Acromioclavicular and Sternoclavicular Injuries and Clavicular, Glenoid, and Scapular Fractures

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InstructionalSelected Course Lectures

The American Academy of Orthopaedic Surgeons

MARY I. O’CONNOR EDITOR,VOL. 59

COMMITTEE MARY I. O’CONNOR CHAIRMAN FREDERICK M. AZAR PAUL J. DUWELIUS KENNETH A. EGOL PAUL TORNETTA III

EX-OFFICIO DEMPSEY S. SPRINGFIELD DEPUTY EDITOR OF THE JOURNAL OF BONE AND JOINT SURGERY FOR INSTRUCTIONAL COURSE LECTURES JAMES D. HECKMAN EDITOR-IN-CHIEF, THE JOURNAL OF BONE AND JOINT SURGERY

Printed with permission of the American Academy of Orthopaedic Surgeons. This article, as well as other lectures presented at the Academy’s Annual Meeting, will be available in March 2010 in Instructional Course Lectures, Volume 59. The complete volume can be ordered online at www.aaos.org, or by calling 800-626-6726 (8 A.M.-5 P.M., Central time). 2492

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Acromioclavicular and Sternoclavicular Injuries and Clavicular, Glenoid, and Scapular Fractures

By Michael S. Bahk, MD, John E. Kuhn, MD, Leesa M. Galatz, MD, Patrick M. Connor, MD, and Gerald R. Williams Jr., MD

An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

Acromioclavicular joint injuries—or (Table I)1. A Type-I injury is a sprain upward pressure beneath the elbow, separations, as they are commonly (stretching) of the acromioclavicular indicating interposition of soft tissue described—are common sports-related ligament. Type-II injuries tear the (deltotrapezial fascia) between the distal injuries resulting from falls or other di- acromioclavicular ligament, leaving the part of the clavicle and the acromioclavi- rect forces on the superolateral aspect coracoclavicular ligament intact. When cular joint. Type VI is an exceedingly of the shoulder pushing the acromion in the coracoclavicular and acromioclavi- rare, high-energy injury characterized an inferior direction. Acromioclavicular cular ligaments are both torn and the by inferior displacement of the clavicle joint injuries represent a spectrum of acromioclavicular separation is reduc- beneath the coracoid. Most surgeons severity, ranging from a simple sprain ible with gentle upward pressure under never encounter this injury, and it is not of the acromioclavicular ligament with the elbow, the injury is classified as Type discussed in detail in this review. no displacement to widely displaced III. A Type-IV acromioclavicular sepa- Neviaser developed a simpler injuries associated with severe soft- ration occurs when the coracoclavicular classification system, also emphasizing tissue injury to the acromioclavicular and acromioclavicular ligaments are the reducibility of the joint in deter- ligament, the coracoclavicular ligament, torn and the scapula is displaced infe- mining the diagnosis and classification2. and the deltotrapezial fascia. Treatment riorly and anteriorly, resulting in a Type I is a sprain of the acromioclavi- options vary according to the severity relative posterior displacement of the cular ligament, and Type II is a tear of of the injury and logically reflect the distal part of the clavicle through a tear this ligament. Type III is subclassified as associated soft-tissue involvement. This in the deltotrapezial fascia. The distal Type IIIA if the injury is reducible and lecture briefly outlines the types of part of the clavicle lies directly subcu- as Type IIIB (corresponding to Rock- injuries and current recommendations taneously in these injuries. A Type-V wood Types IV and V) if the injury is for treatment. injury is characterized by a wide cora- not reducible. coclavicular separation. The distal part Classification of the clavicle is herniated through a Diagnosis The modified Rockwood classification rent in the deltotrapezial fascia with the Type I system is the most commonly used scapula displaced inferiorly. Type-IV Type-I injuries, according to the Rock- method of categorizing these injuries and V injuries are not reducible with wood system, are sprains of the acro-

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the authors, or a member of his or her immediate family, received, in any one year, payments or other beneﬁts in excess of $10,000 or a commitment or agreement to provide such beneﬁts from a commercial entity (Biomet Sports Medicine).

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TABLE I Modiﬁed Rockwood System for Classiﬁcation of Acromioclavicular Separations

