Title Ortho Trauma UL ✅

UPPER LIMB FRACTURE & DISLOCATION CLAVICLE # ANATOMY - Type: Long bone, horizontal, no medullary cavity, Convex medially & concave laterally - Medial→ Manubrium, Lateral→ Acromion of scapula - Weakest point= junction of the outer and middle third (thinnest part of the bone + not protected/reinforce with muscle & ligament attachment IMPORTANT RELATION Posterior surface capsule and sternohyoid, subclavian vessels, lateral cord of brachial plexus, nutrient artery from suprascapular, trapezius occipital fibers. Anterior surface pectoralis major, deltoid. Cephalic vein lies in between the two muscles. Supraclavicular nerve Upper surface base of posterior triangle. Sternocleidomastoid and trapezius with the two layers of cervical fascia Lower surface costoclavicular ligament, subclavius muscle and clavipectoral fascia, conoid ligament, trapezoid ligament Preval ence -Adults→ common(2.4 % - 4 % of fractures) & approx 35% of all shoulder girdle injuries. (Apley) -Children→ clavicle fractures easily, but it almost invariably unites rapidly & without complications. MOI mechanism of injury 1. Direct impact - Fall on the shoulder 2. FOOSH (Fall on the outstretched hand) anything similar Type ● Midshaft #→ lateral fragments pulled down by the weight of the arm & the inner, medial half is held up by the sternocleidomastoid muscle. ○ Medial costoclavicular ligament and lateral coracoclavicular Iman, Izzaty, Nisa, Lissa (3/3/21) Forti
ligament is stronger than the clavicle→ fracture more common at the middle and junction middle and medial third ● Lateral end #, if the ligaments are intact→ little displacement, if the coracoclavicular ligaments torn/ fracture is just medial to these ligaments→ displacement may be more severe and closed reduction impossible. ● May reasonably common site for pathological fractures Classification (Allman, Neer) 1. Allman’s Classification (based on location on clavicle) ● Group 1 (80%) – middle third fractures ● Group 2 (15%)– lateral third fractures ● Group 3 (5%)– medial third fractures 2. Neer Classification Type I : # distal to coracoclavicular(CC) lig (trapezoid/conoid) + minimal # displacement. Acromioclavicular (AC) joint intact Type II : IIA (# medial to conoid lig). IIB (# between CC lig + disruption conoid lig) Type III : # distal to CC lig +extends to AC joint Type IV : in paeds pts. Physis & epiphysis still adjacent to AC joint but displacement at junction metaphysis & physis Type V : Small inferior clavicular fragments remains attached to CC lig Iman, Izzaty, Nisa, Lissa (3/3/21) Forti
CF ➔ Pain that increase with shoulder movement ➔ Arm clasped to the chest - to prevent movement ➔ Subcutaneous lump ➔ Sharp fragments threatens the skin – tenting on the skin ➔ Swelling – abnormal swelling suspect vascular injury ➔ Tenderness ➔ Bruising ➔ Deformity of shoulder (almost always displaced) ➔ Stiffness or inability to move shoulder ➔ Observe for complications ◆ A/w distal nerve dysfunction→ brachial plexus injury ◆ ↓ pulses → subclavian artery injury ◆ Venous stasis/discoloration/swelling→ subclavian venous injury ➔ Look for other bony injuries (glenoid/scapula, ribs/pneumothorax) IX ● X-ray of clavicle ○ Anteroposterior view ○ 15 degree cephalic tilt – Zanca view ○ 45 degree cephalic tilt – Serendipity view ● CT scan with 3 D reconstructions needed if to ○ Determine accurately the degree of shortening ○ Diagnosing a sternoclavicular fracture-dislocation ○ Establish whether a fracture has united Tx Middle Third # ● Undisplaced # → Non-operatively by applying a simple sling for comfort (most unite uneventfully & return to normal fx) ○ discarded once the pain subsides (after 1–3 weeks) & then encouraged to mobilize the limb as pain allows ● Displaced # a/w severe displacement, fragmentation or shortening (>2cm)→ Internal fixation (plating/ intramedullary fixation) of acute clavicular # Lateral Third # ● Undisplaced # (intact CC lig)→ Non-operatively by sling for 2–3 weeks until the pain subsides, followed by mobilization within the limits of pain. ● Displaced # a/w disruption of the coracoclavicular ligaments (unstable injuries) → Surgery if symptomatic non-union (non-union can be asx) ○ Techniques : coracoclavicular screw and plate, hook plate fixation, suture and sling techniques with dacron graft ligaments, lateral clavicle locking plates. Medial Third # (rare #- usually extra-articular) ● Usually Non-operatively ● Unless # displacement threatens mediastinal structures→ suture and graft techniques, newer locking plates. (IF a/w compx : implants migrates to mediastinum esp K-wire) Iman, Izzaty, Nisa, Lissa (3/3/21) Forti
Compx Early - Pneumothorax - Damage to subclavian vessels - Brachial plexus injuries Late - Non-union - > in lateral clavicular # (11.5-40%) - RF: ↑ age, displacement, comminution, female - If sx non-union: small fragments/CC lig intact→ excision of the lateral part of the clavicle or large fragments→ open reduction/internal fixation/bone grafting. Locking plates and hooked plates are used - Malunion - All displaced # heal in a non-anatomical position with some shortening and angulation (mostly asx) - May develop periscapular pain (if shortening>1.5cm) → corrective osteotomy & plating - Stiffness of shoulders (common, temporary) SHOULDER DISLOCATION ANATOMY ↓→ → Synovial ball-and-socket joint → Articular surfaces is covered by hyaline cartilage → Glenoid cavity is deepened by the presence of fibrocartilaginous rim (glenoid labrum) → Blood supply: ant & post circumflex humeral artery, suprascapular artery → Nerve supply: axillary and suprascapular nerves ---------------------------------------------------------- SHOULDER STABILITY Static restraints ● Glenohumeral ligaments ● Glenoid labrum ● Joint capsule ● Articular congruity and version ● Negative intraarticular pressure Dynamic restraints ● Rotator cuff muscles ● Stabilize the glenohumeral joint by compressing the humeral head against the glenoid ● Rotator intervals ● Biceps ● Periscapular muscles Iman, Izzaty, Nisa, Lissa (3/3/21) Forti