1. Dr AMRUTH RAM REDDY
POST GRADUATE
GANDHI MEDICAL COLLEGE

2.  The name clavicle derives from Latin
 It means „little key„ as it is shaped like the key
that the Romans used to lock their doors.
 It is a long bone.
 It transmits the weight of limb to sternum
 It has a shaft and two ends medial and lateral.
 Lateral end articulates with acromion to form
acrominoclavicular joint

3.  Medial end articulates with manubrium
sterni to form sternoclavicular joint
 Articular surface extends to inferior
aspect for articulation with first costal
cartilage
 SHAFT:lateral 1/3>superior surface sub
cutaneous
 Inferior surface has elevation called
conoid tubercle and ridge called
trapezoid ridge.
 They give attachments to conoid and
trapezoid parts of coracoclavicular
ligaments.

6.  Lateral 1/3 shaft :gives origin to deltoid and
trapezius.
 Medial 2/3 shaft:origins of pectoralis major
and clavicular head of sternocleidomastoid.
 Subclavian groove gives insertion to subclavius
muscle.
 It functions as an osseous protector of brachial
plexus,jugular and subclavian vessels.

7.  Only long bone that lies horizontally
 Sub cutaneous through out.
 First bone to start ossifying
 Only long bone which ossifies in membrane
 Only long bone which has two primary centres
of ossification
 It is occasionally pierced by middle
supraclavicular nerve.

8. Moderate or high-energy traumatic impacts to
the shoulder
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
6. The most common mechanism of clavicle
fracture is a fall on the superolateral shoulder

9.  Swelling,bruising,ecchymosis at the fracture site
 deformity of shoulder girdle best seen with patient
standing
 In completely displaced mid shaft fractures there is
shoulder ptosis.
 Foreward translation and rotation of shoulder
 Shortening of clavicle
 Careful neurologic and vascular examination of
involved limb is mandatory

10. •stabilizing on the
medial segment by
•sternoclavicular
ligaments
•superior on the medial
segment through the
sternocleidomastoid
•inferior and medial on
the lateral segment
through the pectoralis
major
•inferior on the lateral
segment through the
weight of the arm
pulling through
coracoclavicular
ligaments

11. For more lateral
fractures
•superior on the medial
segment through the
sternocleidomastoid and
trapezius
•medial on the distal
segment through the
pull of the pectoralis
major, pectoralis
minor, and latissimus
dorsi
•inferior on the distal
segment through the
weight of the arm

12.  Simple A-P view is is sufficient to establish the
diagnosis of clavicle fracture.
 Chest radiograph is useful to compare with the
normal side
 Should be taken in upright position,where
gravity will demonstrate the deformity.
 Radiographic beam should be angled 20
degrees superiorly
 This eliminates the overlap of the thoracic cage

13.  Anteroposterior
View
 30-degree
Cephalic Tilt View

14.  Quesana View
 45-degree angle superiorly and a 45-degree
angle inferiorly
 Provide better assessment of the extent of
displacement

15.  Zanca View
 AP view centered at AC joint with 10
degree cephalic tilt
 Less voltage than used for AP shoulder

17.  Stress views may be taken to determine the
integrity of coracoclavicular ligaments.
 Fractures of medial clavicle especially those
involving SC joint are difficult to assess on
plain radioraphs.
 CT scan is modality of choice here
 It can distinguish between medial epiphyseal #
and true SC dislocations.

18. Clavicular
diastasis
greater than 1
cm hints
scapulothoracic
dissociation
and brachial
plexus traction
injury.

19.  ALLMANS CLASSIFICATION
 Group I: middle third fractures
 Group II: lateral third fractures
 Group III: medial third fractures
 NEERS CLASSIFICATION
 Type I: coracoclavicular ligaments intact
 Type II: coracoclavicular ligaments detached from
the medial segment but trapezoid intact to distal
segment
 Type III: intra-articular extension into the
acromioclavicular joint

20.  Type I-nondisplaced
 Between the CC and AC
ligaments with ligament
still intact
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

21. •A. Conoid and trapezoid attached
to distal fragment
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

22. •Type IIB: Conoid
torn, trapezoid attached
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

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

25.  CRAIG CLASSIFICATION: advantage of
including more unusual injuries, such as
epiphyseal separations and periosteal sleeve
fractures.

26.  ADVANTAGES:analyses fractures of clavicle
in thirds
 Prognostically important variables such as
extension,degree of displacement,degree of
comminution.
 DISADVANTAGES:
 Un usual fracture types included by craig are
not mentioned here.
 Number scheme used do not correpond to
those used by allman.