Acromioclavicular Coracoclavicular Deltotrapezial Type Ligament Ligament Fascia

I Sprained Intact — II Torn Intact — III Torn Torn Intact IV Torn Torn Torn V Torn Torn Torn mioclavicular ligament with no dis- Complete separation of the acromio- involvement. There is very little con- placement. Radiographic findings are clavicular joint and an increase in the troversy regarding the treatment of usually normal if the injury occurs in coracoclavicular distance are seen on Type-I and II injuries or Type-IV and V isolation. The diagnosis is based on the radiographs. injuries. However, treatment of Type-III history and the findings of the physical injuries is controversial, and there is no examination. There is tenderness di- Type IV general consensus3-6. rectly at the acromioclavicular joint. It is The clavicle is driven in a posterior unusual for an inspection of the shoul- direction in a Type-IV separation. This Type I der to reveal a deformity, with the results in a distinct visible deformity Sling immobilization and symptomatic exception of ecchymosis or abrasion on with extreme prominence of the clavicle treatment of pain are usually all that are the superior aspect of the shoulder in over the scapular spine. The clavicle is necessary for these injuries. Activities the acute phase after the injury. herniated through the trapezius and is are resumed as tolerated. subcutaneous. Although the acromio- Type II clavicular joint is unstable, because it is Type II Type-II injuries are tears of the acro- impaled over the scapula, it does not These injuries are usually successfully mioclavicular ligament with an intact move on physical examination. Poste- managed with the methods used for coracoclavicular ligament. Physical ex- rior displacement of the clavicle is seen Type I. Occasionally, pain persists at amination reveals tenderness to palpa- on the axillary radiograph, whereas the the acromioclavicular joint and addition at the acromioclavicular joint. The dislocated acromioclavicular joint and a tional treatment is indicated. Nonop- acromion may be slightly displaced widened coracoclavicular distance are erative measures such as cortisone inferiorly relative to the distal part of the seen on the anteroposterior radiograph. injections and nonsteroidal anti- clavicle, but it continues to be at least inflammatory medication can be ad- partially in contact with the distal part Type V ministered. An excision of the distal of the clavicle. The joint is unstable in Displacement of the distal part of the part of the clavicle alone is insufficient the anteroposterior plane. The distance clavicle occurs predominantly in the treatment; it results in a short, unstable between the coracoid and clavicle re- vertical plane. The injury results in distal part of the clavicle, continued mains normal, but the acromion is obvious visible deformity of the distal pain, and disability. If surgery is se- subluxated relative to the distal part of part of the clavicle associated with lected because of the persistence of the clavicle. downward and slightly anterior dis- pain after nonoperative treatment, the placement of the scapula. The separa- distal aspect of the clavicle should be Type III tion is not completely reducible because removed and a capsular plication with When the acromioclavicular and cora- the distal part of the clavicle is herniated ligament reconstruction should be coclavicular ligaments are both torn, the through the deltotrapezial fascia. There performed. distal part of the clavicle is prominent is usually substantial tenderness and as an obvious visible deformity. The dis- swelling in the acute phase after the Type III tal part of the clavicle is usually tender injury. An increase in the coracoclavi- Type-III injuries should initially be to palpation, and the joint is reducible cular distance (of up to 300%) and treated without surgery1,3,6.Most with upward pressure under the elbow. superior displacement of the distal part patients recover and regain normal Chronic separations are less reducible of the clavicle are seen on the antero- shoulder function, although the visi- because of scar formation around the posterior radiograph. ble deformity is permanent. Early joint. Nevertheless, the deltotrapezial surgical treatment can be considered aponeurosis is intact. The acromio- Treatment for individuals with high sports or clavicular joint is unstable in both the Treatment varies depending on the vocational demands, although this is vertical and the horizontal plane. severity of the injury and the soft-tissue controversial as many high-demand 2494

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TABLE II Injuries Associated with Fracture of the Medial Aspect of the Clavicle*

Associated Injury Percent of Patients

Pneumothorax and/or hemothorax 42 Pulmonary contusion/respiratory failure 55 Rib fracture 73 Vascular injury 2 Facial fracture 31 Head injury 36 Cervical spine injury 25 Visceral injury 29 Upper-extremity injury 45 Lower-extremity injury 31

*Reproduced, with modiﬁcation, from: Throckmorton T, Kuhn JE. Fractures of the medial end of the clavicle. J Shoulder Elbow Surg. 2007;16:49-54; with permission from Elsevier. individuals do well with nonoperative surgical repair does not restore normal for whom nonoperative treatment treatment4. Surgical treatment for pa- strength to the ligaments of the acromi- has failed1,3,7. Many different methods tients with a high risk of recurrent oclavicular joint and reinjury is common. are available, and detailed descriptions injury, such as hockey or football Surgical reconstruction of the are beyond the scope of this article1,5-8. players, is especially controversial as a ligaments is indicated for patients There are common basic principles for

Fig. 1 Classiﬁcation of medial clavicular fractures. (Reprinted, with permission, from: Throckmorton T, Kuhn JE. Fractures of the medial end of the clavicle. J Shoulder Elbow Surg. 2007;16:49-54.) 2495

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Fig. 2 Figure-of-eight reconstruction of the sternoclavicular joint. (Reprinted from: Spencer EE Jr, Kuhn JE. Biomechanical analysis of reconstructions for sternoclavicular joint instability. J Bone Joint Surg Am. 2004;86:98-105.)

all reconstructive methods. The cora- Types IV and V an option10-12. The instrumentation coclavicular ligament is reconstructed Surgical treatment of Types IV and V has been developed but is still under with use of sutures based in anchors at is not controversial as early surgery investigation. Arthroscopy may be used the base of the coracoid or around the improves the results following these as an adjunct to the treatment of coracoid. The sutures are usually injuries1. Ligament reconstruction Type-IV and V injuries, but the distal brought through drill-holes in the is performed in the same way as it part of the clavicle must be exposed clavicle. Transfer of the coracoacro- is for Type-III injuries. Careful at- to reduce it through the torn del- mial ligament to the distal part of the tention is paid to the repair of the totrapezial fascia, which is then clavicle augments the strength and torn deltotrapezial aponeurosis, as repaired. biologic healing of the reconstruction this is a critical aspect of the repair and is advocated as part of the Weaver- and reconstruction in patients Fractures and Dislocations of the Dunn procedure, the most common with an acromioclavicular joint Medial Part of the Clavicle and the procedure performed for treatment separation. Sternoclavicular Joint of these injuries9.Autograftorallo- Anatomy and Clinical Assessment graft augmentation has been advo- Arthroscopic Treatment The sternoclavicular joint is not cated for coracoclavicular ligament Arthroscopic treatment of Type-III in- commonly injured but, when it is, reconstruction, to improve the juries has been reported, but its role in the injury is usually due to high- strength and facilitate healing, the treatment of acromioclavicular energy trauma and may be associated but long-term results are not yet separations has not been studied sufﬁ- with potentially life-threatening available5,8. ciently for it to be recommended as complications. 2496

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Fig. 3 Left: Markedly displaced midshaft clavicular fracture with comminution. Right: Healed fracture after open reduction and internal ﬁxation with use of a precontoured clavicular plate and supplemental interfragmentary ﬁxation.

