2007 ANNUAL MEETING

INSTRUCTIONAL COURSE LECTURE HANDOUT

Course Number: 124

Course Title: SC and AC Injuries, Glenoid and Scapula Fractures:
Treatment and Strategies
Location: San Diego Convention Center
Room 32
Date & Start Time: 14-FEB-2007 10:30
INSTRUCTORS WHO CONTRIBUTED TO THIS HANDOUT:
April D Armstrong, MD
Carl J Basamania, MD
Matthew Lee Ramsey, MD
Michael A Wirth, MD
Guido Marra, MD

The material presented at this course has been made available by the AAOS for educational purposes only.

The AAOS disclaims any and all liability for injury, loss or other damages resulting to any individual attending the course and for all
claims, which may arise from the use of techniques and strategies demonstrated therein. The material is not intended to represent the
only methods, procedures or strategies for the situations discussed. Rather, the course is intended to present an array of approaches,
views, statements and opinions which the faculty believe will be helpful to course participants.

Some drugs or medical devices demonstrated in Academy educational programs or materials have not been cleared by the FDA or
have been cleared by the FDA for specific uses only. The FDA has stated that it is the responsibility of the physician to determine the
FDA clearance status of each drug or device he or she wishes to use in clinical practice.
AAOS 2007 Annual Meeting
San Diego, CA
Instructional Course # 124
SC and AC Injuries, Glenoid and Scapula Fractures: Treatment and Strategies

Current Treatment Options of AC Joint Separations

Matthew L. Ramsey, M.D.
Associate Professor of Orthopaedic Surgery
Chief, Shoulder and Elbow Service
University of Pennsylvania
Philadelphia, Pennsylvania

I. INTRODUCTION

A. Classification

Type I Injury
a. Sprain of the acromioclavicular ligaments only
Type II Injury
a. Acromioclavicular ligament and joint capsule disrupted
b. Coracoclavicular ligaments intact
c. Up to 50% vertical subluxation of the clavicle
Type III Injury
a. Acromioclavicular ligament and capsule disrupted
b. Coracoclavicular ligaments disrupted
c. Dislocation of acromioclavicular joint, with the clavicle displaced
superiorly, and loss of contact between the clavicle and acromion
Type IV Injury
a. Acromioclavicular ligament and capsule disrupted
b. Coracoclavicular ligaments disrupted
c. Acromioclavicular joint dislocation with clavicle displaced posteriorly
into or through the trapezius muscle (posterior displacement confirmed
by axillary radiograph)
Type V Injury
a. Acromioclavicular ligament and capsule disrupted
b. Coracoclavicular ligaments disrupted
c. Complete detachment of deltoid and trapezius fascia from the distal
clavicle Acromioclavicular joint dislocated with extreme superior
elevation of the clavicle (100% to 300% of normal)
Type VI Injury
a. Acromioclavicular ligament and capsule disrupted
b. Coracoclavicular ligaments disrupted
c. Acromioclavicular joint disrupted with the clavicle displaced inferior to
the acromion or coracoid process
 B. Mechanism of Injury

Direct Trauma
• A fall onto the superior aspect of the shoulder with the arm in adduction.
A laterally based force directed to the shoulder, as in a hockey player
hitting the boards.
Indirect Trauma
• Force is typically directed superiorly by the humeral head upward into
the acromion. With this mechanism, injury is primarily to the
acromioclavicular joint as the coracoclavicular ligaments are relaxed
with upward movement of the scapula relative to the clavicle.

II. DIAGNOSIS

A. Clinical Presentation
1. Inspection
a. Abrasion over the superior aspect of the shoulder.
b. Swelling or prominence of the distal clavicle.
2. Palpation
a. Local tenderness over the AC joint.
b. Reducible AC joint (Type II, III, V)
3. Motion
a. Early after injury attempted range of motion is painful and patient
prefers to keep the arm splinted at the side. Rotation of the humerus
with the arm at the side is generally comfortable with these injuries and
can be used to detect associated injuries of the glenohumeral joint.
b. As time progresses and pain diminishes, motion of the shoulder joint is
typically restricted most in abduction or cross-body adduction.

B. Radiographic Examination
1. Standard Radiographic Views
a. Anteroposterior Acromioclavicular Joint Radiograph
1.) ½ x-ray intensity of normal AP of glenohumeral joint. Prevents
over penetration of the film.
b. A 15-degree cephalic tilt view (Zanca) 1.
1.) Superior tilt of the x-ray beam eliminates overlap of AC joint on the
scapular spine.
c. Axillary lateral view
1.) Helpful to evaluate the position of the clavicle relative to the
acromion.
2. Special Radiographic Views
a. Stress radiographs have been used to differentiate type II from type III
acromioclavicular injuries. Since most Type III AC joint injuries are
treated nonoperatively, the value of stress radiographs is limited 2.
3. Radiographic Findings
 a. Type I – Normal
b. Type II - Slight widening of the acromioclavicular joint when compared
with the normal side.
c. Type III - The joint is totally displaced on the anteroposterior
radiograph (up to 100%).
d. Type IV - On the axillary view, posterior displacement of the distal
clavicle in relation to the acromion is most pronounced.
e. Type V - These injuries display gross displacement of the
acromioclavicular and coracoclavicular space. The coracoclavicular
space may be two to three times wider than normal (100-300%).
f. Type VI - On the anteroposterior view, the clavicle will be displaced
inferior to the acromion or coracoid. Associated fractures of the ribs or
scapula should be sought.

III. TREATMENT RECOMMENDATIONS

A. Acute Injury
1. Type I
a. Symptomatic Treatment
1.) Analgesic medications
2.) Sling for comfort
3.) Early range of motion
b. Return to activity directed by comfort level
2. Type II
a. Acute injuries treated symptomatically as in type I injuries.
3. Type III
a. Acute injuries are treated similarly to type I and II injuries however, the
return to activity will be longer given the pain and deformity.
b. Acute reconstruction of type III AC separations has been considered in
laborers or throwing athletes. However, several recent studies do not
demonstrate any difference in strength and function between patients
treated operative or nonoperative for type III separations. This
strengthens the argument for nonoperative treatment of type III
separations 3-8.
4. Type IV, V, VI
a. Acute type IV, V, VI injuries should be treated with surgery because of
the degree of injury and difficulties with nonoperative treatment.
b. Surgical Options
1.) Type IV injuries
a.) Open reduction of clavicle through trapezius defect converting to
a type III defect.
1. Treat type III defect nonoperatively
2. Surgically reconstruct the type III defect
2.) Type V injuries
a.) Reconstruction of the AC joint (see options below)
b.) Meticulous deltotrapezial fascia repair.
 3.) Type VI injuries
a.) Open reduction of the clavicle
b.) Reconstruction of the AC joint (see options below)

B. Chronic Injuries
1. Type 1
a. Degenerative changes may occur over time.
b. Treat the pain with medications and injections.
1.) Nonoperative Treatment-Seldom provides long term relief.
2.) Analgesics and nonsteroidal anti-inflammatory meds
3.) AC joint injection
c. Failure of conservative measures may require distal clavicle resection.
2. Type II
a. Degenerative changes may occur over time.
b. Treat patient with medication and injections
1.) Nonoperative Treatment-Seldom provides long term relief.
2.) Analgesics and nonsteroidal anti-inflammatory meds
3.) AC joint injection
c. Surgical management
1.) Distal clavicle resection – Some patients do poorly after distal
clavicle resection because of abutment of the clavicle on the
posterior aspect of the clavicle against the acromion.
2.) Anteroposterior instability may be improved by imbrication of the
periosteum and deltotrapezial fascia.
3. Type III
a. Surgery for type III injuries is typically delayed until the patient
demonstrates pain with activity following failed nonoperative
management.
b. Indications for late reconstruction
1.) Mechanical symptoms with activity.
2.) Trapezius fatigue.
3.) Neurologic symptoms.
a.) Brachial plexus stretch

