1. Injuries of the Clavicle,Injuries of the Clavicle,
Acromioclavicular Joint andAcromioclavicular Joint and
Sternoclavicular JointSternoclavicular Joint
FahadFahad
zakwanzakwan

2. Goals
•1) Review anatomy of clavicle, AC joint, and sternoclavicular1) Review anatomy of clavicle, AC joint, and sternoclavicular
jointjoint
•2) Review imaging of these areas.2) Review imaging of these areas.
•3) Clavicle Fractures3) Clavicle Fractures
Nonoperative RXNonoperative RX
Surgical RepairSurgical Repair
Nonunions and MalunionsNonunions and Malunions
•4) AC Joint Injuries4) AC Joint Injuries
•5) Sternoclavicular joint injuries5) Sternoclavicular joint injuries

3. THE CLAVICLETHE CLAVICLE
• The clavicle is a doubly curved (S – shaped) bone thatThe clavicle is a doubly curved (S – shaped) bone that
acts as a strut btw the scapula and the sternum, locatedacts as a strut btw the scapula and the sternum, located
directly above the first rib.directly above the first rib.
• Medially it articulates with manubrium of the sternum atMedially it articulates with manubrium of the sternum at
the sternoclavicular joint.the sternoclavicular joint.
• Laterally it articulates with the acromion of the scapulaLaterally it articulates with the acromion of the scapula
at the Acromioclavicular joint.at the Acromioclavicular joint.
• It has rounded medial end and a flattened lateral end.It has rounded medial end and a flattened lateral end.

4. ClavicleClavicle
•Muscle attachments:Muscle attachments:
• Medial:Medial:
sternocleidomastoidsternocleidomastoid
• Lateral: Trapezius,Lateral: Trapezius,
pectoralis majorpectoralis major

5. AC Joint
• Diarthrodial joint between medial
facet of acromion and the lateral
(distal) clavicle.
• Contains intra-articular disk of variable
size.
• Thin capsule stabilized by ligaments on
all sides:
• AC ligaments control horizontal
(anteroposterior ) displacement
• Superior AC ligament most important

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

7. Mechanism of Injury
• Direct impact to the anterior - superior
shoulder of moderate – high force.
1. Fall from height
2. Motor vehicle accident
3. Sports injury
4. Blow to the point of the shoulder
5. Rarely, a direct injury to the clavicle

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

9. Physical Examination
•Palpation
•Evaluate pain
•Look for
instability with
stress
• Neurovascular
examination
• Must be done thoroughly
and documented!
• Evaluate upper extremity
motor and sensation
• Measure shoulder range-
of-motion

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

11. Radiographic Evaluation of the Clavicle
• Quesana ViewQuesana View
• 45-degree angle45-degree angle
superiorly and a 45-superiorly and a 45-
degree angle inferiorlydegree angle inferiorly
• Provide betterProvide better
assessment of theassessment of the
extent ofextent of
displacementdisplacement
•Zanca View
•AP view centered at
AC joint with 10
degree cephalic tilt
•Less voltage than
used for AP shoulder

12. Stress Views of the Distal Clavicle &
AC Joint
• Rationale: demonstrate instability and differentiate
grade III AC separations from partial Grade I-II injuries.
• Performed by having patient hold 10# weight with
injured arm.
• Rarely used today, since most Grade I-III AC joint
injuries are treated the same anyway, and management
of distal clavicle fractures depends on initial
displacement and location of fracture.

13. Radiographic Evaluation of the Medial One
Third
•X-ray: Cephalic tilt
view of 40 to 45
degrees
•CT scan usually
indicated to best assess
degree and direction of
displacement S=sternum
C= medial clavicle
E= esophagus

14. CLAVICLE FRACTURESCLAVICLE FRACTURES

15. Classification of Clavicle Fractures
•Group I : Middle third
•Most common (80% of clavicle fractures)
•Group II: Distal third
•10-15% of clavicle injuries
•Group III: Medial third
•Least common (approx. 5%)

16. Treatment Options
•Nonoperative
• Sling
• Brace
•Surgical
• Plate Fixation
• Screw or Pin Fixation
• Titanium elastic nails (usually inserted medial to
lateral)

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

18. Clavicle Fracture
Sling and Swathe

19. Clavicle Fracture
Velpeau

20. Figure of eight bandage

21. 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.