The sternoclavicular joint is of the clavicle (the Hobbs view, Heinig injuries, and cervical spine and other saddle-shaped with a very large cla- lateral view, and serendipity view)15, upper-extremity injuries (Table II). The vicular head relative to the small fossa computed tomography and magnetic mortality rate is as high as 19% for on the manubrium. This construct has resonance imaging increase the likeli- patients with these fractures16. The little osseous constraint, and its sta- hood that a fracture will be diagnosed16 fractures are classified according to their bility is derived from the strong liga- and help to determine whether the configuration (Fig. 1), with transverse ments. The anterior and posterior medial aspect of the clavicle is displaced and comminuted fractures presenting aspects of the capsule provide the anteriorly or posteriorly. most commonly16. major stabilizing tissue13.Theinter- Nonoperative treatment is most clavicular ligament, which is impor- Fractures of the Medial Aspect often recommended, but an open frac- tant for the poise of the shoulder of the Clavicle ture is an indication for operative fixa- girdle, and the costoclavicular liga- Fractures of the medial third of the tion16. Many patients have residual ment have secondary roles14. clavicle are rare, accounting for between pain16, and the nonunion rate may The subclavian vessels, esophagus, 2% and 9.3% of all clavicular fractures. approach 15%17. Some authors have and trachea are behind the sternoclavi- These fractures are often sustained in reported success with surgical reduction cular joint and are at risk when this high-speed motor-vehicle collisions, and internal fixation18. area is subjected to trauma. A thorough and seat belt use, while life-saving, may clinical and radiographic evaluation is have a role in the production of these Dislocations of the recommended to assess these structures. injuries16. Sternoclavicular Joint Posterior displacement of the medial Typically, patients with a fracture Dislocations of the sternoclavicular aspect of the clavicle relative to the of the medial third of the clavicle also joint are rare, accounting for approx- sternum is associated with the greatest have severe thoracic injuries, including imately 3% of all shoulder injuries19, risk of associated injuries15. pneumothorax and/or pulmonary con- and they can be life-threatening. The While a variety of radiographic tusion, with respiratory failure occur- epiphysis of the medial end of the views have been described to image the ring in nearly half of the patients. Other clavicle does not close until a person is sternoclavicular joint and medial aspect injuries include rib fractures, head in his or her mid-twenties15. As such,

Fig. 4 Left: Markedly displaced midshaft clavicular fracture with a vertical comminuted fragment (a ‘‘zed’’ fracture). Right: Immediate postoperative radiograph after intramedullary ﬁxation. 2497

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Acute traumatic instability is usually treated with an acute reduction of the sternoclavicular joint. Closed reduction is recommended for both acute anterior and acute posterior dislocations, and several techniques have been described. Closed reduction is generally successful if it is done early 27. The reduction of a posterior dislocation of the sternoclavicular joint must be performed carefully as the sternal head could be providing a tamponade of a torn vessel28.Itis advisable to reduce posterior dislocations of the sternoclavicular joint with Fig. 5 the patient under general anesthesia, A distal clavicular plate was used to treat this Type-II distal clavicular with thoracic surgery available as a fracture. The repair was augmented with coracoclavicular sling fixation. back-up. Irreducible anterior dislocations what is initially perceived as a disloca- The mechanisms of injury for are commonly left unreduced, and tion in a young adult may in fact be a sternoclavicular dislocation include many patients do well without the need Salter-Harris Type-I or II physeal frac- motor-vehicle collisions, falls, and for further intervention29,30. Posterior ture; however, reduction and immobi- sports. Most dislocations occur as a dislocations should not be left unre- lization remain the treatment of choice. result of an indirect force. As the duced as late sequelae such as erosion Anterior dislocations are two to three shoulder girdle is pushed back, the into the great vessels or tracheo- timesmorecommonthanposterior clavicle pivots on the first rib and esophageal fistulas can occur31. Open dislocations, and fortunately they are the medial aspect of the clavicle is reduction and reconstruction of the less dangerous. Posterior dislocations pushed forward, producing an ante- sternoclavicular joint ligaments is indi- have been associated with a variety of rior dislocation. Conversely, when cated for both an acute irreducible life or limb-threatening injuries in- the shoulder girdle is pushed forward, posterior dislocation and a chronic cluding tracheal compression, injury to a posterior dislocation may be posterior dislocation. Patients with a the great vessels20,mediastinalcom- produced. chronic anterior dislocation and suffi- pression21, and compression of the These injuries are classified by ciently bothersome symptoms may innominate vein22. Untreated disloca- the direction of the dislocation (ante- benefit from reconstruction of the sterno- tions have been associated with late rior or posterior), by their chronicity clavicular joint. complications23, including erosion into (acute, subacute, or chronic), and by Surgery is contraindicated for the great vessels, tracheoesophageal their severity (ranging from capsular patients who have atraumatic, voluntary fistulas, compression of the subclavian sprains to subluxation events that instability of the sternoclavicular joint. artery 24, thoracic outlet syndrome25, reduce spontaneously to disloca- A connective-tissue disorder such as and compression of the brachial tions that require assistance with Ehlers-Danlos syndrome is a relative plexus26. reduction). contraindication.