C. Treatment Options
1. Type I/II AC Separations (Late)
a. Distal clavicle resection
1.) Prefer arthroscopic management because the superior capsular
ligaments are not violated.
a.) Patients with type II injuries may rarely have difficulty with
anteroposterior instability of the clavicle resulting in abutment of
the posterior margin of the clavicle against the acromion.
Stability may be improved by imbricating the periosteum and
deltotrapezial fascia.
b.) Coracoacromial ligament transfer to the clavicle improves
 superoinferior stability but does not affect anteroposterior
instability. Therefore, this is not an acceptable treatment of AP
instability that may accompany type II AC separations.
2. Type III/IV/V/IV AC Separations (Acute or Late)
a. Dynamic Muscle Transfers
1.) The tip of the coracoid with the attached tendons of the
coracobrachialis and short head of the biceps is transferred to the
clavicle (Intramedullary or undersurface)9-11. Thought to act as a
dynamic depressor of the clavicle holding the
acromioclavicular joint reduced.
2.) Results 10
a.) 50% describe aching in the acromioclavicular joint
b. Primary AC Joint Fixation
1.) Considered for acute type III, IV, V, VI injuries
2.) Surgical Technique
a.) AC joint is reduced and held in reduced position by Kirschner
wires, Steinman pins or screws across the AC joint.
b.) Meticulous repair of the AC capsular ligaments and
deltotrapezial fascia.
c.) Often performed in conjunction with coracoclavicular ligament
repair.
3.) Immediate concerns
a.) Hardware problems
1. Breakage
2. Need for second surgery for hardware removal
4.) Late concerns
a.) Degenerative changes of the AC joint
c. Primary Coracoclavicular (Extraarticular) Stabilization
1.) Coracoclavicular Screw
2.) Suture Anchor
3.) Coracoclavicular Cerclage
4.) Coracoclavicular Reconstruction
5.) Each of the above options often accompanied by coracoclavicular
ligament repair, acromioclavicular ligament repair, and
deltotrapezial fascia repair.
d. Coracoclavicular Fixation (Reconstruction)
1.) Biologic reconstruction of coracoclavicular ligaments
2.) Improved AP and Superior/Inferior stability compared to other
reconstructions
e. Distal Clavicle Excision +/- Coracoacromial Ligament Reconstruction
(Weaver-Dunn)
1.) Distal clavicle resection (Limit the amount of resection but be sure
that enough posterior clavicle is resected to prevent posterior
abutment of the clavicle on the acromion).
2.) Coracoacromial ligament transfer to the resected end of the
clavicle.
 3.) Coracoclavicular stabilization
a.) Coracoclavicular screw
b.) Coracoclavicular cerclage
1. Braided PDS suture
2. Nonabsorbable suture
3. Wire
c.) Cerclage technique
1. Pass beneath base of coracoid
2. Management on the clavicular side
a. Wrap around clavicle
• Tends to displace the clavicle anteriorly.
b. Drill holes through the clavicle (at junction of anterior
and middle 1/3 of clavicle) 12.
4.) Acromioclavicular ligament repair
5.) Deltotrapezial fascia repair

D. RESULTS
1. Review of the literature fails to demonstrate a clear choice from among the
many different procedures, modifications, and combinations that have been
described.
2. Acromioclavicular and coracoclavicular fixation have been compared in
several studies.6, 13-15
a. Coracoclavicular fixation has generally been favored because of its
lower complication rate and overall superior results.
b. In addition, a higher degree of late degenerative arthritis has been noted
with acromioclavicular fixation.6,15
3. Generally good results of the Weaver and Dunn procedure have been
described based on joint stability, pain, and function.16,17
a. In some series distal clavicle resection does not appear to influence
the results of surgery 18 while in other series there is a higher rate of
arthritis of the distal clavicle when the distal clavicle is not excised.15

E. COMPLICATIONS
1. Ossification in the coracoclavicular interval
a. Can occur after injury or as a result of surgery.
b. Does not affect final result
2. Arm weakness, paresthesias, or other vague symptoms
suggestive of traction
on the brachial plexus.
3. Surgical Complications
a. Persistent or recurrent deformity
b. Hardware Complications
1.) Breakage, migration, and fixation failure.19
2.) Erosion of the clavicle by wire or nonabsorbable suture used in
coracoclavicular fixation has also been observed with some
frequency.20-22
F. REFERENCES

1. Zanca P. Shoulder pain: involvement of the acromioclavicular joint. Analysis of

1,000 cases. AJR Am J Roentgenol 1971; 112: 493–500.
2. Bossart PJ, Joyce SM, Manaster BJ, Packer SM. Lack of efficiency of weighted
radiographs in diagnosing acute acromioclavicualr separation. Ann Emerg Med
1988; 17: 47–51.
3. Jacobs B, Wade PA. Acromioclavicular joint injury: an end-result study. J Bone
Joint Surg [Am] 1966; 48: 475–486.
4. Larsen E, Bjery-Nielsen A, Christensen P. Conservative or surgical treatment of
acromioclavicular dislocation: a prospective, controlled, randomized study. J
Bone Joint Surg [Am] 1986; 68: 552–555.
5. MacDonald PB, Alexander MJ, Frejuk J, Johnson GE. Comprehensive functional
analysis of shoulders following complete acromioclavicular separation. Am J
Sports Med 1988; 16: 475–480.
6. Taft TN, Wilson FC, Oglesby JW. Dislocation of the acromioclavicular joint: an
end-result study. J Bone Joint Surg [Am] 1987; 69: 1045–1051.
7. Tibone J, Sellers R, Tonino P. Strength testing after third degree
acromioclavicular dislocations. Am J Sports Med 1992; 20: 328–331.
8. Walsh WM, Peterson DA, Shelton G, Newmann RD. . Shoulder strength
following acromioclavicular injury. Am J Sports Med 1985; 13: 153–158.
9. Berson BL, Gilbert MS, Green S. Acromioclavicular dislocations: treatment by
transfer of the conjoined tendon and distal end of the coracoid process to the
clavicle. Clin Orthop 1978; 135: 157–164.
10.Ferris BD, Bhamra M, Paton DF. Corcacoid process transfer for
acromioclavicular dislocations. A report of 20 cases. Clin Orthop 1989; 242: 184–
187.
11.Skjeldal S, Lundblad R, Dullerud R. Coracoid process transfer for
acromioclavicular dislocation. Acta Orthop Scand 1988; 59: 180–182.
12.Morrison DS, Lemos MJ. Acromioclavicular separation. Reconstruction using
synthetic loop augmentation. Am J Sports Med 1995; 23: 105–110.
13.Bargren JH, Erlanger S, Dick HM. Biomechanics and comparison of two
operative methods of treatment of complete acromioclavicular separation. Clin
Orthop 1978; 130: 267–272.
14.Lancaster S, Horowitz M, Alonso J. Complete acromioclavicular separations: a
comparison of operative methods. Clin Orthop 1987; 216: 80–88.
15.Smith MJ, Stewart MJ. Acute acromioclavicular separations. Am J Sports Med.
1979; 7: 62–71.
16.Rauschning W, Nordesjo LO, Nordgren B, Sahlstedt B, et al. Resection
arthroplasty for repair of complete acromioclavicular separations. Arch Orthop
Traumatol Surg 1980; 97: 161–164.
17.Weaver JK, Dunn HK. Treatment of acromioclavicular injuries, especially
complete acromioclavicular separation. J Bone Joint Surg 1972; 54: 1187–1194.
18.Browne JE, Stanley RF Jr, Tullow HS. Acromioclavicular joint dislocations. Am
J Sports Med 1977; 5: 258–263.
19.Cappello T, Nuber GW, Nolan KD, McCarthy WJ. Acute ischemia of the upper
limb fifteen years after anterior dislocation of the glenohumeral joint and a
modified Bristow procedure. J Bone Joint Surg [Am] 1996; 78: 1578–1582.
20. Kappakas GS, McMaster JH. Repair of acromioclavicular separation using a
Dacron prosthesis graft. Clin Orthop 1978; 131: 247–251.
21.Nelson CL. Repair of acromioclavicular separations with knitted Dacron graft.
Clin Orthop 1979; 143: 289.
22. Park JP, Arnold JA, Coker TP, et al. Treatment of acromioclavicular separations:
a retrospective study. Am J Sports Med 1980; 8: 251–256.
 Glenoid Fractures
Indications and Results

Guido Marra M.D.

