midshaft clavicle fractures & acj dislocations

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Cardiff School of Engineering Coursework Cover Sheet Personal Details Student No: 1056984 Family Name: Divecha First Name: Hiren Personal Tutor: Prof Sam Evans Discipline: MMM Module Details Module Name: Surgical Practice Module No: ENT547 Coursework Title: Weekend 2 Coursework - Shoulder Lecturer: Submission Deadline: 10/1/2012 Declaration I hereby declare that, except where I have made clear and full reference to the work of others, this submission, and all the material (e.g. text, pictures, diagrams) contained in it, is my own work, has not previously been submitted for assessment, and I have not knowingly allowed it to be copied by another student. In the case of group projects, the contribution of group members has been appropriately quantified. I understand that deceiving, or attempting to deceive, examiners by passing off the work of another as my own is plagiarism. I also understand that plagiarising another's work, or knowingly allowing another student to plagiarise from my work, is against University Regulations and that doing so will result in loss of marks and disciplinary proceedings. I understand and agree that the University’s plagiarism software ‘Turnitin’ may be used to check the originality of the submitted coursework. Signed: …..…………………………………….………... Date: ……………………

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  • 1. Cardiff School of EngineeringCoursework Cover SheetPersonal DetailsStudent No:1056984Family Name: DivechaFirst Name:HirenPersonal Tutor:Prof Sam Evans Discipline:MMMModule DetailsModule Name: Surgical PracticeModule No: ENT547Coursework Title:Weekend 2 Coursework - ShoulderLecturer:Submission Deadline: 10/1/2012DeclarationI hereby declare that, except where I have made clear and full reference to the work ofothers, this submission, and all the material (e.g. text, pictures, diagrams) contained in it, ismy own work, has not previously been submitted for assessment, and I have not knowinglyallowed it to be copied by another student. In the case of group projects, the contribution ofgroup members has been appropriately quantified.I understand that deceiving, or attempting to deceive, examiners by passing off the work ofanother as my own is plagiarism. I also understand that plagiarising anothers work, orknowingly allowing another student to plagiarise from my work, is against UniversityRegulations and that doing so will result in loss of marks and disciplinary proceedings. Iunderstand and agree that the Universitys plagiarism software Turnitin may be used tocheck the originality of the submitted coursework.Signed: ...... Date:

2. Coursework 2 Midshaft ClavicleFractures & ACJ DislocationsHiren Maganlal DivechaCandidate Number: 1056984ENT547 Surgical PracticeWord count 3402 3. Contents1.Classify clavicle shaft fractures ....................................................................................................12.Discuss management of midshaft clavicle fractures with reference to biomechanics ...................3 a)Undisplaced ............................................................................................................................3 b)Displaced.................................................................................................................................33.Classify ACJ injuries .....................................................................................................................64.Critique this classification ............................................................................................................75.Describe the biomechanics of ACJ stabilisers ...............................................................................8 a)Static stabilisers.......................................................................................................................8 b)Dynamic stabilisers ..................................................................................................................96.Describe treatment options for Type IV/V ACJ injuries. Give biomechanical advantages/disadvantages of these options ......................................................................................................... 107.With respect to ACJ injuries, review the literature and discuss treatment options for all groups 12 a)Type I/ II ................................................................................................................................ 