Fig. 6 Left: A displaced Type-II distal clavicular fracture with comminution of the distal fracture fragment. Right: Utilization of isolated coracoclavicular ﬁxation led to successful healing and an excellent clinical result. 2498

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A variety of surgical techniques Midshaft Clavicular Fractures cular fractures, Nowak et al.46 found has been described for treatment of an Acute midshaft fractures of the clavicle that 46% of the patients continued to unstable sternoclavicular joint. Resec- have historically been treated with have clinical sequelae up to nine years tion of the sternal head of the clavicle benign neglect, with the clinical per- after the injury. Robinson et al.17 yields poor results32-34. Spencer and ception that the vast majority of these showed that the prevalence of clavicular Kuhn35 reviewed the biomechanical fractures heal and patients have suc- nonunion following nonoperative treat- properties of three of the most popular cessful clinical outcomes. In addition, ment increased with advancing age, procedures: transfer of the subclavius historic reviews showed the prevalence female sex, complete displacement of tendon36, transfer of the intra-articular of nonunion after surgical manage- the fracture ends, and the presence of disk and ligament into the resected end ment to be higher than that after comminution in their study of 281 of the clavicle34, and reconstruction of nonoperative treatment43. However, the diaphyseal clavicular fractures. Al- the anterior and posterior aspects of current literature reveals that not all though the overall prevalence of clavi- the capsule with use of a figure-of-eight patients with this injury do well with cular fracture nonunion was found to be semitendinosus autograft. The figure- nonoperative treatment. In a recent 4.5% in their series, the prevalence of of-eight reconstruction with the review of 2144 clavicular fractures, nonunion following nonoperative semitendinosus was found to have Zlowodzki et al.44 reported a 15.1% treatment of completely displaced and significantly better mechanical prop- prevalence of nonunion of fractures comminuted fractures ranged from erties than the reconstructions per- treated without surgery and a 2.2% rate 20% to 47% in patients between formed with the other techniques35 of nonunion of fractures treated with twenty-five and sixty-five years of age. (Fig. 2). Because of pin breakage and plate fixation. In a study of 242 con- McKee et al.47,48 suggested that utiliza- migration into vital structures with secutive clavicular fractures, Hill et al.45 tion of a patient-based outcome mea- disastrous complications, the use of found that 31% of fifty-two patients in surement (i.e., the Disabilities of the Steinmann pins, Kirschner wires, whom a completely displaced middle- Arm, Shoulder and Hand [DASH] threaded pins with bent ends, and third clavicular fracture had been score)49 may reveal more residual clini- Hagie pins is contraindicated for the treated with nonoperative means had cal impairment following nonoperative treatment of sternoclavicular joint in- an unsatisfactory clinical result. In a management of displaced clavicular stability 37-42. similar study, of 245 consecutive clavi- fractures than is demonstrated by surgeon-based or radiographic measures. Thus, the evolution of management of these injuries has included efforts to define which fractures are most likely to progress to symptomatic nonunion or malunion if they are treated initially without surgery and to determine whether primary surgical treatment of these specific fractures may improve the clinical results. Indications for operative treatment of acute midshaft clavicular fractures include open fractures, fractures with compromised skin due to severe fracture displacement (‘‘tented skin’’), and fractures associated with a vascular or neurological injury. On the basis of several studies that have defined the clinical outcome of the nonoperative management of midshaft clavicular fractures17,44-47,50, evolving indications for acute surgical management include midshaft clavicular fractures with complete dis- Fig. 7 placement (i.e., no osseous contact), Frequency of scapular fractures. (Reprinted from: Goss TP. Fractures of initial clavicular shortening of ‡2cm, the scapula. In: Rockwood CA, Matsen FA, Wirth MA, Lippitt SB, editors. and comminuted fractures with a The shoulder. 3rd ed. Philadelphia: Saunders; 2004. p 413-54; with displaced transverse ‘‘zed’’ (or permission from Elsevier.) z-shaped) fragment. As female sex and 2499

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postoperative hematoma; and provide a physiologic barrier to the plate and screws, thereby playing an im- portantroleinavoidinghardware prominence. It is important to achieve anatomic reduction of the fracture fragments and stable, compressive fixation with use of either a limited- contact dynamic compression plate (or its equivalent) or one of the newer anatomic plates. The use of a tubular plate is not recommended52,57,58.It has been shown that placing the plate on the superior (tension) side of the clavicle creates the most stable con- struct59, and ensuring that the plate does not protrude off the medial aspect of the clavicle anteriorly will help to avoid painful hardware. The Fig. 8 periosteum and soft-tissue attach- Scapular neck fractures most commonly occur medial to ments of the fracture fragments the coracoid (line B) and uncommonly lateral to the cor- should be saved, and bone-grafting acoid (line A). (Reprinted, with permission, from: Goss TP. should be considered in acute cases Fractures of the glenoid neck. J Shoulder Elbow Surg. with severe comminution and in all 1994;3:42-52.) cases of nonunion. Intramedullary fixation is an- increasing patient age have been asso- tively. There were no catastrophic other option for the surgical manage- ciated with increased rates of non- complications related to surgical man- ment of a displaced midshaft union17, these confounding variables agement. In addition to this prospective clavicular fracture (Fig. 4). Use of this should also be taken into consider- randomized clinical trial, there have technique makes it possible to avoid ation when choosing operative or been multiple other cohort studies the larger approach necessary for plate nonoperative treatment. showing success with operative man- fixation and, if the implant is later The Canadian Orthopaedic agement of displaced midshaft clavi- removed through a small posterior Trauma Society performed a multicen- cular fractures51-56. approach as is typically recommended, ter, randomized clinical trial comparing Although the literature contains the issue of persistent or painful nonoperative treatment and plate fixa- anecdotal reports of many complica- hardware is eliminated. The primary tion of displaced midshaft clavicular tions of plate fixation (hardware disadvantage of intramedullary fixa- fractures in 132 patients50. Acute oper- prominence requiring removal, non- tion is that it does not provide axial ative fixation led to statistically better union, malunion, hardware failure, or rotational stability when used for results with regard to Constant and infection, supraclavicular neuroma, nontransverse and comminuted frac- DASH scores, return to activities, time subclavian vein injury, and pneumo- tures60. In addition, smooth Kirschner to union, nonunions, symptomatic thorax), these complications can be wires and other nonstable intramed- malunions, and patient satisfaction. Al- avoided through meticulous surgical ullary fixation methods have had an though hardware removal was the most technique (Fig. 3). The supraclavicular unacceptably variable complication common reason for repeat intervention nerves, which traverse the clavicle from rate (range, 5% to 50%)61,62,themost in the operatively treated group, only a superomedial to an inferolateral di- notable of which is hardware migra- two of sixty-seven patients required rection, should be identified and pro- tion into the vital structures near the removal of symptomatic hardware after tected throughout the procedure. It is shoulder girdle63. Methods of intra- the fracture had healed. Three patients important to be precise about creating medullaryfixationthatprovidemore with a postoperative infection were a full-thickness deltotrapezial fascial stability while minimizing the com- managed with antibiotics and local approach that can be meticulously plications of loss of fixation and wound care and ultimately had the plate repaired at the conclusion of the pro- hardware migration have been de- removed after bone-healing, and one cedure. This thick ‘‘watertight’’ delto- vised. Successful outcomes have been broken plate was removed after the trapezial fascial repair will augment the reported after use of these tech- patient was involved in an all-terrain- vascular supply to the fracture; mini- niques61,62,64,65,althoughnoprospective vehicle accident six weeks postopera- mize dead space and the potential for a randomized studies comparing intra- 2500