Department of Orthopaedic Surgery
Loyola University Medical Center
Maywood, Illinois

I. Introduction
Uncommon fracture, 5% of all fractures involving the shoulder6
High-energy injuries
Most common in males between the ages 25-4011;12
Mortality 16%14

II. Clinical Evaluation

Skin inspection
Cervical spine and thoracic spine examination
Chest auscultation
Neurologic examination
Vascular examination
On average 3.9 additional injuries: rib fractures, clavicle fracture,
hemopneumothorax, pulmonary contusion, head injury, skull fractures, spine
fractures 14

III. Radiographic Evaluation

Trauma series: AP in the scapular plane, a scapular Y and an axillary view
CT scan aids in comminuted fractures
3-D reconstruction
Chest radiograph: evaluate possible pneumothorax
C-spine/T-spine series
Angiogram

IV. Classification
Anatomic location.15
Scapular body: 45%
Glenoid neck: 25%
Glenoid fossa: 10%
Acromion: 8%
Coracoid process: 7%
Complex: 5% (involve more than one anatomic location)

Ideberg: Glenoid fractures8

Type I: avulsion of the anterior margin
Type II: transverse fracture exiting inferiorly
 Type III: oblique fracture through the glenoid that exits superiorly often
associated with an acromioclavicular injury
Type IV: transverse fracture exiting the medial border of the scapula
Type V: is a combination of types II and IV
Later modified by Goss4

Superior suspensory shoulder complex (SSSC)5

Biomechanical guide to clarify complex fracture patterns involving the
shoulder girdle
Composed of the distal clavicle, the acromioclavicular joint, the acromion,
the coracoclavicular ligaments, the coracoid and the glenoid process
• Treatment
Scapular Body Fracture
Majority are minimally displaced and are best managed non-operatively.3
Sling with early range of motion x 6 week
High union rates with 90% satisfactory results1;15
Displacement of >10-mm associated with higher rates of disability13

Glenoid Extra-articular Fractures

Impacted fractures <1-cm or 40 degrees of angulation: Sling with early range
of motion x 6 week (majority) 15
Treatment is similar to that outlined for the scapular body fracture.
>1 cm or 45 degrees of angulation: ORIF1 6;13
Some feel greater degree of displacement may be compatible with good
function
Operative results for displaced fractures: 90%6;11

“Floating Shoulder”
Glenoid neck associated with ipsilateral clavicle fractures7
The weight of the arm pulls the glenoid fragment distally and medially if AC
and CC ligaments injuries
ORIF indication like above but:
Plate fixation of the clavicle can indirectly reduce glenoid7
If significant displacement of glenoid persists then precede with ORIF of
glenoid11

Intra-articular Glenoid fractures

Ideberg Type I
Goals of treatment: maintain glenohumeral stability and to prevent
arthrosis.2;10
ORIF of glenoid rim fractures >10-mm of fracture displacement or
involving more than 25% of the anterior rim3
Not comminuted: Screw fixation with or without capsulolabral
repair
 Comminution: Fragment excision with bone-grafting procedure
(Bristow)9

Ideberg Type II-V

Minimal displacement: functional rehabilitation.
>5mm articular displacement or humeral head is subluxation ORIF
Good to excellent functional results:82% when anatomic
reconstruction achieved 12

Reference List

1. ADA, J.R. and MILLER, M.E.: Scapular fractures: an analysis of 113 cases. Clin
Orthop, 289: 174-180, 1989.

2. ARMSTRONG, C.P. and VAN DER SPUY, J.: The fractured scapula: importance
and management based on a series of 62 patients. Injury, 15: 324-329,
1984.

3. DEPALMA, A.F.: Surgery of the shoulder. Philadephia, LB Lippincott, 1983.

4. GOSS, T.P.: Fractures of the glenoid cavity: current concepts review. J Bone Joint
Surg [Am], 74: 2991992.

5. GOSS, T.P.: Double disruptions of the superior shoulder complex. J Orthop

Trauma, 7: 991993.

6. HARDEGGER, F.H.; SIMPSON, L.A.; and WEBER, B.G.: The operative

treatment of scapular fractures. J Bone Joint Surg [Br], 66: 725-731, 1984.

7. HERSCOVICI, D.; FIENNES, A.G.; ALLGÖWER, M.; and RÜEDI, T.P.: The
floating shoulder: ipsilateral clavicle and scapular neck fractures. J Bone
Joint Surg [Br], 74: 362-364, 1992.

8. IDEBERG, R.: Fractures of the scapula involving the glenoid fossa. In Surgery of
the shoulder, pp. 63-66. Edited by J.E. Bateman and R.P. Welsch.
Philadephia, B.C.Decker, 1984.

9. KAVANAGH, B.F.; BRADWAY, J.K.; and COFIELD, R.H.: Open reduction and
internal fixation of displaced intra-articular fractures of the glenoid fossa. J
Bone Joint Surg [Am], 75: 479-484, 1993.

10. KUMMEL, B.M.: Fractures of the glenoid causing chronic dislocation of the
shoulder. Clin Orthop, 69: 1891970.

11. LEUNG, K.S. and LAM, T.P.: Open reduction and internal fixation ipsilateral
fractures of the scapular neck and clavicle. J Bone Joint Surg [Am], 75:
1015-1018, 1993.
12. MAYO, K.A.; BENIRSCHKE, S.K.; and MAST, J.W.: Displaced fractures of the
glenoid fossa: results of open reduction and internal fixation. Clin Orthop,
347: 122-130, 1998.

13. NORDQVIST, A. and PETERSSON C: Fractures of the body, neck, or spine of the
scapula. Clin Orthop, 283: 139-144, 1990.

14. THOMPSON, D.A.; FLYNN, T.C.; MILLER, P.W.; and FISCHER, R.P.: The
significance of scapula fractures. J Trauma, 25: 974-977, 1985.

15. WIBER, M.C. and EVANS, E.B.: Fractures of the scapula. An analysis of forty
cases and a review of the literature. J Bone Joint Surg [Am], 59: 358-362,
1977.

V. Results
 Acute Clavicle Fractures

Carl J. Basamania, MD, FACS

Chief, Adult Reconstructive Shoulder Surgery
Division of Orthopaedic Surgery
Duke University Medical Center

“…a fracture of the clavicle has been greatly underrated in respect to pain and
disability.
…the ‘usual or routine treatment’ is perhaps far short of satisfying, relieving therapy.”
Carter R. Rowe, 1968

• Clavicle fractures are very common, accounting for 5-15% of all fractures and
nearly half of all shoulder fractures.
• Middle third fractures are by far the most common, accounting for 80% of all
clavicle fractures with lateral third fractures accounting for about 10-15% and
medial third fractures accounting for about 5% 24.
• It used to be thought than most clavicle fractures occurred as the result of a direct
blow to the clavicle. However, the clavicle is typically fractured by a fall on to the
25
lateral aspect of the shoulder . Less commonly, it can also be fractured by a
direct blow as seen in “seat belt fractures” or in sports such as lacrosse. There are
reported cases of stress fractures of the clavicle, typically in overhead athletes.
• Midshaft clavicle fractures tend to occur in younger individuals while lateral third
fractures tend to occur in older individuals.
• Earlier literature suggested that the rate of healing with non-operative treatment
20,29
was quite high ; approximately 99% were felt to heal without complication.
However, no recent study has been able to reproduce these results. In fact, most
recent studies have shown a nonunion rate of 15-25% 11, 22, 27 . More importantly,
when looking at patient satisfaction, 30 - 50% of patients who had sustained a
 clavicle fracture, even as long as ten years previously, felt that they had not fully
recovered and were dissatisfied with the result 22.
• Most clavicle fractures are multiplanar injuries; that is, the fracture displacement
occurs in multiple planes: angulation, shortening and medial rotation. This is due
to the weight of the arm and the pull of the various muscles about the shoulder,
particularly the anterior muscles such as the pectoralis.