27.  MID SHAFT FRACTURES:most midshaft clavicle
fractures are effectively treated nonoperatively.
 They include 1)simple arm sling
2)figure of eight brace.
 There is no change in functional outcome between
these two methods.
 If injury occurs in dominant shoulder figure of 8
brace is given.
 dominant hand can remain free for
writing, keyboarding, and other activities

28.  useful For fractures with shortening also as
this retracts the scapula and allows to maintain
length.
 For fractures in non dominant extremity simple
sling will suffice.
 This is more comfortable and tolerable.
 This is maintained for 4 to 6 weeks.
 Immobilisation is discontinued when there is
no pain or no palpable fracture motion.

29.  forward elevation and external rotation
stretches performed supine to negate the
displacing effects of gravity.
 major displacing force for this injury is the
weight of the arm
 so, pendulum exercises will magnify the
displacing moment and should be avoided.
 Cuff and collar with strapping should be
avoided.
 This will allow weight of elbow to generate
traction force and distract the fracture.

30.  Cuff and collar should never be used in
treatment of clavicle fractures.
 Simple sling that elevates the shoulder is all
that required.
 Displaced mid shaft clavicle fractures cause
persistent disability even if they heal
uneventfully.

31.  Absolute
 Shortening of >20 mm
 Open injury
 Impending skin disruption and irreducible
fracture
 Vascular compromise
 Progressive neurologic loss
 Displaced pathologic fracture with associated
trapezial paralysis
 Scapulothoracic dissociation

32.  Relative
 Displacement of >20 mm
 Neurologic disorder
 Parkinson's
 Seizures
 Head injury
 Multi trauma
 Expected prolonged recumbency
 Floating shoulder
 Intolerance to immobilization
 Bilateral fractures
 Ipsilateral upper extremity fracture
 Cosmesis

33.  Traditional means of ORIF
 Plate applied superiorly or inferiorly
 Inferior plating associated with lower risk of
hardware prominence
 Used for acute displaced fractures and
nonunions.
 3.5-mm locking dynamic compression plate
 less desirably, a 3.5-mm reconstruction plate.
 There are several advantages to this type of
fixation over intramedullary fixation.

34.  For transverse fractures, compression across the
fracture site is achieved.
 For oblique fractures or butterfly fragments, lag
screw fixation is possible .
 Secure rotational control of the fracture is
achieved.
 Fixation is rigid enough to allow the patient to
minimally weight-bear on the extremity.
 Minimal soft-tissue disruption is necessary.
 Often, the injury itself has caused fairly extensive
local soft-tissue stripping.
 For plate application, only soft-tissue along the
superior aspect of the clavicle need be elevated

35.  Two surgical approaches are commonly used
 1)anterosuperior:most popular operative
method of fixation of clavicle.
 Advantages:incision can be extended to both
medial and lateral ends of clavicle.
 Clear radiographic views postoperatively.
 Disadvantages:underlying neurovascular
structures and lung are at risk.
 Hard ware prominence can be problematic.

36.  Antero inferior approach:less commonly used.
 ADVANTAGES:less liklihood of injury to
underlying structures.
 Technically easy to contour small fragment
compression plate along anterir border
compared to superior border.
 DISADVANTAGES:lack of familiarity of this
approach to most surgeons.
 Biomechanical studies revealed superior
position for plate placement is advantageous.

40.  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

41.  Type II fractures, alternatively, are unstable
injuries, secondary to four displacing forces
 the weight of the arm
 the pull of the pectoralis major, pectoralis
minor, and latissimus dorsi
 scapular rotation, which affects the distal
segment but not the proximal
 the trapezius muscle, which draws the medial
segment posterior and superior

42.  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

43.  Type I and Type III distal clavicle fractures are
treated nonoperatively
 The main deforming force and source of
discomfort is the weight of the arm.
 a simple sling is more effective than a figure-
of-eight brace or shoulder immobilizer at
countering this force.
 those with Type III injuries, are warned of the
possibility of late acromioclavicular arthrosis
with the possible need for subsequent distal
clavicle excision

44.  Type 2 fractures are usually treated with
operative fixation.
 direct fixation of the fracture site without
coracoclavicular stabilization
 direct fixation of the fracture site with
coracoclavicular stabilization
 coracoclavicular stabilization with or without
excision of the lateral clavicular segment

45.  Indications :
 (a) very distal fracture in a young individual
 (b) fractures that involve the clavicular
insertion of the coracoclavicular ligaments.