12 b)Type III .................................................................................................................................. 12 c)Types IV/ V/ VI....................................................................................................................... 138.How would you have a Type III injury treated if it was your shoulder? How would you manage anelite rugby player with the same acute injury? .................................................................................. 159.References ................................................................................................................................ 16 4. 1. Classify clavicle shaft fracturesOne of the earliest clavicle fracture classifications was described by Allman (Allman, 1967) and simplygrouped the fractures according to location and in descending order of incidence: Group 1 middle 1/3rd Group 2 distal to coraco-clavicular ligaments (non-union common) Group 3 proximal 1/3rdMost modern classifications are based on this, but subdivide each group further. Craigs (1990) andRobinsons (1998) classifications are commonly used (table 1) and take into account fracturelocation, displacement, stability and joint involvement. This may make the day to day use of suchsystems a bit more difficult, but including these variables allows for some guidance as to the risk ofdelayed/ non-union (and of post-traumatic OA in the case of intra-articular involvement). In acomparison of prognostic value in predicting delayed/ non-union between 5 classification systems,ONeill et al (2011) found that Craigs classification had the greatest prognostic value for lateral thirdfractures whilst Robinsons classification had the greatest prognostic value for middle third fractures.1 5. RobinsonCraig a1. Undisplaced - Extra-articular a2. Undisplaced - Intra-articularType 1 (medial 1/5)Group I (mid. 1/3) b1. Displaced - Extra-articular b2. Displaced - Intra-articular Type1: Minimal displacement (inter-ligamentous) a1. Cortical alignment - UndisplacedType 2: Displacement secondary to fracture medial to ligaments a2. Cortical alignment - Angulated a. Conoid and trapezoid attachedType 2 (mid. 3/5) Group II (dist. 1/3) b. Conoid torn, trapezoid attached b1. Displaced - Simple, wedge Type 3: Intra-articular b2- Displaced - Multifrag, segmentalType 4: Ligaments attached to periosteal sleeve, displacement of prox. frag. Type 5: Comminuted, ligaments attached to comminuted inf. frag. a1. Undisplaced - Extra-articular Type1: Minimal displacement a2. Undisplaced - Intra-articular Type 2: Significant displacement (ligaments ruptured)Type 3 (lateral 1/5) Group III (prox. 1/3) Type 3: Intra-articular b1. Displaced - Extra-articular Type 4: Epiphyseal separation (paediatric) b2. Displaced - Intra-articular Type 5: Comminuted Table 1: Outline of Robinsons and Craigs classification systems of clavicle fractures 2 6. 2. Discuss management of midshaft clavicle fractures with referenceto biomechanicsThe goal of treatment of these injuries is to restore shoulder function to (near) normal levels.a) UndisplacedUndisplaced midshaft clavicular fractures can be treated non-operatively (Khan, et al., 2009). Initially,patients are immobilised in a sling for 2-4 weeks followed by physiotherapy and active motionthereafter. Depending on radiographic signs of union, full mobilisation can begin at 6 weeks andcontact sports at 3 months (Khan, et al., 2009) (Preston & Egol, 2009). A figure of eight bandagingtechnique used to be employed, however this has not been found to affect fracture healing outcomeand can be associated with patient discomfort, axillary pressure sores and neurovascularcompromise (Andersen, et al., 1987) (Stanley, et al., 1988). In a large systematic review, the non-union rate with non-operative treatment in undisplaced fractures was reported at 5.9% (increasing to15% in displaced fractures) (Zlowodzki, et al., 2005).b) DisplacedHistorically, displaced clavicular shaft fractures were treated non-operatively. Amongst reasons forthis was the reported increased non-union rates following attempted ORIF (Neer, 1968) (Rowe,1968)). More recent studies (McKee, et al., 2006) including a large prospective randomised trial bythe Canadian Orthopaedic Trauma Society (2007), have shown lower non-union rates and betterfunctional outcomes following ORIF for displaced midshaft clavicular fractures. Indications foroperative intervention include:1. Open fracture/ overlying skin compromise2. High energy injuries with more than 2 cm displacement (increased non-union risk) 16 3 7. 