Injuries of shoulder girdle

clavicle fracture

scapula fracture

CLAVICLE :

Is an S-shape long, curved ,tubular bone , lies horizontally a cross the root of neck .

It articulate with sternum medially to form sternoclavicularjoint.

Also articulate with acromion process of scapula at acromioclavicular joint and acromioclavicular ligament .

the muscles inserting on clavicle are : sternocleidomastoid,

And subclavius muscles .

The subclavian vessels and brachial plexus lie posterior to clavicle .

CLAVICLE ANATOMY

Fractures of the clavicle:

common fracture in all ages

especially in children .

It is 2 – 10% of all fractures .

Mechanism of injury :

Direct traumatic impact or fall on the shoulder 87% .

Direct impact to clavicle 07% .

Fall on outstretched hand 06% .

From fall on the side .

Vigorous muscle contraction , seizures [rare] .

Pathological fracture [rare] .

Mechanism of injury

Most common causes are :

Road traffic accident [RTA]

Sporting injuries

Allman classification : according to site of

fracture :

group 1: Fracture mostly occur in the

middle one third of clavicle 80% .

group 2: The fractures of outer third is 15% .

Fractures involving the acromioclavicular joint 28% .

group 3: fracture of inner [medial] third 5% .

Why does the fracture occur in middle

third more ?

It is the thinnest part of the bone .

It is the junction of the tow main curves of shaft .

Site of entrance of nutrient artery .

common pattern of fractures of

clavicle are :

1 - Green stick fracture :

Common at the junction between

middle and outer third .

Common in children .

2 - Un displaced fracture in :

3 - Separation of bone end :

4 - With greater displacement :

•There is over lapping and shortening .

Clinical presentation :

pain and tenderness at site of injury .

Obvious deformity and swelling sometimes

occur .

Patient come support his injured limb with other

hand and head tilted

toward injured side .

Local bruising .

vascular compilication are rare , but we must look

for it by : check pulse , gently palpate root of neck

.

Outer third # are easily missed for

acromioclavicular joint .

Diagnosis :

- Clinical picture \ examination .

investigation :

x-ray [AP view ] :

# is usually in middle third, outer fragment below

the inner .

#of outer third may be missed .

CT scan : useful for non union assessment .

arteriography : if vascular injury suspected .

Treatment :

The aim is to provide support for the weight of the

arm .

Fracture of clavicle unite with or without treatment .

Healing occurs usually in 3-6 weeks .

It may be :

conservative or surgical .

Conservative treatment :

Support the arm in a sling until the pain subsides , usually 1-3

weeks .

Figure of 8- bandage .

Clavicle ring .

Analgesics .

Rehabilitation :

The patient should be instructed regarding hand

wrist and elbow exercises during immobilization .

And regarding shoulder exercises once fracture

healed .

Surgical treatment :

Rarely indicated , except in :

- lateral one third fracture .

- presence of neurovascular injury .

- non union cases .

Internal fixation plate .

Complication:late :

Malunion .

Ununion : treated by internal fixation and bone grafting .

Neurovascular injury [rare] . .

Stiffness of shoulder in elderly .

Ulnar neuropathy .

Refracture .

Early : [subclavian or carotid artery injury

,pneumothorax and hemothorax ,brachial injury ]

Scapula

Fractures of scapula …

Scapula :Is a flat triangular bone that lies on the posterior thorax wall between 2-7 rib.

It envelope by :

supraspinatus muscle

infraspinatus muscle

subscapularis muscle

Attached to clavicle at acromioclavicular joint ,secured by acromioclavicular ligament .

Articulate with humerus at glenohumeral joint .

Attached to thorax in scapulothoraxic joint .

Fracture of scapula :

Fractures of scapula are uncommon because of scapula location and surrounding muscles whitchprotect it .

-Fractures of scapula

are result of high energy

trauma with high incidence

Of associated injuries

by 60-98 % .

Associated life threatening injuries with scapula # :

pneumothorax

pulmonary contusion

arterial injury

abdominal injury

head injury

splenic or liver laceration

brachial plexus injury

Fractures of scapula are classified

according to location :

body fracture 50 % .

neck fracture 5-30 % .

glenoid fracture 10 % .

Coracoid fracture 8 % .

Acromion fracture 7 % .

Mechanism of injury :

# of body : from sever direct trauma

- fall from height with direct landing on posterior aspect of trunk .

- motor vehicle crush .

# of neck : direct blow to shoulder

- fall on shoulder .

- fall on outstretched hand .

# of glenoid : direct blow to lateral aspect of shoulder .

or impaction of humeral head in to glenoid fossa .

# of coracoid process :

direct blow or shoulder dislocation .

# of acromion :

direct down ward blow to shoulder .

Clinical picture :

Sight > swelling deformity ecchymosis erosion .

Touch > pain tenderness crepitation .

Pain exacerbated by movment .

Clinical picture :

-Brusing over scapula or chest area .

-Pain in movement .

-Swelling around back of shoulder .

-Tenderness at site of # .

Arm is held immobile .

Diagnosis :

After initial assessment , according to advanced trauma

life support [ATLS] principles , radiograghic evaluation is

indicated as soon as possible as patient stable .

X – ray :

Anteroposterior view \ lateral \ axillary view .

C T scan :is useful in glenoid or body # . .

Treatment :

Reduction is usually unnecessary .

Patient wears a sling for comfort and from start

movement.

Check repeatedly for dislocation of the shoulder .

# of body by :

conservatively by analgesics and simple

sling to rest shoulder for 2-3 weeks .

# of acromion process :

Un displaced :

sling for 3-4 weeks for rest shoulder.

displaced :

acromion should be reduced and fixed .

# of coracoid :

conservatively in major , using a sling for 2-3

weeks.

Vigorous exercises should be prohibited for 2 m .

If there is marked displacement > open reduction .

# of neck and glenoid :

- sling for 2-3 weeks

- if there is displacement > shoulder spica after reduction .

- open reduction > indicated if there is isolated glenoid rim fractures associated with dislocation or subluxation of

shoulder .

Complication :

Malunion \non union > rare

Glenohumeral arthritis .

Limitation in range of motion .

After surgery :

local dyscomfort

infection

nerve injuries

post traumatic arthritis

rotator cuff dysfunction

Notes :

Scapular fracture should alert the surgeon to

presence of other injuries .

Sever chest injury should also raise suspicion

of possible scapular injury .