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Fig. 9-A

Fig. 9-B Fig. 9-A Radiographs of a distal clavicular fracture and a displaced scapular neck fracture. Fig. 9-B The distal clavicular fracture has been reduced and has been fixed with tension-band and Kirschner wires (right) while the displaced scapular neck fracture has been reduced and has been fixed posteriorly with a plate that curves inferiorly along the lateral border (left). (Reprinted, with permission, from: Getz C, Deutsch A, Williams GR Jr. Scapular and glenoid fractures. In: Warner JJP, Iannotti JP, Flatow EL, editors. Complex and revision problems in shoulder surgery. 2nd ed. Philadelphia: Lippincott Williams and Wilkins; 2005. p 365-94.) medullary and plate fixation are verse the medullary canal is recom- there is a tendency for the intramed- available to our knowledge. mended to enhance fracture stability ullary device to exit the distal part of As is the case with plate fixation, (particularly for nontransverse frac- the clavicle too superiorly; care should complications following intramedullary tures and those with comminution), be taken to ensure that the device exits fixation of displaced midshaft clavi- and the threads of the implant should the posterior part of the clavicle as cular fractures can often be minimized not lie at the level of the fracture site. It far distally and inferiorly as possible. through meticulous surgical technique. is important to completely reduce the At the conclusion of the procedure, Only a minimal incision over the frac- fracture prior to placement of the comminuted fragments are reapproxi- ture site is necessary to reduce the intramedullary device; this requires mated with cerclage suture and the fracture fragments; the soft-tissue and superior translation of the lateral part deltotrapezial fascia is closed over the periosteal attachments to osseous of the shoulder girdle, which prevents fracture site. fragments should be maintained. The thecreationofan‘‘A-frame’’mal- An important issue regarding largest-diameter device that will tra- alignment of the clavicle. In addition, recommendations for the treatment of 2501

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TABLE III Results of Treatment of Glenoid Neck Fractures81,92-99*

Mean Duration of Follow-up Author(s) Year No. of Patients (Range) Treatment Results

Herscovici et al.92 1992 7 Not available Clavicle All excellent operatively fixed Nordqvist and 1992 68 14 yr Nonoperative 51 good, 15 fair, 2 poor. Petersson81 Residual deformity associated with pain Leung and Lam93 1993 15 25 mo (14-47) Operative 14 good to excellent, fixation 1 fair; no stratification by displacement Edwards et al.94 2000 20 28 mo (9-79) Nonoperative 17 excellent, 3 good. Less displacement associated with better results Low and Lam95 2000 4 3.3 yr (2-4) Clavicle 3 excellent, 1 good. operatively fixed No stratification by displacement Egol et al.96 2001 19 Not available 7 operative, More flexion in 12 nonoperative operative group; no difference in shoulder outcome scores Van Noort et al.97 2001 35 35 mo 31 nonoperative, 3 late reconstructions; 4 operative no difference between groups except that severe displacement resulted in caudal dislocation. Hashiguchi and Ito98 2003 5 57.4 mo Clavicle 5 good; operatively fixed average UCLA score, 34.2 points Labler et al.99 2004 17 Not available 8 nonoperative, 5 good to excellent 9 operative in each group; associated injures affected outcome; displacement poor prognostic indicator

*Although the patient groups and treatment methods are variable, patient satisfaction seemed to be related to residual displacement or angulation in nonoperatively treated patients and surgical management was most successful when anatomic reduction and healing were achieved.

displaced midshaft clavicular fractures the Constant scores and endurance Lateral Clavicular Fractures is the timing of surgical management. strength were marginally better after There is general agreement that lat- In a study to address this issue, Potter the acute fracture repair. These authors eral clavicular fractures, which ac- et al.66 compared fifteen patients who pointed out that these data should not count for 10% to 15% of all clavicular had had immediate fixation of this be used in isolation to recommend fractures, with complete displace- injury with fifteen who had undergone primary operative fixation of this in- ment are associated with a higher delayed fixation of a clavicular nonun- jury but rather could be used in coun- prevalence of nonunion than are ion or symptomatic malunion after seling patients on the relative midshaft clavicular fractures17,43,67; failure of nonoperative care. Although advantages and disadvantages of im- this is likely due to a combination of no significant differences in fracture- mediate operative repair compared bone and ligamentous injury. healing, in strength of shoulder flexion, with potentially delayed reconstruction Nordqvistetal.67 found that 25% of abduction, or rotation, or in DASH for the treatment of displaced midshaft Type-II lateral clavicular fractures scores were noted between the groups, fractures66. (fractures that occur between the 2502

