this ppt about clavicle scapula & proximal humerus fractures and acromioclavicular disruption also described.

1. Clavicle Fracture
Dr Divyprasad Bamaniya
Assitant professor
Department of orthopaedic
Baroda medical college

2. Also known as “collar bone” and
“beauty bone”

3. Anatomy of clavicle

7. Mechanism of Injury
• Indirect injury
• Direct injury

8. Clinical Evaluation
• Clinical Presantation
• Neurovascular examination
• Skin integrity ,open or close
• Rule out chest injury

9. Associated injuries
• 9 % clavicle fracture associated with rib injury
• Most brachial plexus injury associated with
medial third clavicle fracture

10. Radiographic evaluation
• Standard AP view
• 30 degree cephalad view

11. Clavicle fracture AP view

12. Serendipity view

14. Allman Classification

18. Treatment
• Nonoperative / conservative
• Operative

19. Nonoperative management
• Figure of eight banadage
• Sling
• Minimally displaced fracture treated conservatively

20. Figure of eight bandage

22. sling

23. physiotherapy

24. Indication for Operative management
• Open fracture
• Fracture with neurovascular injury
• Fracture with skin tent
• Potential for progression to open fracture

25. Modalities of operative fixation
• Plate fixation
• Intramedullary fixtation

26. Plate fixation
• Incision
• Open the fracture
• Reduction of fracture
• Fixation with plate and screw
• Advantage: more secure fixation than nail
• Disadvantage: palpable hardware, iatrogenic
neurovscular injury, cosmetic deformity

27. 1.Superior platting
2. anteroinferior platting

28. Postoperative xray

29. Intraoperative images

30. Intramedullary fixation
• 50 % cases operated with nailing associated
with complication
• Hardware migration
• Insertion site skin erosion and infection

31. Complication
• Neurovascular injury
• Malunion
• Nonunion
• Post-traumatic arthritis

32. Malunion
• Cosmetic deformity
• Shoulder dysfunction

33. factors responsible for development of
NONUNION
• Open fracture
• Displaced fracture
• Soft tissue interposition
• Old age
• Poor nutritional status
• Inadequate immobilisation

35. Shoulder Dislocation
• Also known as glenohumeral dislocation
• Most commonaly dislocated joint of body
• Constitute 45% of all dislocation

36. Types of shoulder dislocation
• Anterior –most common type
• Poterior – second most common
• Superior
• Inferior / also known as LUXATIO ERECTA

37. Anatomy of shoulder joint

38. • Greatest range of motion of any joint in body
• Due to shallow glenoid fossa which 25% of
size of humeral head
• Major contributor for stability is not bone
• But soft tissue envelope composed of capsule
,ligaments,and muscle are major stabiliser of
shoulder joint

39. Joint capsule

40. Glenohumeral ligaments

41. Rotator cuff muscle
• Active stabiliser of shoulder
• Four muscle- subscapularis, pteres minor,
supraspinatus ,infraspinatus

42. Pteres minor and pteres major

43. Supraspinatus and infraspinatus

44. Long head of biceps

45. Shoulder joint stabiliser
• Passive
• active

46. Passive shoulder joint stabiliser
1. Joint conformity
2. Vaccum effect of joint
3. Adhesion and cohesion forces due to presence
of synovial fluid
4. Scapular inclination
5. Joint capsule
6. Glenoid labrum
7. Bony prominences like acromion and coracoid

47. Active shoulder stabiliser
• Long head of biceps
• Rotator cuff muscle

48. Pathoanatomy of shoulder dislocation
1. Streching and tearing of capsule
2. HAGL lesion- humeral avulsion of
glenohumeral ligament
3. Bankart lesion – bony bankart, soft tissue
bankart
4. HILL-SACHS lesion- posterolateral head
defect cuased by impression fracture on
glenoid rim

49. Bankart lesion
• Soft tissue bankart • Bony bankart

50. Hill sachs lesion

51. Mechanism of injury
1. Indirect
 For anterior shoulder dislocation
upper limb with shoulder abducted ,extension
and external rotation
 For posterior shoulder dislocation
upper limb with shoulder adducted, flexed and
internally rotated
 In inferior shoulder dislocation
shoulder is hyper abducted