Fracture Classification
• There are numerous classification systems for clavicle fractures 22, 25, 29; however,
it is really only important to describe them as displaced or nondisplaced and
comminuted or simple. Lateral third fractures are usually referred to as Type II or
III fractures; however, in this case, it is important only to recognize whether or
not the stabilizing CC ligaments are involved. If the ligaments are involved, as
would typically be the case in a fracture in the region of the coracoid, the fracture
is inherently unstable, whereas fractures occurring in the lateral most aspect of the
clavicle or lateral to the CC ligament insertions are inherently stable.
• It is important to note that in skeletally immature patients, lateral clavicle
fractures are usually periosteal sleeve avulsions and can be treated non-
operatively since they have considerable potential for remodeling, even towards
the end of the growth period.

Clinical Evaluation
• Clavicle fractures typically do not present as a diagnostic dilemma since the
injury is rather obvious in most cases. There is usually a clear history of some
form of either direct or indirect injury to the shoulder. The patient typically
presents splinting the injured side due to the pain. There is usually tenting of the
skin over the fracture site; however, open fractures of the clavicle are quite rare.
• It is of utmost importance to assess for other associated injuries due to the trauma
4, 15, 19
. These can be classified as injuries to the surrounding bone and soft tissue,
lung, vascular structures and the brachial plexus. A careful neurovascular exam
should be documented in all clavicle fractures. The obvious nature of the clavicle
 fracture should not detract from other boney injuries such as those to the scapula
and underlying ribs.

Radiographic Evaluation
• Many physicians accept a single AP radiographic view to assess injuries to the
clavicle; however, it is impossible to assess fracture displacement on a single
radiograph. Unfortunately, it is not possible to obtain orthogonal views (views at
right angles to each other) of the clavicle. The next best technique is to obtain an
AP and 45 degree cephalic tilt AP radiograph. The contour and displacement can
best be seen on the 45-degree cephalic tilt view.
• Lateral third clavicle fractures must include an axillary radiograph to assess
posterior displacement of the medial fragment relative to the lateral fragment.
• It is not possible to assess accurately shortening of a clavicle fracture on plain
radiographs. This is because the shortening occurs obliquely to the plane of the
radiograph. In fact, short of 3D CT reconstructions with side-to-side comparisons,
shortening can only be measured clinically.

Treatment
• The statement that “all clavicle fractures heal well” is probably one of the greatest
20, 29
fallacies in all of orthopaedics . Many clavicle fractures can be treated non-
operatively. However, as more and more studies have suggested a poorer outcome
with non-operative treatment, it is important to recognize those that may require
operative intervention 11, 22, 27.
• For those fractures that are nondisplaced or are minimally displaced (100% or less
displacement and less than 15-20mm of shortening), patients can be treated in a
sling or a figure of eight harness. Studies have suggested that there is no
difference in these two treatment modalities 1; however, both have significant
limitations. First, the figure of eight harness tends to be very awkward to put on
and maintain. It should be adjusted frequently to keep proper tension on the brace.
Secondly, the figure of eight harness itself usually lies directly over the fracture
 and can actually exacerbate the discomfort rather than alleviate it. The advantage
of the figure of eight harness is that it frees up both upper extremities for day-to-
day activities. It can also be used quite successfully in treating medial third
clavicle fractures. The primary problem with the sling is that it is typically worn
with the arm internally rotated and this can exacerbate the shortening and rotation
of the fracture. If used, the sling is better if the arm is held in a neutral position;
i.e., with the forearm pointing straight ahead.
• An attempt at closed reduction of clavicle fractures is not only painful but also
probably futile. At best, patients will remain in the position they present with on
first evaluation. Repeat exams and radiographs are justified to make sure a
minimally or non-displaced fracture remains so.
• In the case of lateral third fractures, a Kenny Howard brace, which forces the
clavicle downward and the shoulder/arm upward, can be tried; however,
compliance with this brace is very poor. Ironically, patients who do comply with
wearing of this brace can be at risk for skin breakdown under the brace.
• There are certain cases where operative intervention is indicated 11, 22, 27:
1. Neurovascular injury or compromise that is progressive or that fails to reverse
with closed reduction of the fracture
2. Severe displacement caused by comminution with resultant angulation and tenting
of the skin severe enough to threaten its integrity and that fails to respond to a closed
reduction
3. An open fracture that will require operative debredment
4. Multiple trauma, when mobility of the patient is desirable and closed methods of
immobilization are impractical or impossible
5. A "floating" shoulder, with a displaced clavicular fracture and an unstable
scapular fracture, with compromise of the acromioclavicular and coracoacromial
ligaments.
6. Factors that render the patient unable to tolerate closed immobilization, such as
the neurological problems of Parkinsonism, seizure disorders, or other neurovascular
disorders
 7. The very rare patient for whom the cosmetic lump over the healed clavicle would
be intolerable
• A relative indication for operative intervention is displacement of the fracture
fragments more than 100% (the width of the clavicle) and shortening more than
20mm. Poor outcomes after non-operative treatment of clavicle fractures typically
occur in patients who with this much displacement. In addition, patients who have
a butterfly fragment that is flipped 90 degrees on the 45-degree cephalic tilt
radiograph tend to have poorer outcomes and should be considered for operative
intervention 22.
• In a multicenter, randomized study of non-operative versus operative treatment, it
was found that operative fixation of a displaced clavicle fractures resulted in
improved functional outcome and a lower rate of malunion and nonunion
compared with nonoperative treatment 5.
Operative Treatment
• There are two primary forms of operative treatment of midshaft clavicle fractures:
plate and screw fixation and intramedullary fixation. Due to the significant forces
placed on the clavicle, most other types of fixation, such as circlage wires, are
inadequate, and should not be considered.
• One type of fixation that is contraindicated in clavicle fractures is smooth wire
fixation. For some reason, smooth wires have a very significant tendency to
migrate and the literature is replete with cases of smooth wires migrating from the
shoulder to almost unimaginable locations such as the lung, trachea, abdomen,
and spine 16, 18, 21, 30.
• Both intramedullary fixation and plate fixation have been shown to have good
outcomes in treating clavicle fractures. The choice is more related to the
experience and comfort level of the surgeon in regards to operating in this area.
The primary advantage of plate and screw fixation is that most orthopaedic
surgeons are comfortable with using this technique. The primary disadvantage is
that this type of surgery has to be performed through a rather large, non-cosmetic
incision with the risk of compromise of the bone’s blood supply due to soft tissue
stripping. Removal of the plate and screws requires a second major procedure that
 can leave the clavicle with multiple stress rises and can place the patient at risk
for later re-fracture 3.
• The primary advantage of intramedullary fixation is that it can be accomplished
through a small, cosmetic incision and the hardware can later be removed under
local anesthesia. The primary disadvantage of this type of fixation is that most
surgeons are unfamiliar with this technique and that fact that there is less
rotational control of the fragments with the intramedullary fixation 10.
• In a prospective, randomized series of plate versus pin or non-operative treatment,
patients who underwent intramedullary fixation with a DePuy Clavicle pin were
found to have a 100% union rate within 2-4 months with minimal complications
whereas a plate fixation group had a 24% rate of scar related pain and an
additional 17.5% had painful hardware. The non-operatively treated group had a
23.5% nonunion and 6% malunion rate with 29.4% having cosmetic complaints
30
.
• Lateral third clavicle fractures represent a special dilemma: most occur in older
patients from standing height falls; however, the nonunion rate from non-
operative treatment is rather high 26, 28. Some surgeons suggest that many of these
nonunions are relatively asymptomatic; however, most surgeons feel that
operative intervention is indicated due to the high nonunion rate 6, 8, 14, 32.
• Fixation of lateral third fractures can be difficult due to the location of the fracture
and the difficulty in getting enough adequate purchase with the fixation devices.
Plate and screw fixation is very difficult to achieve unless the plate extends out on
to the acromion 17. Because of this, most surgeons prefer suture circlage or
coracoclavicular screw fixation 2, 32. Pin or smooth wire fixation through the
acromion and into the clavicle can be used; however, this is rather weak fixation
and carries the risk of damage to the acromioclavicular joint and smooth pin
migration 8. With suture fixation, sutures are passed around the coracoid the
around or through the medial clavicle fragment to achieve and hold the reduction.
Although relative easy to do, there is a risk of the sutures sawing through the
clavicle or coracoid if non-absorbable sutures are used. Absorbable sutures can be
used; however, these may weaken and fail before adequate healing has taken
 place. With coracoclavicular screw fixation, a screw is passed through the medial
fragment into the coracoid. This is a very strong form of fixation when properly
placed; however, it is technically more difficult and the screw should be removed
once healing is achieved, necessitating a second operative procedure.
• Late treatment of lateral third nonunions usually consists of excision of the distal
fragment. The medial fragment must be stabilized with a ligament transfer due to
the earlier injury to the CC ligaments. Failure to do so can result in significant
instability of the clavicle.
• Intraarticular distal clavicle fractures can be treated with rest until there is
evidence of radiographic and clinical healing. If the patient has later symptoms,
they can be treated with a simple distal clavicle resection. Stability of the
remaining clavicle should be assessed at the time of surgery to make sure that
there was not an associated ligamentous injury.