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Fig. 10 Types I through VI glenoid fossa fractures. (Reprinted, with permission, from: Goss TP. Scapular fractures and dislocations: diagnosis and treatment. J Am Acad Orthop Surg. 1995;3:22-33.)

conoid and trapezoid coracoclavicu- and nonoperative treatment for frac- screw fixation into the lateral fracture larligaments)progressedtononun- tures of the lateral third of the clavicle. fragment have been created; however, ion or caused chronic pain, and When these fractures are managed even these may be of insufficient Robinson et al.17 showed that 21% of operatively, the remaining part of the strength to withstand the traction patients with this injury required clavicle that is lateral to the fracture forces of the lateral part of the surgery. Although the proportion of site is often either substantially com- shoulder girdle. Thus, it has been lateral clavicular fractures that pro- minuted or of insufficient quantity to recommended that coracoclavicular gress to nonunion, particularly in enable rigid fixation with traditional fixation or reconstruction be used to elderly patients, may be higher than plates or intramedullary implants. supplement the osseous fixation74. the proportion of midshaft clavicular An array of different technical proce- This is typically provided through fractures that do so, many of the durestoaddressthisproblem,with suture or allograft ligament sling nonunions are asymptomatic and do use of screws, pins, and plates, have fixation around the base of the cora- not require further treatment17. been described in multiple small case coid and the reduced clavicle to We are not aware of any pro- series60,68-73. Newer, precontoured an- augment or reconstruct the injured spective studies comparing operative atomic plates that enable locking coracoclavicular ligament (Fig. 5). 2503

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Fig. 11-A

Fig. 11-B Fig. 11-A A Type-Ia glenoid rim fracture. Fig. 11-B Suture anchors have been placed in the fracture bed, and sutures have been passed through the fragment and tied extra-articularly. (Reprinted, with permission, from: Getz C, Deutsch A, Williams GR Jr. Scapular and glenoid fractures. In: Warner JJP, Iannotti JP, Flatow EL, editors. Complex and revision problems in shoulder surgery. 2nd ed. Philadelphia: Lippincott Williams and Wilkins; 2005. p 365-94.)

Occasionally, if the lateral-distal described for this particular injury. because of the high prevalence of part of the clavicular bone has been Although isolated series have shown acromial erosion and rotator cuff determined, qualitatively or quanti- successful results with this implant, damage from the hook. tatively, to be unable to accept osse- theprevalenceandmagnitudeof ous ﬁxation, isolated coracoclavicular complications preclude its universal Glenoid and Scapular Fractures ﬁxation can be used successfully to recommendation. If it is used, it Fractures of the glenoid and scap- treat these injuries (Fig. 6). Utilization should always be removed approxi- ula account for 1% of all fractures of a hook plate70,71,75 has also been mately three months postoperatively and 5% of all shoulder fractures76-79. 2504

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Fig. 12-A

Fig. 12-B Fig. 12-A A Type-Ib glenoid rim fracture. Fig. 12-B The posterior fragment has been ﬁxed with two screws. (Reprinted, with permission, from: Getz C, Deutsch A, Williams GR Jr. Scapular and glenoid fractures. In: Warner JJP, Iannotti JP, Flatow EL, editors. Complex and revision problems in shoulder surgery. 2nd ed. Philadelphia: Lippincott Williams and Wilkins; 2005. p 365-94.)

These fractures most commonly injuries, which are sometimes life- range-of-motion exercises for four to involve the scapular body (45%), threatening76-78,81,82.Theseinjuries six weeks. An overhead pulley exer- the glenoid neck (25%), and the include rib fractures, hemothorax or cise program can usually be added by glenoid cavity (10%). Fractures af- pneumothorax, a ruptured viscus, six weeks postinjury. Rotator cuff and fecting the acromion process (8%), closed head injury, and long-bone scapular muscle strengthening is ini- coracoid process (7%), and scapular fracture. Management of a scapular tiated at six to eight weeks and is spine (5%) are less common76,80 body fracture may be deferred be- continued for two to three months. (Fig. 7). Management varies accord- cause of these other injuries, espe- Improvement occurs for nine to ing to the fracture location and cially in patients who have sustained twelve months. Successful fracture displacement. polytrauma. In 90% of cases, the union, minimal pain, and good scapular body fracture is treated function are expected in most Scapular Body Fractures nonoperatively with a sling for com- cases76,81,82. However, nonunion and Fractures of the scapular body are fort for seven to ten days, followed by symptomaticmalunionhavebeen often associated with concomitant pendulum exercises and passive reported76,83-85. 2505

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Fig. 13 An extended posterior approach is utilized to expose the glenoid, glenoid neck, and lateral border of the scapula. (Reprinted, with permission, from: Getz C, Deutsch A, Williams GR Jr. Scapular and glenoid fractures. In: Warner JJP, Iannotti JP, Flatow EL, editors. Complex and revision problems in shoulder surgery. 2nd ed. Philadelphia: Lippincott Williams and Wilkins; 2005. p 365-94.)