48.  comminuted lateral clavicular segment;
 (b) older patients in whom potential healing of
a small lateral clavicular segment would be
difficult
 (c) underlying acromioclavicular arthropathy
 (d) fractures lateral to the trapezoid origin
 (e) fractures that involve the coracoclavicular
ligament origin as an inferiorly displaced
fragment.

50.  Nonunion
 Malunion
 Neurovascular Sequelae
 Post-Traumatic Arthritis

51.  clavicle nonunion is defined as lack of evidence
of healing 4 to 6 months after injury
 Factors Associated with Development of
Nonunion
 Type II fracture
 Fracture shortening of >20 mm
 Fracture displacement of >20 mm
 Increasing patient age
 Increasing severity of trauma
 Refracture

52.  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.

53.  Electrical Stimulation and Low-Intensity Pulse
Ultrasound
 Open Bone Graft and Immobilization
 Open Bone Graft and Screw Fixation
 Open Bone Graft and Plate Fixation
 Open Bone Graft and Intramedullary Fixation
 Clavicular Excision

54.  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

55.  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.

57.  It is a plane synovial joint.
 Formed by the articulation of small facets
between lateral end of clavicle and medial
margins of acromion process of scapula.
 Cavity of joint has articular disc
occasionally,which may be perforated.

58.  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.

59.  Sprain of
acromioclavicular
ligament
 AC joint intact
 Coracoclavicular
ligaments intact
 Deltoid and
trapezius muscles
intact
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

60.  AC joint disrupted
 < 50% Vertical
displacement
 Sprain of the
coracoclavicular
ligaments
 CC ligaments intact
 Deltoid and
trapezius muscles
intact
Type II
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

61.  AC ligaments and CC
ligaments all disrupted
 AC joint dislocated and
the shoulder complex
displaced inferiorly
 CC interspace greater
than the normal
shoulder(25-100%)
 Deltoid and trapezius
muscles usually
detached from the
distal clavicle
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

62.  AC and CC
ligaments disrupted
 AC joint dislocated
and clavicle
displaced posteriorly
into or through the
trapezius muscle
 Deltoid and
trapezius muscles
detached from the
distal clavicle
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

64.  AC ligaments
disrupted
 CC ligaments
disrupted
 AC joint dislocated and
gross disparity
between the clavicle
and the scapula (100-
300%)
 Deltoid and trapezius
muscles detached from
the distal half of
clavicle
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

65.  AC joint dislocated
and clavicle displaced
inferior to the
acromion or the
coracoid process
 AC and CC ligaments
disrupted
 Deltoid and trapezius
muscles detached
from the distal clavicle
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

66.  Nonoperative: Ice and protection until pain
subsides (7 to 10 days).
 Return to sports as pain allows (1-2 weeks)
 No apparent benefit to the use of specialized
braces.

67.  Type II operative treatment
 Generally reserved only for the patient with chronic
pain.
 Treatment is resection of the distal clavicle and
reconstruction of the coracoclavicular ligaments.

68.  Imaging:normal AP view including opposite
shoulder for comparision
 ZANCA view with 15 degree cephalic tilt.
 Stryker notch view for visualizing coracoid
fractures.

69.  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 fixation
 Excision of the distal clavicle
 Dynamic muscle transfers

70.  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.

71.  Type III injuries in
highly active patients
 Type IV, V, and VI
injuries

72.  Coracoid process transfer to distal transfer
(Dynamic muscle transfer)
 Primary AC joint fixation
 Primary Coracoclavicular Fixation
 Distal Clavicle Excision with CC ligament
reconstruction.

75.  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

76.  Migration of Pins
 Failure of Soft Tissue Repairs
 Complications Related to Nonabsorbable Tape
or Suture.
 Acromino clavicular arthritis

79.  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

80.  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.

81.  Medial Physis- Last of the ossification centers
to appear in the body and the last epiphysis to
close.
 Does not ossify until 18th to 20th year
 Does not unite with the clavicle until the 23rd
to 25th year

82.  Mediastinal
Compression
 Pneumothorax
 Laceration of the
superior vena cava
 Tracheal erosion

83.  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

84.  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.

85.  Abduction traction
 Adduction traction
 “Towel Clip” - anterior force applied to
clavicle by percutaneously applied towel
clip

86.  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.