أ. د حسان النعمانى

استاذ - رئيس الجامعة - جامعة سوهاج

كلية الطب

العنوان: العنوان الشخصى : ش الجمهورية بسوهاج -عنوان العمل : مبنى الادارة المركزية - الدور الثالث -جامعة سوهاج

إعجاب

Clavicle Shaft Fractures

2018-10-21 19:57:40 |

Introduction

Epidemiology
- incidence
  - 75-80% of all clavicle fractures will occur in the middle third segment
- demographics
  - most often seen in young, active patients
Pathophysiology
- mechanism
  - fall on an outstretched arm or direct trauma to lateral aspect of shoulder
- pathoanatomy
  - displaced fractures
    - medial fragment: sternocleidomastoid muscle pulls the medial fragment posterosuperiorly
    - lateral fragment: pectoralis and weight of arm pull the lateral fragment inferomedially
  - open fractures usually the result of the medial fragment "buttonhole" through platysma
Associated injuries
- are rare but may include:
  - ipsilateral scapular fracture
  - scapulothoracic dissociation
    - should be considered with significantly displaced/widened fracture fragments
  - rib fracture
  - pneumothorax
  - neurovascular injury
Pediatric Clavicle fractures
- fracture patterns include
  - medial clavicle physeal injury
  - distal clavicle physeal injury

Relevant Anatomy

Acromioclavicular Joint Anatomy
AC joint stability
- static stabilizers
  - acromioclavicular ligament
    - provides anterior/posterior stability
    - has superior, inferior, anterior, and posterior components
      - superior ligament is strongest, followed by posterior
  - coracoclavicular ligaments (trapezoid and conoid)
    - provides superior/inferior stability
      - trapezoid ligament inserts 3 cm from end of clavicle
      - conoid ligament inserts 4.5 cm from end of clavicle in the posterior border
    - conoid ligament is strongest
  - capsule
- dynamic stabilizers
  - deltoid and trapezius

Classification

Neer Classification - Middle third clavicle fracture
Nondisplaced	Less than 100% displacement	Nonoperative
Displaced	Greater than 100% displacement Nonunion rate of 4.5%	Operative

AO Classification - Middle third clavicle fracture
Type A=Simple	A1 = spiral A2 = oblique A3 = transverse	Nonoperative or Operative
Type B=Wege	A1 = spiral wedge A2 = bending wedge A3 = fragmented wedge	Nonoperative or Operative
Type C=Complex	A1 = complex spiral A2 = segmental A3 = irregular	Operative

Presentation

Symptoms
- anterior shoulder pain
Physical exam
- deformity
- perform careful neurovascular exam
- tenting of skin (impending open fracture)

Imaging

Radiographs
- views
  - sitting/standing upright, standard AP view of bilateral shoulders
- additional views
  - 15° cephalic tilt (ZANCA view) determine superior/inferior displacement
    - may consider having the patient hold 5 to 10 lbs weight in affected hand
CT
- views
  - coronal, saggital, axial
  - 3D reconstruction views
- findings
  - may help evaluate displacement, shortening, comminution, articular extension, and nonunion
  - vascular injury

Treatment

Nonoperative
- sling immobilization with gentle ROM exercises at 2-4 weeks and strengthening at 6-10 weeks
  - indications
    - minimally displaced Group I (middle third)
      - shortening and displacement <2cm
      - no neurologic deficit
      - no significant displacement to the superior shoulder suspensory complex (<10mm displacement)
  - outcomes
    - nonunion (1-5%)
      - risk factors for nonunion
        
        comminution
        
        100% displacement & shortening (>2 cm)
        
        advanced age and female gender
    - poorer cosmesis
    - decreased shoulder strength and endurance
      - seen with displaced midshaft clavicle fracture healed with > 2 cm of shortening
Operative
- open reduction internal fixation
  - indications
    - absolute
      - open fxs
      - displaced fracture with skin tenting
      - subclavian artery or vein injury
      - floating shoulder (clavicle and scapula neck fx)
      - symptomatic nonunion
      - symptomatic malunion
    - relative and controversial indications
      - displaced Group I (middle third) with >2cm shortening
      - bilateral, displaced clavicle fractures
      - brachial plexus injury (questionable b/c 66% have spontaneous return)
      - closed head injury
      - seizure disorder
      - polytrauma patient
  - outcomes
    - advantages of ORIF
      - improved results with ORIF for clavicle fractures with >2cm shortening and 100% displacement
      - improved functional outcome / less pain with overhead activity
      - faster time to union
      - decreased symptomatic malunion rate
      - improved cosmetic satisfaction
      - improved overall shoulder satisfaction
      - increased shoulder strength and endurance
    - disadvantages of ORIF
      - increased risk of need for future procedures
        