Glenoid Neck Fractures Glenoid neck fractures can be treated with open reduction and in- Glenoid neck fractures exit the superior classified according to the amount of ternal fixation of the clavicular shaft part of the scapula either medial or displacement and angulation86. Type-I and the scapular spine. The glenoid lateral to the base of the coracoid76,86 glenoid neck fractures are displaced neck will be reduced by ligamentotaxis (Fig.8).Thosethatexitlaterallyare <1 cm, are angulated <40°, and account through the intact coracoclavicular inherently unstable and often require for 90% of cases. Type-II fractures are and/or coracoacromial ligaments. In operative stabilization. However, they displaced >1 cm, are angulated >40°, patients with a subacute fracture, or a are very uncommon. Glenoid neck and represent only 10% of glenoid neck fracture pattern that is not amenable fracturesthatexitmedialtothebase fractures76,89-91. In the absence of an to ligamentotaxis, the glenoid neck of the coracoid divide the scapula into additional fracture or ligamentous in- must be reduced and stabilized di- a medial fragment (consisting of the jury, most glenoid neck fractures are rectly through a posterior approach scapular body, scapular spine, and inherently stable87 and can be managed deep to the posterior border of the acromion) and a lateral fragment (the nonoperatively with a protocol similar posterior part of the deltoid through glenoid and the coracoid process). to the one described above for scapular the internervous plane between the The lateral fragment is attached to the body fractures. teres minor and the infraspinatus. A medial fragment by the coracoacro- Displaced or angulated fractures plate is placed along the posterior mial ligament and to the axial skele- in young active patients are treated aspect of the glenoid and curves down ton by the coracoclavicular and operatively76,91.Thetypeofoperative the lateral angle of the scapula (Figs. acromioclavicular ligaments and the treatment depends on the associated 9-A and 9-B). clavicle87. injuries to the superior shoulder sus- Reported results of the treat- Goss described the superior pensory complex and the time from the ment of glenoid neck fractures are shoulder suspensory complex as a lat- injury. For example, an acute (less than sparse and difficult to interpret. Pa- eral osseous and soft-tissue ring (the seven-day-old) displaced glenoid neck tients with and without combined glenoid process, coracoid process, cora- fracture combined with an ipsilateral injuries to the superior shoulder sus- coclavicular ligament, distal part of the clavicular shaft fracture and disruption pensory complex have been included clavicle, acromioclavicular joint, and of the coracoacromial and acromio- in studies of the treatment of glenoid acromion process) supported by supe- clavicular ligaments can be managed neck fractures, and results have been rior and inferior osseous struts (the with open reduction and internal fix- rarely stratified according to displace- clavicular shaft and the lateral scapular ation of the clavicle. The glenoid neck mentorangulation.However,patient body and spine)76,82,86,88. Together with will be reduced by the intact coraco- satisfaction after nonoperative treat- the coracoacromial ligament, the re- clavicular ligament (i.e., by ligamen- ment seems to be related to residual maining intact portions of the superior totaxis). Likewise, an acute displaced displacement or angulation, and sur- shoulder suspensory complex resist glenoid neck fracture combined with gical management is most successful displacement and angulation of glenoid displaced ipsilateral clavicular shaft when anatomic reduction and healing neck fractures. and scapular spine fractures can be are achieved. The results of several 2506

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Fig. 14-A

Fig. 14-B Fig. 14-A A Type-Va glenoid fossa fracture with an associated midshaft clavicular fracture. Fig. 14-B An extended posterior approach was used to fix the glenoid with supplementation by a medial border plate. (Reprinted, with permission, from: Getz C, Deutsch A, Williams GR Jr. Scapular and glenoid fractures. In: Warner JJP, Iannotti JP, Flatow EL, editors. Complex and revision problems in shoulder surgery. 2nd ed. Philadelphia: Lippincott Williams and Wilkins; 2005. p 365-94.) reported series81,92-99 are summarized glenoid rim. Type-II through IV Most glenoid fractures can be in Table III. fractures start with a transverse frac- treated nonoperatively in a manner ture between the superior and infe- similar to what is used for scapular body Glenoid Cavity Fractures rior halves of the glenoid and exit fractures. Nonoperative treatment is also Glenoid cavity fractures involve the inferiorly through the lateral scapular indicated for Type-VI fractures that are glenoid rim and are usually associated border (II), superiorly through or too comminuted to support stable fixa- with instability or are fractures of the near the superior scapular notch tion. Operative treatment is reserved for glenoid fossa causing incongruity of (III), or medially through the medial Type-I fractures associated with an un- the articular surface. They are classi- scapular border (IV). Type-V frac- stable glenohumeral joint or any fracture fied, according to their location tures are more complex and are a (other than Type VI) with intra-articular and severity, into six types76,88,100,101 combination of Type-II through IV displacement exceeding 5 mm102. (Fig. 10). fractures. Type-VI fractures are se- Surgery for Type-I fractures is of- Type-I fractures involve the ante- verely comminuted and often not ten done arthroscopically103, especially if rior (Ia) or posterior (Ib) aspect of the reconstructible. it is performed acutely. When the rim 2507

