“S”-shaped bone
Medial - sternoclavicular joint
Lateral - acromioclavicular joint and coracoclavicular
ligaments
Muscle attachments:
– Medial: sternocleidomastoid
– Lateral: Trapezius, pectoralis major
AC Joint
Coracoclavicular ligaments
– “Suspensory ligaments of the upper
extremity”
– Two components:
• Trapezoid
• Conoid
– Stronger than AC ligaments
– Provide vertical stability to AC joint
Mechanism of Injury
Palpation
Evaluate pain
Look for instability with stress
Physical Examination
Neurovascular examination
– Must be done thoroughly and documented!
Evaluate upper extremity motor and sensation
Measure shoulder range-of-motion
Radiographic Evaluation
of the Clavicle
Anteroposterior View
Quesana View
– 45-degree angle superiorly and a 45-degree
angle inferiorly
– Provide better assessment of the extent of
displacement
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 Joint
S=sternum
C= medial clavicle
E= esophagus
Clavicle Fractures
Classification of Clavicle
Fractures
Andersen et al., Acta Orthop Scand 58: 714, 1987.
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.
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.
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.
Courtesy T. Higgins
Nonoperative Treatment Compared with Plate
Fixation of Displaced Midshaft Clavicular Fractures.
A multicenter, randomized clinical trial
132 patients
– 67 ORIF
– 65 sling
Constant and DASH scores significantly improved in ORIF
group.
Time to union 16 vs 28 weeks in favor of ORIF
9 patients in sling group had symptomatic malunion
9 patients in ORIF group had hardware complications
Canadian Orthopedic Trauma Society; JBJS Am;2007:89A: 110
Intramedullary Fixation
Large threaded cannulated screws
Flexible elastic nails
K-wires
Associated with risk of migration
Mueller M, et al. J Trauma 2008;64:15281534
Minimally Invasive Intramedullary Nailing of Midshaft
Clavicular Fractures Using Titanium Elastic Nails
Mueller M, et al. J Trauma 2008;64:15281534
30 patients: simple shoulder sling 30 patients elastic nail
90% union 100% union
2 symptomatic malunions req’d OR 7 cases medial nail protrusion
2 refractures
Better DASH and Constant outcome
scores, significantly different during
first 18 weeks.
Patients more satisfied with cosmetic
appearance and overall outcome.
Comparison of Techniques
No studies available that compare one
operative technique to another.
Both elastic nails and plates seem equivalent in
stable fractures; benefits of minimally
invasive approach used in elastic nailing
awaiting study.
Plate fixation best in comminuted fractures, but
again no evidence.
Does Timing of Surgery Matter?
Potter JM, et al. J Shoulder Elbow Surg 2007;16:5148
Does Timing of Surgery Matter?
Potter JM, et al. J Shoulder Elbow Surg 2007;16:5148
Does Timing of Surgery Matter?
Potter JM, et al. J Shoulder Elbow Surg 2007;16:5148
Complications of Clavicular
Fractures and its Treatment
Nonunion
Malunion
Neurovascular Sequelae
Post-Traumatic Arthritis
Risk Factors for the Development
of Clavicular Nonunions
Location of Fracture
– (outer third)
Degree of Displacement
– (marked displacement)
Primary Open Reduction
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.
Correction of symptomatic nonunion with IM screw
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
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.
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.
Type I-nondisplaced
– Between the CC and AC
ligaments with ligament
still intact
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
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
Type IIA
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
Type IIB
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
Classification of Distal
Clavicular Fractures
Type III:articular
fractures
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
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
Displaced Type II fractures of the distal
clavicle are often treated more aggressively
because of the increased risk of nonunion
with nonoperative treatment
Techniques for Acute Operative
Treatment of Distal Clavicle Fractures
Horizontal incision
Manual reduction of fracture
Dorsal tension band suture and
reconstruction/augmentation of
coracoclavicular ligaments.
Look for avulsion fracture of CC
ligament attachment
Pain
Weakness
Deformity
Techniques For Late Surgery For
Distal Clavicle Fractures
Medial Clavicle
Distal Clavicle
Case Example 1
Fixation to Acromion
Coracoclavicular
fixation not visible
Case Example 2
This fragment likely has CC ligament attached; need
to reduce and hold clavicle shaft to this piece.