References:

1. 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):71-4.

2. Ballmer FT, Gerber C. Coracoclavicular screw fixation for unstable

fractures of the distal clavicle. A report of five cases. J Bone Joint Surg Br
1991 Mar;73(2):291-4.

3. Bostman O, Manninen M, Pihlajamaki H. Complications of plate fixation

in fresh displaced midclavicular fractures. J Trauma 1997 Nov;43(5):778-
83.

4. Canadian Orthopaedic Trauma Society. Nonoperative Treatment

Compared With Plate Fixation Of Displaced Midshaft Clavicular
Fractures. J. Bone Joint Surg. Am. 89:1-10, 2007

5. Dath R, Nashi M, Sharma Y, Muddu BN. Pneumothorax complicating

isolated clavicle fracture. Emerg Med J 2004 May;21(3):395-6.

6. Edwards DJ, Kavanagh TG, Flannery MC. Fractures of the distal clavicle:
a case for fixation. Injury 1992;23(1):44-6.
7. Emond SD, Tayoun P, Bedolla JP, Camargo CA, Jr. Injuries in a 1-day
recreational cycling tour: Bike New York. Ann Emerg Med 1999
Jan;33(1):56-61.

8. Eskola A, Vainionpaa S, Patiala H, Rokkanen P. Outcome of operative

treatment in fresh lateral clavicular fracture. Ann Chir Gynaecol
1987;76(3):167-9.

9. Fann CY, Chiu FY, Chuang TY, Chen CM, Chen TH. Transacromial
Knowles pin in the treatment of Neer type 2 distal clavicle fracturesA
prospective evaluation of 32 cases. J Trauma 2004 May;56(5):1102-5.

10. Grassi FA, Tajana MS, D'Angelo F. Management of midclavicular

fractures: comparison between nonoperative treatment and open
intramedullary fixation in 80 patients. J Trauma 2001 Jun;50(6):1096-100.

11. Hill JM, McGuire MH, Crosby LA. Closed treatment of displaced middle-
third fractures of the clavicle gives poor results. J Bone Joint Surg Br 1997
Jul;79(4):537-9.

12. Iannotti MR, Crosby LA, Stafford P, Grayson G, Goulet R. Effects of

plate location and selection on the stability of midshaft clavicle
osteotomies: a biomechanical study. J Shoulder Elbow Surg 2002
Sep;11(5):457-62.

13. Jubel A, Andermahr J, Prokop A, Isenberg J, Rehm KE. [Minimal

invasive biological osteosynthesis of the clavicle with a titanium nail].
Kongressbd Dtsch Ges Chir Kongr 2002;119:485-90.

14. Kao FC, Chao EK, Chen CH, Yu SW, Chen CY, Yen CY. Treatment of
distal clavicle fracture using Kirschner wires and tension-band wires. J
Trauma 2001 Sep;51(3):522-5.

15. Kendall KM, Burton JH, Cushing B. Fatal subclavian artery transection
from isolated clavicle fracture. J Trauma 2000 Feb;48(2):316-8.

16. Leppilahti J, Jalovaara P. Migration of Kirschner wires following fixation

of the clavicle--a report of 2 cases. Acta Orthop Scand 1999
Oct;70(5):517-9.

17. Mizue F, Shirai Y, Ito H. Surgical treatment of comminuted fractures of

the distal clavicle using Wolter clavicular plates. J Nippon Med Sch 2000
Feb;67(1):32-4.

18. Naidoo P. Migration of a Kirschner Wire from the clavicle into the
abdominal aorta. Arch Emerg Med 1991 Dec;8(4):292-5.
19. Natali J, Maraval M, Kieffer E, Petrovic P. Fractures of the clavicle and
injuries of the sub-clavian artery. Report of 10 cases. J Cardiovasc Surg
(Torino) 1975 Sep;16(5):541-7.

20. Neer CS II: Nonunion of the clavicle. JAMA 172:1006–1011, 1960.

21. Nordback I, Markkula H. Migration of Kirschner pin from clavicle into

ascending aorta. Acta Chir Scand 1985;151(2):177-9.

22. Nowak J. Clavicular Fractures: Epidemiology, Union, Malunion,

Nonunion. Uppsala, Sweden: Acta Universitatis Upsalaiensis; 2002.

23. Poigenfurst J, Rappold G, Fischer W. Plating of fresh clavicular fractures:

results of 122 operations. Injury 1992;23(4):237-41.

24. Postacchini F, Gumina S, De Santis P, Albo F. Epidemiology of clavicle

fractures. J Shoulder Elbow Surg 2002 Sep;11(5):452-6.

25. Robinson CM. Fractures of the clavicle in adults. Epidemiology and

classification. J Bone Joint Surg Br 1998;80-B(3):476-84.

26. Robinson CM, Cairns DA. Primary nonoperative treatment of displaced

lateral fractures of the clavicle. J Bone Joint Surg Am 2004 Apr;86-
A(4):778-82.

27. 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 Jul;86-A(7):1359-65.

28. Rokito AS, Zuckerman JD, Shaari JM, Eisenberg DP, Cuomo F, Gallagher
MA. A comparison of nonoperative and operative treatment of type II
distal clavicle fractures. Bull Hosp Jt Dis 2002;61(1-2):32-9.

29. Rowe CR. An atlas of anatomy and treatment of midclavicular fractures.

Clin Orthop 1968 May;58:29-42.

30. Subbotin VM, Sukhanov SG. [Migration of a foreign body into the aorta
following osteosynthesis of the clavicle]. Grud Serdechnososudistaia Khir
1991 Feb;(2):56.

31. Thyagarajan, DS. Treatment of Displaced Midclavicle Fractures with

Rockwood Pin: A Comparative Study. AAOS Annual meeting,
Washington, DC 2005.

32. Yamaguchi H, Arakawa H, Kobayashi M. Results of the Bosworth method

for unstable fractures of the distal clavicle. Int Orthop 1998;22(6):366-8.
 1

American Academy of Orthopaedic Surgery

Annual Meeting 2007
San Diego, CA

CLAVICLE NONUNION
Course #124
April Armstrong, BSc (PT), MD,MSc FRCSC

MIDSHAFT CLAVICLE FRACTURES

Clavicle fractures are common injuries, 5 – 10% incidence; however, clavicle
nonunion and malunions are uncommon. Treatment of clavicle nonunion/malunions can
be difficult due to the unique anatomy and challenges with fixation.