52. 2. Direct
impact force directly on shoulder anteriorly
or posteriorly
3.Convulsion and electric shock produce
posterior shoulder dislocation

53. Clinical evalution
• Injured shoulder held in abduction and external
rotation
• Shoulder is painful with muscular spasm
• On examination sqauaring of shoulder with
relative prominance of acromion and hollow
beneath the acromion posteriorly and palpable
mass anteriorly
• Neurovascular examianation
check integrity of axillary nerve and
musculocutaneus nerve

54. Clinical image ; left shoulder
dislocation

55. Test for shoulder dislocation
1. Bryant test: anterior axillary fold at lower level
2. Callway test: vertical circumference of axilla is
increased
3. Dugas test: it is not possible for pt to bring
elbow near to opposite shoulder
4. Hamilton ruler test: because of flattening of
shoulder ruler placed on lateral side of arm and
it touches acromion and lateral condyle of
humerus

57. Clinical presentation of inferior
shoulder dislocation
• Salute fashion; humerus locked in 110 to 160
degree of abduction and forward elevation
• Humeral head palpable on lateral chest wall
• Almost all cases associated with neurovascular
injury

58. Salute fashion

59. Apprehension test
• For recurrent shoulder dislocation
• Passively shoulder placed in abduction
,extension and external rotation this position
reproduce patient sense of instability and pain

60. Radiographic evalution
• Standard AP view
• Axillary view

61. Axillary view

63. Anterior dislocation classification
• Sub corocoid
• Subglenoid
• intrathoracic

64. Posterior dislocation classification
• Sub acromion
• Subglenoid
• Subspinous

65. Treatment
nonoperative
1. Traction -counter traction method
2. Hippocratic technique
3. Stimson gravity technique
4. Milch technique
5. Kocher maneuver

66. Traction- counter traction method

67. Hippocratic technique

68. Stimson gravity technique

69. Kocher maneuver

70. Indication for operative management
or open reduction
• Shoulder is not reduced by reduction methods
• Shoulder dislocation with greater tubercle
fracture
• Dislocation with Glenoid rim fracture

71. Operative management of recurrent
shoulder dislocation
1. Bankart repair: detached anterior strcture are
attached to rim of glenoid cavity with suture
2. Puttiplat operation : subscapularis tendon
and capsule overlapped and tightned
3. Latarjet bristow operation: transplantation of
coracoid with its attachment to anterior rim
of glenoid

72. Bankart repair

73. Latarjet bristow operation

74. Complications
1. Recurrent dislocation
2. Osseous lesion
 Hill sachs lesion
 Bankart lesion
 Greater tuberosity facture
 Fracture of acromion and coracoid
3.Soft tissue injury
 Rotator cuff tear
 Capsular injury
4.Vascular injury – involve axillary artery
5.Nerve injury – involve axillary nerve and
musculocutaneus nerve

76. PROXIMAL HUMERUS FRACTURE
Relevent anatomy
• The humeral head
• The lesser tuberosity
• The greater tuberosity
• The humeral shaft

77. Deforming muscular forces on the
osseous segment
1. Greater tuberosity displaced superiorly and
posteriorly by supraspinatous and external
rotators
2. The lesser tuberosity displaced medially by
pull of subscapularis
3. The humeral shaft is displaced medially by
pectoralis major
4. The deltoid insertion cause abduction of
proximal fragment

78. Direction of displacement of osseous
fragment due to muscular forces

79. Neurovascular supply
a) Major blood supply from anterior and
posterior humeral circumflex arteries
b) Arcuate artery is continuation of ascending
branch of anterior humeral circumflex.
c) Its enter from bicipital groove and supply
most of humeral head
d) Fracture of anatomic neck have poor
prognosis because of precarious vascular
supply of humeral head

81. Axillary nerve
a) It is particular risk for traction injury because
of its close vicinity

82. Mechanism of injury
1. Most common is a fall onto outstreched
upper limb from height, commonaly in older
,osteoporotic woman.
2. Proximal humerus fracture in younger patient
associated with road traffic accident
3. Less common mechanism include excessive
shoulder abduction,electric shock, seizure,
benign and malignant involvement of
proximal humerus

