View Zanca View

87. Case Example After Weaver-Dunn procedure

88. Sternoclavicular Joint From Wirth MA and Rockwood CA, JAAOS, 4:268, 1996

89. The Anatomy of the Sternoclavicular Joint Diarthrodial 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

90. Interclavicular 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.

91. Epiphysis of the Medial Clavicle Medial 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

92. Radiographic Techniques for Assessing Sternoclavicular Injuries 40-degree cephalic tilt view CT scan- Best technique for sternoclavicular joint problems From Wirth MA and Rockwood CA, JAAOS, 4:268, 1996

93. Injuries Associated with Sternoclavicular Joint Dislocations Mediastinal Compression Pneumothorax Laceration of the superior vena cava Tracheal erosion From Wirth MA and Rockwood CA, JAAOS, 4:268, 1996

94. Treatment of Anterior Sternoclavicular Dislocations Nonoperative 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 joint

95. Treatment of Posterior Sternoclavicular Dislocations Careful 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.

96. Abduction traction Adduction traction “Towel Clip” - anterior force applied to clavicle by percutaneously applied towel clip Closed Reduction Techniques

97. Resection arthroplasty –May result in instability of remaining clavicle unless stabilization is done. –Suggest minimal resection of bone and fixation of medial clavicle to first rib. Sternoclavicular reconstruction with suture, tendon graft. Operative Techniques Return to Upper Extremity Index E-mail OTA about Questions/Comments If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e-mail to ota@aaos.orgota@aaos.org