ANATOMY

ƒ ‘S’ shaped curve

o curves anteromedially and posterolaterally
ƒ larger medial curvature widens the space for passage of neurovascular structures
ƒ lateral curvature contributes to ROM of shoulder, 30 degree motion between
scapula and clavicle
ƒ early scapular rotation during elevation is initiated by motion of the clavicle
ƒ acts a bony strut to link the chest with the upper limb
ƒ contributes to power and stability of upper extremity, especially in overhead
activities
ƒ central third predisposed to nonunion
o thinnest and narrowest
o transitional region of bone in curvature and cross-sectional anatomy
o lacks muscular coverage or ligamentous support

DEFORMITY WITH NONUNION

ƒ apex superior deformity – result of muscular pull of soft tissues

ƒ medially the clavicle is pulled upward by the clavicular head of the
sternocleidomastoid muscle
Notes___________________________________________________________________
 2

ƒ laterally the clavicle is pulled downward and inward by the weight of the arm and
medial pull of the pectoralis major
ƒ “Ptosis of the shoulder” – mediolateral shortening, drooping, adduction, and
protraction of the shoulder

INCIDENCE

ƒ 0.1% - 7 %31,33,39,41
ƒ recently prevalence reported higher than earlier reports

Neer, 1960:
ƒ 0.1% (2235 fractures) incidence nonunion treated nonoperatively
Rowe, 1968:
ƒ 0.8% (690 fractures) closed treatment of midshaft fractures
Robinson et al, 2004:
ƒ 868 patients
ƒ 4.5% incidence nonunion diaphyseal fractures
ƒ Increased risk: displacement of fracture, female gender, comminution,
advancing age
Nowak et al, 2004
ƒ 208 patients
ƒ 7% nonunion
ƒ Increased risk: no bony contact, comminuted with transverse fragment, older
patients

Zlowodzki, M et al. 2005 Treatment of Acute Midshaft Clavicle fractures: Systematic

review of 2144 fractures: Evidence based orthopaedic trauma working group
ƒ Nonunion rates with nonop treatment
o overall 5.9 % (1145 fractures)
o displaced fractures 15.1 % (159 fractures)
ƒ displacement not quantified

PREDISPOSING FACTORS

TRADITIONALLY POORLY DEFINED!!!

Notes___________________________________________________________________
 3

1. severity of initial trauma37

2. extent of displacement
3. shortening >2 cm15
4. comminution (‘Z sign’)33,37
5. advancing age *#
6. female gender *
*# recent reported risk factors33,39

IMMOBILIZATION

ƒ figure 8 vs sling
ƒ no correlation of type of immobilization to incidence of nonunion

NONUNION and IMMEDIATE ORIF

ƒ earlier reports have suggested higher nonunion rates with immediate ORIF
compared to conservative treatment

Neer et al:
ƒ retrospective review
ƒ 0.1% incidence nonunion treated nonoperatively
ƒ 4.6% incidence nonunion treated operatively
Rowe, 1968:
ƒ 0.8% closed treatment
ƒ 3.7% ORIF
Poigenfurst et al, 1992:
ƒ 4% nonunion rate in 122 fractures treated by ORIF

ƒ questionable fixation techniques and extensive soft tissue dissection in earlier

reports, ? may predispose to nonunion

¾ lower nonunion rates reported more recently with improved surgical technique and
fixation methods
¾ plate fixation2,43
ƒ allows for anatomic, rigid fixation
ƒ PROBLEMS:
Notes___________________________________________________________________
 4

• difficult to contour plate

• requires stripping of periosteum
• potentially high complication rate (ie. infection, skin
sensitivity/neuroma)
• need for plate removal in high number of patients and
possible refracture after plate removal

¾ intramedullary fixation5,17,45
ƒ potentially less invasive than traditional plate ORIF
ƒ PROBLEMS:
• ? rotational control of fracture
• pin migration (early reports, devastating consequences)
• still require hardware removal

“Treatment of Acute Midshaft Clavicle Fractures: Systematic Review of 2144 Fractures,

Evidence Based Orthopaedic Trauma Working Group, J Orthop Trauma, 2005”46
ƒ nonoperative treatment of acute midshaft clavicle fractures, overall nonunion rate
5.9%, nonunion rate for displaced fractures 15.1%
ƒ factors associated with nonunion: fracture displacement, fracture comminution,
female gender, advancing age
ƒ plating vs nonop treatment of acute fractures
o nonrandomized data: nonunion 2.5 % when plated, 5.9% nonop
ƒ anterior inferior plating associated with fewer symptoms
ƒ intramedullary fixation of acute fractures vs nonop
o conflicting data, some studies with similar results, others in favour
of pinning, others in favour of nonop
ƒ bottom line: nonoperative treatment of clavicle fractures to needs closer look,
for now nonoperative treatment for most midshaft clavicle fractures is the
accepted method of treatment we need multi-centre randomized controlled trials
to compare operative with nonoperative treatment
ƒ **operative complications not reported**

NEED TO BALANCE NONOPERATIVE AND OPERATIVE RISKS!

Notes___________________________________________________________________
 5

MALUNION

ƒ paucity of literature regarding associated dysfunction

ƒ most patients do well
ƒ dissatisfied patients may present with:
o exuberant callous – local compression on underlying brachial plexus
which may resolve as the callous matures
o shoulder pain
o upper extremity weakness
o loss of endurance
o cosmetic appearance – “drooping” shoulder with complaints of straps
easily slipping off the involved shoulder
corrective osteotomy has been advocated in small series26,27
Nowak et el 2004
ƒ 208 patients, 9 – 10 year follow up
ƒ Despite healing 39% still had “sequelae”
o “Are you fully recovered from your clavicular injury?”
o Yes or no
McKee et al 2006
ƒ 30 patients, mean follow up 55 months
ƒ Residual deficits shoulder strength, esp endurance strength
ƒ ?selection bias

Brachial plexus palsy

ƒ rare 20
ƒ local compression of underlying brachial plexus16,23
o hypertrophic callous25,28
o compromise of costoclavicular space
o dynamic narrowing of thoracic outlet6
ƒ medial cord structures typically involved, producing ulnar nerve symptoms
(distinguished from traction palsy at initial presentation)
ƒ recent report of 3 case studies transient brachial plexus palsies with IM nailing36
o authors hypothesized that delivering fracture ends through wounds may
have led to neuropraxia
Notes___________________________________________________________________
 6

Vascular structures

ƒ rare8,14,42,44
ƒ compression or thrombosis/embolis of subclavian vein
ƒ aneurysm/pseudoaneurysm

Is shortening associated with shoulder dysfunction?

ƒ Current literature inconclusive

EXAMINATION

ƒ pain at site of nonunion

ƒ altered shoulder mechanics
ƒ “ptosis” of shoulder
o mediolateral shortening
o drooping
o adduction
o protraction of shoulder girdle
ƒ forces contributing to persistence or worsening of deformity
o weight of shoulder
o deforming forces of attached muscles and ligaments
ƒ medial fragment – elevated by sternocleidomastoid muscle
ƒ lateral fragment – adduction and inward rotation of
shoulder by pectoralis major
ƒ apex of deformity is typically superior

STUDIES

ƒ plain radiographs
ƒ CT scan
ƒ AP film of opposite clavicle to determine length

Notes___________________________________________________________________
 7

SURGERY FOR ESTABLISHED NONUNION

Rigid ORIF with plate fixation is the treatment of choice!

ƒ high union rates reported 1,3,4,7,9,11,18,19,22,24,34,35

ƒ 3.5 LC- DCP plates, newer clavicle specific plates available
ƒ plate typically placed superiorly, tension side
ƒ ? anterior inferior plating: ?safer, ?less prominent
ƒ Surgical tips
o Prep drape to midline
o Protect supraclavicular nerves
o Myfascial closure to prevent wound complications
o Protect neurovascular structures
o 3 screws each side of fracture, lag screw if able
o LC –DCP stronger that recon plate

Hypertrophic nonunion
ƒ excess bone at the fracture site is removed and interposed soft tissue excised
ƒ autogenous bone graft surrounding nonunion site

Atrophic nonunion
ƒ sclerotic bone ends are freshened with a rongeur until viable bone is visible
ƒ medullary canal is opened using a power burr or drill
ƒ autogenous bone graft surrounding nonunion site
ƒ intercalary bone graft may be required if significant shortening of clavicle

DISTAL CLAVICLE FRACTURES

CLASSIFICATION

Type I
ƒ fracture is distal to the coracoclavicular ligaments
ƒ little displacement of the fracture
Notes___________________________________________________________________
 8

Type IIA
ƒ fracture is medial (Type II A) or between (Type II B) to the
coracoclavicular ligments
ƒ the medial fragment looses vertical stability from the coracoclavicular
ligaments and it can displace superiorly
ƒ displacement is accentuated by the muscle forces and the weight of the
arm
ƒ NONUNION may occur