THE J OURNAL OF B ONE &JOINT S URGERY d JBJS. ORG ACROMIOCLAVICULAR AND S TERNOCLAVICULAR I NJURIES VOLUME 91-A d N UMBER 10 d O CTOBER 2009 AND CLAVICULAR,GLENOID, AND S CAPULAR F RACTURES fragment contains the labrum, which it with a plate that starts below the surface. The teres minor and teres oftendoes,itcanbeusedforfixation. fracture line on the lateral scapular major origins are partially reflected off In many cases, the most inferior portion of border and extends superiorly onto the the lateral scapular margin, and the the osseous fragment is still attached to the posterior surface of the glenoid. Care fracture is reduced. The articular sur- native glenoid through an intact labral must be taken to avoid damage to the face is reconstructed and is fixed pro- connection. The superior part of the suprascapular nerve by the plate and to visionally with pins. The remaining fragment usually contains a portion of the avoid placing screws into the joint. fractures are reduced, and a plate is labrum superior to it that can be reat- Type-III fractures are often best placed from the lateral scapular border tached to the glenoid with suture anchors. approached anteriorly. The strongest to the posterior surface of the glenoid. Open treatment of Type-Ia frac- deforming force is the conjoined tendon Cannulated screws can be passed over tures is performed through a standard of the short head of the biceps and the the pins that were used for provisional deltopectoral or anterior axillary ap- coracobrachialis. Control of the frag- fixation. After the plate has been proach. The displaced fragment is stabi- ment is easiest when the coracoid can be secured, fracture stability is assessed. In lized with interfragmentary screws (if it used to lever the fragment. A neutral- some cases, a medial plate may also be is large enough) or suture anchors. The ization plate can be placed anteriorly required (Figs. 14-A and 14-B). anchors are placed in the native glenoid and supplemented with a lag screw The results of surgical manage- inferior and superior to the fragment, placed percutaneously from superior to ment of glenoid cavity fractures depend with the labrum used for fixation. inferior, between the clavicle and the on the quality of the reduction. When Alternatively, the anchors are placed in scapular spine or acromion. residual joint incongruity is <2 mm, the fracture bed and the sutures are The treatment of Type-IV frac- results are good or excellent in 80% passed through the fragment and tied tures is similar to that of Type-II frac- to 90% of cases and posttraumatic ar- extra-articularly (Figs. 11-A and 11-B). tures. In some cases, even after a plate thritis is minimal after four years of Type-Ib fractures that are associ- has been applied laterally, the fracture is follow-up79,102. ated with an unstable glenohumeral joint rotationally unstable. Under these cir- are usually fixed with interfragmentary cumstances, the medial border of the Overview screws through a limited posterior axil- scapula is exposed and a plate is placed Collectively, fractures and dislocations lary approach. With the patient in the across the medial extent of the fracture. of the acromioclavicular joint, sterno- lateral decubitus position and the arm The most important aspect of clavicular joint, clavicle, and scapula abducted, the posterior part of the operative management of Type-V frac- account for a large percentage of deltoid is retracted superolaterally with- tures is to be sure that there are enough shoulder girdle injuries. Treatment rec- out detaching any of its origin or large fragments for stable and anatomic ommendations vary according to the insertion. The interval between the in- fixation of the articular surface. An severity and location of the injury. Most fraspinatus and the teres minor is split, extensile posterior approach is used in acromioclavicular injuries are treated and the infraspinatus is retracted supe- most cases79,104. Combining anterior and nonoperatively unless the displacement riorly while the teres minor is retracted posterior approaches is rarely required is severe or irreducible. Sternoclavicular inferiorly. The infraspinatus insertion but may be necessary for Type-Vb and dislocations are treated with closed does not require detachment in most Vc fractures when the superior glenoid reduction. Anterior dislocations often cases. The capsule is incised to visualize fragment is severely rotated by the are unstable after reduction and are the articular surface. The fragment is conjoined tendon. subsequently treated nonoperatively. then reduced and fixed with two screws The extensile posterior approach Unstable or irreducible posterior dislo- (Figs. 12-A and 12-B). is performed with the patient lying in cations are reduced and stabilized with Type-II fractures are also ap- the lateral decubitus position. The skin open means because of the potential for proached through a posterior axillary incision starts at the medial extent of mediastinal injury. Markedly displaced incision, through the same interval the scapular spine, courses laterally to medial and lateral clavicular fractures without detachment of the infraspina- the posterior corner of the acromion, are associated with a high prevalence of tus. If a plate is required to obtain and then curves inferiorly and medially symptomatic nonunion; therefore, op- adequate fixation, the inferior limb of to follow the lateral scapular border erative reduction and fixation are often the posterior axillary incision is ex- (Fig. 13). The posterior deltoid origin recommended. Traditionally, midshaft tended inferiorly and medially over the is released from the scapular spine and clavicular fractures have been treated lateral scapular margin. The infraspi- retracted laterally. The interval between nonoperatively in most cases. Recently, natus origin and the dorsal portions of the infraspinatus and the teres minor is high prevalences of symptomatic non- the origins of the teres minor and teres split, and the infraspinatus is detached union and malunion have been identi- major are reflected off the scapula to from the humerus and reflected medi- fied. Hence, operative management expose the lateral border and the frac- ally. Care is taken to prevent traction with a plate or intramedullary pin has ture line. The fracture is reduced, held on the suprascapular nerve. The cap- been advocated for displaced fractures. provisionally with pins, and stabilized sule is then incised to expose the joint Scapular fractures are most often treated 2508

THE J OURNAL OF B ONE &JOINT S URGERY d JBJS. ORG ACROMIOCLAVICULAR AND S TERNOCLAVICULAR I NJURIES VOLUME 91-A d N UMBER 10 d O CTOBER 2009 AND CLAVICULAR,GLENOID, AND S CAPULAR F RACTURES nonoperatively. Operative reduction and Philadelphia, PA 19107. Patrick M. Connor, MD internal ﬁxation is reserved for displaced E-mail address for G.R. Williams Jr.: Shoulder and Elbow Center, or angulated glenoid neck fractures, [email protected] OrthoCarolina, 1025 Morehead Medical Drive, glenoid rim fractures associated with Suite 300, Charlotte, NC 28204 instability, and glenoid fossa fractures John E. Kuhn, MD with articular displacement of >5 mm. Vanderbilt Sports Medicine, 3200 MCE South Tower, 1215 21st Avenue South, Printed with permission of the American Nashville, TN 37232 Academy of Orthopaedic Surgeons. This article, as well as other lectures presented at the Academy’s Annual Meeting, will be Michael S. Bahk, MD Leesa M. Galatz, MD available in March 2010 in Instructional Gerald R. Williams Jr., MD Department of Orthopedic Surgery, Course Lectures, Volume 59. The complete Shoulder and Elbow Service, Washington University, Campus Box 8233, volume can be ordered online at The Rothman Institute, 660 South Euclid Avenue, www.aaos.org, or by calling 800-626-6726 925 Chestnut Street, St. Louis, MO 63110 (8 A.M.-5 P.M., Central time).

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