22. 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.

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

24. Relative Indications for Acute Treatment of
Clavicle Fractures
1. Widely displaced fractures
2. Multiple trauma
3. Displaced distal-third fractures
4. Floating shoulder
5. Seizure disorder
6. Cosmetic deformity
7. Earlier return to work.

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

33. Intramedullary Fixation
•Large threaded cannulated screws
•Flexible elastic nails
•K-wires
Associated with risk of migration
•Useful when plate fixation contra-
indicated
Bad skin
Severe osteopenia
•Fixation less secure

34. Titanium Elastic Nails
•Same as used in pediatric femur fractures.
•Accommodate three-dimensional anatomy
of the clavicle.
•Typically inserted “retrograde” (from
medial to lateral)
•Best in fractures without comminution
•Small incision at fracture site may be
needed.

35. 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.

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

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

38. 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.

39. Correction of symptomatic nonunion with IM screw

42. 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

43. 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.

44. DISTAL THIRD CLAVICLE FRACTURESDISTAL THIRD CLAVICLE FRACTURES

45. Classification of Distal Clavicular Fractures
(Group II Clavicle Fractures)
•Type I-nondisplacedType I-nondisplaced
•Between the CC and
AC ligaments with
ligament still intact

46. Type II
•Typically displaced secondary to a fracture
medial to the coracoclavicular ligaments,
keeping the distal fragment reduced while
allowing the medial fragment to displace
superiorly
•Highest rate of nonunion (up to 30%)
•Two Types

47. Type IIA
A. Conoid and
trapezoid
attached to
distal fragment

48. Type IIB
B: Conoid torn,
trapezoid attached

49. Type III:
• articular fractures
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

50. 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

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

52. Techniques for Acute Operative Treatment of
Distal Clavicle Fractures
•Kirschner wires inserted into the distal fragment
•Dorsal plate fixation
•CC screw fixation
•Tension-band wire or suture
•Transfer of coracoid process to the clavicle
•Clavicular Hook Plate

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

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

56. Hook Plate - Results
•Recent series of distal clavicle fractures treated
with the Hook Plate document high union rates
of 88% - 100%.
•Complications are rare but potentially
significant, including new fracture about the
implant, rotator cuff tear, and frequent
subacromial impingement.

57. Preferred technique for fixation of
acute distal third clavicle fractures
•Horizontal incision
•Manual reduction of fracture
•Dorsal tension band suture and
reconstruction/augmentation of
coracoclavicular ligaments.

58. Look for avulsion fracture of CC ligament
attachment
• If present, this fragment can be sutured to proximal
(eg. medial) clavicle to restore stability, without
need for hardware.
• Jackson WFM, et al. J Trauma 2006;61:222-
225

59. Indications For Late Surgery For Distal
Clavicle Fractures
•Pain
•Weakness
•Deformity

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

61. Case ExampleCase Example
11

62. Case Example 1Case Example 1
Distal Clavicle
Medial Clavicle

63. Case ExampleCase Example
11
Coracoclavicular
fixation not visible
Fixation to Acromion

64. Case Example 2Case Example 2
This fragment likely has CC ligament attached; need
to reduce and hold clavicle shaft to this piece.

65. Case Example 2Case Example 2
This fragment likely has CC ligament attached; need
to reduce and hold clavicle shaft to this piece.
Sutures passed into this
fragment (not visible)

66. Case Example 2
This fragment likely has CC ligament attached; need
to reduce and hold clavicle shaft to this piece.
Sutures passed into this
fragment (not visible)
4 months

67. Acromioclavicular Joint

68. Mechanism
•Sports injury or trauma.Sports injury or trauma.
•Impact to superior acromion, drivingImpact to superior acromion, driving
the arm down and rupturing the ACthe arm down and rupturing the AC
joint capsule (first) and then the thejoint capsule (first) and then the the
coracoclavicular ligaments (second).coracoclavicular ligaments (second).