Case Example 2
Sutures passed into this
This fragment likely has CC ligament attached; need
fragment (not visible)
to reduce and hold clavicle shaft to this piece.
Case Example 2
Sutures passed into this
This fragment likely has CC ligament attached; need
fragment (not visible)
to reduce and hold clavicle shaft to this piece.
4 months
Case Example 2
Sutures passed into this
This fragment likely has CC ligament attached; need
fragment (not visible)
to reduce and hold clavicle shaft to this piece.
2 years
Acromioclavicular Joint
Mechanism
Sports injury or trauma.
Impact to superior acromion, driving the arm
down and rupturing the AC joint capsule
(first) and then the the coracoclavicular
ligaments (second).
Physical Findings
Pain over lateral clavicle / AC joint
May have prominent distal clavicle
May have skin abrasions
Unwilling to lift arm.
Should have full passive ROM of the
shoulder.
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.
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: 774784, 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.
413476.
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
Type II
AC joint disrupted
< 50% Vertical
displacement
Sprain of the
coracoclavicular
ligaments
CC ligaments intact
Deltoid and trapezius
muscles intact
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
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, 1997
Type III Variants
“Pseudo-dislocation” through an
intact periosteal sleeve
Physeal injury
Coracoid process fracture
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, 1997
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 clavicle
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
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, 1997
Treatment Options For Types I - II
Acromioclavicular Joint Injuries
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
Indications for Late Surgical
Treatment of Acromioclavicular
Injuries
Pain
Weakness
Deformity
Techniques for Late Surgical
Treatment of Acromioclavicular
Injuries
AP View
Zanca View
Case Example
After WeaverDunn
procedure
Sternoclavicular Joint
From Wirth MA and Rockwood CA, JAAOS, 4:268, 1996
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
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.
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
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
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
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
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.
Closed Reduction Techniques
Abduction traction
Adduction traction
“Towel Clip” - anterior force applied to
clavicle by percutaneously applied towel
clip
Operative techniques
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.
Literature – For those interested in further review.
Clavicle Fractures
Andersen K; Jensen PO; Lauritzen J. Treatment of clavicular fractures. Figure-of-eight bandage versus a
simple sling. Acta Orthop Scand 1987 Feb;58(1): p71-4.
Canadian Orthopaedic Trauma Society. Nonoperative Treatment Compared with Plate Fixation of
Displaced Midshaft Clavicular Fractures. A multicenter, randomized clinical trial. J Bone Joint Surg
2007;89-A:1-10.
McKee MD, Pedersen EM, Jones C, et al. Deficits following nonoperative treatment of displaced
midshaft clavicular fractures. J Bone Joint Surg 2006;88-A:35-40.
Mueller M, Rangger C, Striepens N, Burger C. Minimally Invasive Intramedullary Nailing of Midshaft
Clavicular Fractures Using Titanium Elastic Nails. J Trauma 2008;1528-1534.
Nowak J, Holgersson M, Larsson S. Can we predict long-term sequelae after fractures of the clavicle
based on initial findings? A prospective study with nine to ten years of follow up. J Shoudler Elbow
Surg 2004;13:479-486.
Potter JM, Jones C, Wild LM, Schemitsch EH, McKee MD. Does delay matter? The restoration of
objectively measured shoulder strength and patient-oriented outcome after immediate fixation versus
delayed reconstruction of displaced midshaft fractures of the clavicle. J Shoulder Elbow Surg
2007;16:514-518.
Robinson CM, Court-Brown CM, McQueen MM, Wakefield AE. Estimating the risk of nonunion
following nonoperative treatment of a clavicular fracture. J Bone Joint Surg Am 2004;86-A:1359-
1365.
Smekal V, Irenberger A, Struve P, Wambacher M, Krappinger D, Kralinger FS. Elastic Stable
Intramedullary Nailing Versus Nonoperative Treatment of Displaced Midshaft Clavicular Fractures
—A Randomized, Controlled, Clinical Trial. J Orthop Trauma 2009;23:106-112.
Literature – For those interested in further review.