Type III
ƒ intra-articular fracture, usually without ligament disruption
ƒ usually little or no displacement

ANATOMY

Type II fractures
ƒ Proximal fragment
ƒ detached from the coracoclavicular ligments and unstable
ƒ trapezius and sternocleidomastoid muscles draw the proximal
fragment posteriorly and superiorly
ƒ Distal fragment
ƒ remains attached to the coracoid and scapula
ƒ the weight of the arm pulls the distal fragment with its attachments
to the coracoclavicular ligaments downward and forward
ƒ pectoralis major and minor, latissimus dorsi draw the distal
segment medially to cause overriding
ƒ the scapular ligments may rotate the outer fragment up to 40 degrees with
movement of the arm, no similar rotation to the medial fragment as it is
detached

INCIDENCE
ƒ 20 – 30 % has been reported12,31
ƒ 11.5% (868 patients) more recently reported39
o Risk Factors
ƒ advancing age
ƒ displacement of fracture (lack of cortical apposition)
Notes___________________________________________________________________
 9

TREATMENT

ƒ Neer’s original reports suggested operative management due to high nonunion

rate29,30
ƒ results, however, have been less than optimal
ƒ potential for high complication rate13,21
o fixation or implant failure
o infection
o persistent nonunion

IMPORTANT QUESTION!

Does this injury result in significant symptoms or functional deficit?

ƒ recent literature now supports that nonoperative treatment of type II distal clavicle
fractures can result in a good functional outcome and pain control for the
patient10,32,38,40
ƒ nonunion does not necessarily lead to a poor clinical outcome
ƒ long term follow up studies required to elucidate the long term success of this
treatment approach
ƒ benefit of initial nonoperative treatment
o commence early therapy program and removal of sling

SURGERY

ƒ multiple fixation techniques described, most typically modified weaver dunn

procedure or plate fixation recommended
ƒ modified Weaver-Dunn procedure
o distal fragment is excised
o CA ligament detached from the acromion and transferred to the distal end
of the proximal clavicle fragment
o CC ligament reconstruction with tendon graft or sutures should be
considered to reinforce the reconstruction
Notes___________________________________________________________________
 10

o arthroscopic identification and preparation of the CA ligament

ƒ minimizes the incision and deltoid dissection
ƒ can preserve valuable length of CA ligament
ƒ large distal fragment
o plate fixation with iliac crest bone graft
o specialized plates

Notes___________________________________________________________________
 11

BIBLIOGRAPHY

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2. Bostman, O.; Manninen, M.; and Pihlajamaki, H.: Complications of plate fixation
in fresh displaced midclavicular fractures. J Trauma, 43(5): 778-83, 1997.
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clavicle: a case for fixation. Injury, 23(1): 44-6, 1992.

Notes___________________________________________________________________
 12

13. Eskola, A.; Vainionpaa, S.; Patiala, H.; and Rokkanen, P.: Outcome of operative
treatment in fresh lateral clavicular fracture. Ann Chir Gynaecol, 76(3): 167-9,
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fractured clavicle. Jama, 200(1): 72-3, 1967.
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middle-third fractures of the clavicle gives poor results. J Bone Joint Surg Br,
79(4): 537-9, 1997.
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complications. A study of fourteen cases. J Bone Joint Surg Am, 47(7): 1335-46,
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stable intramedullary nailing of midclavicular fractures with a titanium nail. Clin
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complications and surgical management. J Bone Joint Surg Am, 69(5): 753-60,
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of midclavicular nonunion: comparison of dynamic compression plating and low-
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396-403, 2004.
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115-20, 1990.
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complicating a comminuted clavicle fracture in a college football player. Case
report and review of the literature. Am J Sports Med, 17(4): 581-3, 1989.
Notes___________________________________________________________________
 13

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clavicle. J Bone Joint Surg Am, 85-A(5): 790-7, 2003.
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Notes___________________________________________________________________
 14

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Notes___________________________________________________________________
 INSTRUCTIONAL COURSE LECTURE
124

DISLOCATION OF THE STERNOCLAVICULAR JOINT

Michael A. Wirth, M.D.

Professor of Orthopaedics
Department of Orthopaedics
University of Texas Health Science Center
San Antonio, Texas

NOTES

I. Introduction

A. Sternoclavicular joint injuries are rare.

B. These injuries represent approximately 3%
of all shoulder girdle injuries.
C. Distinguished as a potentially life-threatening injury.

II. Surgical Anatomy

A. Ligaments of the Sternoclavicular Joint

1. Intra-Articular Disc Ligament
a. Divides the sternoclavicular joint into
two separate spaces.
b. Functions as a check rein against medial
displacement of the proximal clavicle.

2. Costoclavicular Ligament
a. Also known as the rhomboid ligament.
b. Stabilizes joint during rotation and
elevation of the clavicle.

3. Interclavicular Ligament
a. Grant, Method of Anatomy, 1965
Comparable to the wish bone of birds.
b. Assists the capsular ligaments in
providing “shoulder poise.”

4. Capsular ligament
a. Bearn, J. Anat., 1967
 Strongest ligament of the
sternoclavicular joint.
b. Most important ligament in preventing
superior displacement of the
medial clavicle.

B. Retrosternal Structures
1. “Curtain” of muscles—
Sternohyoid, sternothyroid, and scaleni.
2. Vital Structures--
Innominate vessels, internal jugular vein,
vagus and phrenic nerves, trachea, and esophagus.
III. Classification of Sternoclavicular Dislocations
A. Direction (anterior vs posterior)
1. Nettles and Linscheid, J. Trauma, 1968
+ Series of 60 patients
(57 anterior and 3 posterior).
2. Waskowitz, Am. J. Orthop., 1961
+ Series of 18 patients
(all anterior injuries).
3. Rockwood and Wirth, Injuries to the SC joint,
in Fractures, 1996
+ Series of 185 patients
(135 anterior and 50 posterior).

B. Etiology
1. Traumatic
2. Atraumatic

IV. Mechanisms of Injury

A. Direct force
B. Indirect force (most common)
 Posterior SC injury: occurs when the shoulder
is compressed and rolled backward.
 Anterior SC injury: occurs when the shoulder
is compressed and rolled forward.

C. Most common causes

1. Omer, J. Trauma, 1967
+ 47 percent MVA and 31 percent sports.
2. Wirth and Rockwood, Complications in
Orthop. Surgery, 1994
+ 79 percent resulted from MVA
and sports related trauma.

Management of Traumatic Sternoclavicular Joint Injuries Wirth 2

V. Physical Examination of Traumatic Injuries
A. Signs common to anterior and posterior dislocations
 Moderate to severe pain with any movement of arm.
 Injured arm usually supported across chest.
 Affected shoulder appears shortened and thrust forward.
 Head may be tilted toward side of injury.
 Discomfort increases when patient is supine
(involved shoulder is protracted and will not
lie flat on examining table.)

B. Signs and Symptoms of posterior dislocations

1. Posterior displacement of medial clavicle
(May be obscured secondary to swelling).
2. Corner of sternum is palpable.
3. Venous congestion in neck or upper extremity.
4. Breathing difficulties, shortness of breath,
or choking sensation.
5. Decreased circulation of ipsilateral arm.

6. Difficulty swallowing or “lump in the throat”

sensation.
7. Voice change.

VI. Radiographic Findings

A. Projected Views
1. Heinig, J. Bone Joint Surg., 1968
2. Hobbs, Radiology, 1968
3. Rockwood, in Fractures, 1975

B. Special Techniques
1. Tomograms
2. CT scan
+ Unquestionably the best technique.
+ Remember to obtain scan of both
SC joints for comparison purposes.

VII. Treatment
A. Traumatic Injuries
1. Nonoperative treatment
a. Anterior injuries - May attempt
reduction with direct pressure;
figure-of-eight clavicle strap or
sling and swath until symptoms subside.