69. 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.

70. 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.

71. 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.

72. Type IType I
•Sprain of
acromioclavicular
ligament
•AC joint intact
•Coracoclavicular
ligaments intact
•Deltoid and trapezius
muscles intact

73. • AC joint disrupted
• < 50% Vertical
displacement
• Sprain of the
coracoclavicular
ligaments
• CC ligaments intact
• Deltoid and trapezius
muscles intact
Type IIType II

74. Type IIIType 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

75. Type IIIType III
VariantsVariants
• “Pseudo-dislocation” through an intact
periosteal sleeve
• Physeal injury
• Coracoid process fracture

76. Type IVType 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

77. Type VType 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

78. Type VIType 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

79. Treatment Options For Types I - II
Acromioclavicular Joint Injuries
Nonoperative:Nonoperative:
•Ice and protection until pain subsides (7 to 10 days).Ice and protection until pain subsides (7 to 10 days).
•Return to sports as pain allows (1-2 weeks)Return to sports as pain allows (1-2 weeks)
•No apparent benefit to the use of specialized braces.No apparent benefit to the use of specialized braces.
operative treatmentoperative treatment
• Generally reserved only for the patient with chronic pain.Generally reserved only for the patient with chronic pain.
• Treatment is resection of the distal clavicle and reconstruction of theTreatment is resection of the distal clavicle and reconstruction of the
coracoclavicular ligaments.coracoclavicular ligaments.

80. Treatment Options For Type III-VI
Acromioclavicular Joint Injuries
• Nonoperative treatment
• Closed reduction and application of a sling and harness to maintain
reduction of the clavicle
• Short-term sling and early range of motion
• Operative treatment
• Primary AC joint fixation
• Primary CC ligament reconstruction (usually with allograft, often
with augmentation)
• Excision of the distal clavicle
• Dynamic muscle transfers

81. • Type III Injuries: Need for acute surgical treatment remains very
controversial.
• Most surgeons recommend conservative treatment except in the
throwing athlete or overhead worker.
• Repair generally avoided in contact athletes because of the risk of
reinjury.

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

83. Surgical Options for AC Joint Instability
• Coracoid process transfer to distal transfer (Dynamic muscle
transfer)
• Primary AC joint fixation
• Primary Coracoclavicular Fixation
• CC ligament reconstruction +/- distal clavicle excision.

84. Weaver-Dunn Procedure
• The distal clavicle is excised.
• The CA ligament is transferred
to the distal clavicle.
• The CC ligaments are repaired
and/or augmented with a
coracoclavicular screw or
suture.
• Repair of deltotrapezial fascia
•
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

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

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

87. Case Example
AP View
Zanca View

88. Case Example
After Weaver-Dunn
procedure

89. STERNOCLAVICULAR JOINTSTERNOCLAVICULAR JOINT

90. 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

91. • 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.

92. Epiphysis of the Medial Clavicle
•Medial Physis- Last of the ossificationMedial Physis- Last of the ossification
centers to appear in the body and thecenters to appear in the body and the
last epiphysis to close.last epiphysis to close.
•Does not ossify until 18th to 20th yearDoes not ossify until 18th to 20th year
•Does not unite with the clavicle untilDoes not unite with the clavicle until
the 23rd to 25th yearthe 23rd to 25th year

93. Radiographic Techniques for Assessing
Sternoclavicular Injuries
•40-degree cephalic
tilt view
•CT scan- Best
technique for
sternoclavicular joint
problems

94. Injuries Associated with Sternoclavicular
Joint Dislocations
•Mediastinal
Compression
•Pneumothorax
•Laceration of the
superior vena cava
•Tracheal erosion

95. 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

96. 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.

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

98. 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.