        implant removal
        
        debridement for infection

Techniques

Sling Immobilization
- technique
  - sling or figure-of-eight (prospective studies have not shown difference between sling and figure-of-eight braces)
  - after 2-4 weeks begin gentle range of motion exercises
  - strengthening exercises begin at 6-10 weeks
  - no attempt at reduction should be made
Closed Reduction, Intramedullary Fixation
- equipment options
  - cannulated screw
  - specialized screw systems (e.g, Dual Trak)
  - titanium elastic nail
  - Hagle pin
- approach
  - beach chair or supine
  - posterolateral incision
- contraindications
  - substantial comminution
  - segmental fractures
- advantages
  - smaller incision
  - less soft-tissue disruption
  - less prominent hardware
  - avoids the supraclavicular cutaneous nerves commonly injured with plating
- disadvantages
  - higher complication rate including hardware migration
  - biomechanically inferior to plating
Open Reduction, Plate and Screw Fixation
- equipment
  - most common
    - limited contact precontroured, dynamic compression plate
    - k-wires for preliminary fixation
  - others
    - 3.5mm reconstruction plate
    - locking plates
- approach
  - beach chair or supine
  - direct superior vs anterior incision
- biomechanics
  - superior vs anteroinferior plating
    - higher load to failure (superior plating > anterointerior plating)
    - plate strength with inferior bone comminunion (anteroinferior plating > superior plating)
    - lower risk of neurovascular injury (anteroinferior plating > superior plating)
    - lower removal of deltoid attachment (superior plating > anterointerior plating)
- outcomes
  - time to union
    - operative (16.4 weeks) vs. non-operative (28.4 weeks)
Postoperative Rehabilitation
- early
  - sling for 7-10 days followed by active motion
- late
  - strengthening at ~ 6 weeks when pain free motion and radiographic evidence of union
  - full activity including sports at ~ 3 month

Complications

Nonoperative treatment
- nonunion (1-5%)
  - risk factors
    - fracture comminution (e.g, Z deformity)
    - fracture displacement
    - female
    - advancing age
    - smoker
  - treatment of nonunion
    - if asymptomatic, no treatment necessary
    - if symptomatic, ORIF with plate and bone graft (particularly atrophic nonunion)
- malunion
  - definition
    - shortening >3cm, angulation >30 degrees, translation >1cm
  - complaints
    - increased fatigue with overhead activities
    - thoracic outlet syndrome
    - dissatisfaction with appearance
    - difficulty with shoulder straps, backpacks and the like
  - treatment
    - clavicle osteotomy with bone grafting, if symptomatic
Operative treatment
- hardware prominence
  - ~30% of patient request plate removal
  - superior plates associated with increased irritation
- neurovascular injury (3%)
  - superior plates associated with increased risk of subclavian artery or vein penetration
  - subclavian thrombosis
- nonunion (1-5%)
- infection (~4.8%)
  - risk factors
    - illicit drug use
    - diabetes
    - previous shoulder surgery
- mechanical failure (~1.4%)
- pneumothorax
- adhesive capsulitis
  - 4% in surgical group develop adhesive capsulitis requiring surgical intervention

المرفقات

1540151861 - Introduction.pdf 0

الواجبات

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تواصل معي

العنوانالعنوان الشخصى : ش الجمهورية بسوهاج -عنوان العمل : مبنى الادارة المركزية - الدور الثالث -جامعة سوهاج
رقم الهاتف1002554984
الفاكس932332761
البريد الإلكترونيhassan.noaman@med.sohag.edu.eg

جميع البيانات و المستندات الموجوده لكل موقع من مواقع الاعضاء تقع صحتها قانونيا و أدبيا على العضو نفسه

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