83. Radiographic evalution
• Standard AP view
• Axillary view

84. Neer’s classification
• Neer divided proximal humerus in four part
• Greater and lesser tuberosity, humeral shaft
and humeral head
• Fracture types:
1. One part fracture: no displaced fragment
regardless of fracture lines
2. Two part fracture: anatomic neck,surgical
neck, greater tuberosity,lesser tuberosity

85. 3. Three part fracture:
 Surgical neck with greater tuberosity
 Surgical neck with lesser tuberosity
4. Four part fracture
5.Fracture dislocation
6. Articular surface fracture

86. Neer’s classification

87. Treatment
1. One part fracture / not displaced
• Upto 85 % fracture are nondisplaced
• treated with Sling and immobilization

88. Two part fracture
A. Anatomic neck fracture
• Associated with high incidence of
osteonecrosis
• They require open reduction internal fixation
(ORIF)
• If fracture is not fixable required shoulder
hemiarthroplasty using neers prosthesis

89. ORIF

90. Neer’s prosthesis

91. Hip prosthesis

92. B. Surgical neck fracture
Reducible fracture and fracture with good
bone quality fixed percutaneously using k wire
and cannulated screw
Irreducible fracture and fracture with poor
bone quality require ORIF

93. C. Greater tuberosity fracture
 undisplaced fracture treated non operatively
Displaced fracture around 5 to 10 mm
require ORIF
D. Lesser tuberosity fracture
 its treated when it block internal rotation

94. Three and four part fracture
management
 displaced fracture require ORIF
 Delto pectoral approach
In Younger patient fracture fixed using plates
older patient benefit from prosthetic
replacement(hemiarthroplasty)

95. Articular surface fracture
• Hill sach and reverse hill sach lesion
• Patient with more than 40% head involvement
require prosthetic replacement

96. Complication
1. Vascular injury: axillary artery
2. Neural injury; axillary nerve and brachial
plexus injury
3. Osteonecrosis of head
4. Shoulder stiffness
5. Malunion
6. Nonunion

97. Acromioclavicular joint injury
• It is synovial plane joint
• It is complex of four ligament :anterior
posterior, superior ,inferior
• Superior is strongest of all
• Horizontal stability conferred by AC ligaments
• Vertical stability maintained by
coracoclavicular ligaments

99. Classification of acromioclavicular joint
injury
• Classification depending on degree of
direction of displacement of distal clavicle
• Rockwood classification

101. Clinical image and xray

102. Management of AC joint injury
• For nonoperative management ice packs and
sling is useful
• For operative management with hook platting,
cancelous screw fixation, fixation with k wire,
reconstrction of ligament are useful

103. Coracoclavicular ligament
reconstructed using autograft

104. Scapula fracture

105. Radiographic evaluation
• AP ,Axillary and scapular Y view required for
fracture diagnosis

106. Scapular Y view

107. Anatomic classification
I. Scapular body fracture
II. Apophseal fracture including acromion and
coracoid
III. Fracture of scapular neck and glenoid

108. Ideberg classification of intra articular
glenoid fracture

109. Classification of acromial fracture
I. Minimally displaced
II. Displaced but does not reduce subacromial
space
III. Displaced with narrowing of subacromial
space

110. Classification of coracoid fracture
I. Proximal to coracoclavicular ligament
II. Distal to coracoclavicular ligament

111. Floating shoulder?
• Double disruption of superior shoulder
suspensory complex(SSSC)

112. • Superior strut is middle third clavicle and
inferior strut is lateral scapular body
• Traumatic disruption of two or more
component described as floating shoulder
• Historically operative management has been
recommended because of potential instability
• Recent study show nonoperative treatment of
floating shoulder reported good result.

113. Nonoperative managment
• Non operative treatment required for most
scapular fracture

114. Indication for operative management
• Displaced intraarticular glenoid fracture involving
greater than 25% of articular surface
• Scapular neck fracture with greater than 40
degree of angulation or 1 cm medial translation
• Scapular neck fracture with associated displaced
clavicle fracture
• fracture of acromion that impinge on subacromial
space
• Fracture of coracoid process result in AC joint
sepration

115. Xray of operative management

116. Thank you
Protect your shoulder