Management of Traumatic Sternoclavicular Joint Injuries Wirth 3

  Most anterior dislocations are unstable
after closed reduction.
b. Posterior injuries -
+ A careful examination is extremely important
1. Worman and Leagus, J. Trauma, 1967
Case report of medial clavicle
impaling pulmonary artery.
2. Cooper et al., Injury, 1992
Case report of posterior SC dislocation
which transected the internal mammary
artery and lacerated the brachiocephalic vein.
c. Physeal injuries - Medial clavicular epiphysis
appears at approximately age 18 and doesn’t close
until 23rd to 25th year (last epiphysis in body
to appear and last to close).
+ Many “sternoclavicular dislocations”
in young patients are actually physeal injuries.
This is important because most will heal promptly
with excellent remodeling potential and this
obviates surgery in patients who do not
demonstrate compromise of the hilar structures.
d. Closed reduction
Abduction Traction Technique
(the most popular)
Patient is placed supine with injured side
on edge of table and sandbag between shoulders.
Lateral traction is applied to the abducted arm,
which is then gradually extended.
+ Occasionally may require sterile towel clip
to facilitate reduction.
+ Reduction is usually successful if performed
within 4 to 5 days of injury. Figure-of-eight
used for approximately 6 weeks.

2. Operative treatment
Numerous procedures reported to maintain reduction
a. Facia Lata - Bankart, Milch, Speed, Allen,
Key and Conwell.
b. Subclavius Tendon - Burrows,
J. Bone Joint Surg., 1951
c. Osteotomy of Medial Clavicle - Omer,
J. Trauma, 1967
d. Medial Clavicle Resection - McLaughlin,
Bateman, Milch, Breitner and Wirth.
e. Costoclavicular ligament reconstruction
with medial clavicle resection - Rockwood et al,

Management of Traumatic Sternoclavicular Joint Injuries Wirth 4

 J. Bone Joint Surg., 1996.

B. Atraumatic Injuries
1. Most of these are spontaneous events which occur
without significant trauma.
2. Usually younger female patients
(less than 20 years of age).
3. One or both of medial clavicles displace anteriorly
during abduction or flexion.
4. Reduction occurs when the arm is returned to the side.
5. Rockwood and Odor, J. Bone Joint Surg., 1989
37 cases; described as self-limiting condition.
Recommended the condition not be treated
with attempted reconstruction, because the joint
continued to subluxate or dislocate and surgery
was often associated with increased pain,
unsightly scarring, and other complications.

VIII. Complications
A. Nonoperative
+ The serious injuries that occur with dislocation
of the SC joint are primarily limited to posterior injuries.

1. Wasylenko and Busse, Can. J. Surg., 1981

 Fatal tracheoesophageal fistula
2. Gangahar and Flogaites, J. Trauma, 1978
 Severe thoracic outlet syndrome with swelling
and cyanosis of upper extremity
3. Paterson, J. Bone Joint Surg., 1961
 Pneumothorax and laceration of the
superior vena cava
4. Borowiecki et al, Arch. Otalaryngol., 1972
 Rupture of esophagus
5. McKenzie, J. Bone Joint Surg., 1963
 Brachial plexopathy
6. Worman and Leagus, J. Trauma, 1967
 16 of 60 patients reviewed
from the literature suffered complications
of the trachea, esophagus, or great vessels.

B. Operative
1. Through 1992, seven deaths and three near deaths
from complications of transfixing the sc joint
with Kirschner wires or Steinmann pins.
2. Pins, either intact or broken, have migrated

Management of Traumatic Sternoclavicular Joint Injuries Wirth 5

 into the heart, pulmonary artery, innominate artery,
subclavian artery, aorta, and lung.

+ Do not use transfixing pins - large or small, smooth or threaded,

bent or straight - across the sternoclavicular joint!

IX. Summary

Management of Traumatic Sternoclavicular Joint Injuries Wirth 6

 REFERENCES

1. Bearn, JG: Direct Observations on the Function of the Capsule of the

Sternoclavicular Joint in Clavicular Support. J. Anat., 101:159-170, 1967.

2. Borowiecki, B., Charow, A., Cook, W., Rozycki, D., and Thaler, S.: An
Unusual Football Injury (Posterior Dislocation of the Sternoclavicular
Joint). Arch. Otolaryngol., 95:185-187, 1972.

3. Burrows, HJ: Tenodesis of Subclavius in the Treatment of Recurrent

Dislocation of the Sternoclavicular Joint. J. Bone Joint Surg., 33B:240-243,
1951.

4. Cooper, GJ., Stubbs, D., Waller, DA., Eildinson, GAL., and Saleh, M.:
Posterior Sternoclavicular Dislocation: A Novel Method of External Fixation.
Injury, 23:565-567.

5. Gangahar, DM., and Flogaites, T.: Retrosternal Dislocation of the Clavicle

Producing Thoracic Outlet Syndrome. J. Trauma, 18:369-372, 1978.

6. Grant, JCB.: Method of Anatomy, 7th ed. Baltimore, Williams & Wilkins,
1965.

7. Heinig, CF.: Retrosternal Dislocation of the Clavicle: Early Recognition, X-

ray Diagnosis, and Management (abstract). J. Bone Joint Surg., 50A:830,
1968.

8. Hobbs, DW.: Sternoclavicular Joint: A New Axial Radiographic View.

Radiology, 90:801-802, 1968.

9. McKenzie, JMM.: Retrosternal Dislocation of the Clavicle: A Report of Two

Cases. J. Bone Joint Surg., 45B:138-141, 1963.

10. Nettles, JL., and Linscheid, R.: Sternoclavicular Dislocations. J. Trauma,

8:158-164, 1968.

11. Omer, GE.: Osteotomy of the Clavicle in Surgical Reduction of Anterior

Sternoclavicular Dislocation. J. Trauma, 7:584-590, 1967.

12. Paterson, DC.: Retrosternal Dislocation of the Clavicle. J. Bone Joint Surg.,
43B:90-92, 1961.

Management of Traumatic Sternoclavicular Joint Injuries Wirth 7

 13. Rockwood, CA., Jr.: Dislocation of the Sternoclavicular Joint. In Rockwood,
CA., Jr., and Green, DP (eds.): Fractures, 1st ed. Vol. 1, pp. 756-787.
Philadelphia, J.B. Lippincott, 1975.

14. Rockwood, CA., Jr. and Odor, JM.: Spontaneous Atraumatic Anterior
Subluxations of the Sternoclavicular Joint in Young Adults: Report of 37
Cases (abstract). Orthop. Trans., 12:557, 1988.

15. Rockwood, CA., Jr. and Wirth, MA.: Injuries to the Sternoclavicular Joint
In Rockwood, CA., Jr., Green, DP., Bucholz, RW., and Heckman, JD., (eds.):
Fractures 4th ed. Vol. 1, pp. 1415-1471, Philadelphia, Lippincott-Raven, 1996.

16. Rockwood, CA., Jr., Groh, GI., Wirth, MA., and Grassi, FA.: Resection
Arthroplasty of the Sternoclavicular Joint. J. Bone Joint Surg., In press.

17. Waskowitz, WJ.: Disruption of the Sternoclavicular Joint: An Analysis and

Review. Am. J. Ortho., 3:176-179, 1961.

18. Wasylenko, MJ. and Busse, EF.: Posterior Dislocation of the Clavicle
Causing Fatal Tracheoesophageal Fistula. Can. J. Surg., 24:626-627, 1981.

19. Wirth, MA. and Rockwood, CA.: Complications Following Repair of the
Sternoclavicular Joint. In Epps, CH. (ed.) Complications in Orthopaedic
Surgery, 3rd ed., pp. 229-253. Philadelphia, J.B. Lippincott, 1994.

20. Wirth, MA. And Rockwood CA., Jr.: “Complications Following Repair of the
Sternoclavicular Joint.” In Complications of the Shoulder edited by Louis
Bigliani, M.D., Williams and Wilkins, Baltimore, pp. 139-153, 1993.

21. Worman, LW., and Leagus, C.: Intrathoracic Injury Following Retrosternal
Dislocation of the Clavicle. J. Trauma, 7:416-423, 1967.

Management of Traumatic Sternoclavicular Joint Injuries Wirth 8