3. Associated neurovascular compromise/ injury may necessitate exploration and repair followedby fracture fixationRelative indications include:1. Polytrauma2. Floating shoulder injury3. Symptomatic mal/ non-unionOther studies have shown that non-union rates may be as high as 20% in displaced and comminutedfractures after nonsurgical treatment and that strength and endurance deficits are more common inthese cases.36,52 These reports, in combination with a more prognostic classification system, haveled many authors to recommend acute surgical fixation for these fracture subtypes.53Historically, K-wires and threaded pins (e.g.: Knowles pins) have been used to stabilise these fracturetypes. These methods have been associated with significant complication rates, non-union and inparticular the risk of pin migration into nearby vital structures (Grassi, et al., 2001). Osteosynthesis ofmidshaft clavicular fractures can be achieved with plate or intramedullary pin fixation. Plate fixation allows for accurate reduction and absolute fracture stability through rigid fixation.This allows early mobilisation. Use of anatomically contoured plates obviates the need forremoval of prominent hardware, usually. Antegrade or retrograde IM pin fixation allows for relative stability but benefits from bettercosmesis and less periosteal stripping. As they are not locked, they have little rotational stability(Golish, et al., 2008) (Renfree, et al., 2010).Renfree et al (2010) compared IM pins with unicortically locked plates and bicortically non-lockedplates in synthetic clavicle fracture models under cantilever and 3-point bending. They concludedthat both plate constructs provided similar rigid fixation (added advantage of unicortical screws 4 8. avoid plunging into underlying neurovascular structures). The IM pin was less stiff (greaterdisplacements) and provided little rotational stiffness. Interestingly, a clinical comparison of unionrates and functional outcomes between plate and IM fixation has reported similar good results withno differences in complication rates (Liu, et al., 2010). A clinical comparison between locked and non-locked plates by Cho et al (2010) similar times to union and functional outcome scores between the 2groups, with less evidence of screw loosening in the locked group.It remains apparent that good results may be achieved operatively, but the ideal fixation deviceremains uncertain. Future work should be directed at clinically based, comparative/ controlled,functional outcome related research in this area. An example of this is the multicentre randomisedcontrolled trial in progress in the UK (Longo, et al., 2011). 5 9. 3. Classify ACJ injuriesAcromio-clavicular joint injures were originally classified by Tossy et al in 1963 (1963) and later byAllman in 1967 (1967) into three groups. This was then expanded in 1989 to 6 groups by Williams etal (1989) to describe the Rockwood classification (table 2), which remains in current use:Type AC Lig CC Ligs Delto-trapezial fascia InstabilityRadiographic CC distance I Sprained IntactIntact None Normal (1.1-1.3 cm)II Torn SprainedIntact AP 300%) screw Largest posterior translations with CC sling (330%) Rockwood screw most rigid construct, but results in increased joint forces(Costic, et al., 2004) Intact ACJ vs. ACCR (semitendinosus)Stiffness and ultimate load to failure of the ACCR was significantly lower than in the normal ACJ with clinically insignificant elongation following cyclic loading(Deshmukh, et al., 2004) Weaver-Dunn vs. augmented Weaver-Dunn Greater load to failure in augmented Weaver-Dunn (319N vs. 177N) and less instability procedure No significant difference between suture anchor choice for the augmentation(Lee, et al., 2003)CA ligament transfer vs. CC Mersilene tape slingCA ligament transfer weakest, Mersilene tape better initial strength vs. ACCR (semitendinosus, gracilis, long toeACCR superior to both (similar ultimate load to failure among different grafts) extensors)(Wilson, et al., 2005) Weaver-Dunn vs. Weaver-Dunn augmented Augmented Weaver-Dunn better approximated normal ACJ stability with CC suture anchor fixation(Harris, et al., 2000) CA ligament transfer vs. CC sling vs. 2 CC suture CA ligament transfer weakest. CC slings had high tensile strength but elongated at failure. anchors vs. unicortical Bosworth screw vs.Bicortical CC screws provided the highest tensile strength and stiffness bicortical Bosworth screwTable 3: Summary of ACJ reconstruction methods (adapted from pg 216-7 in (Simovitch, et al., 2009)) 14 18. 8. How would you have a Type III injury treated if it was yourshoulder? How would you manage an elite rugby player with thesame acute injury?I would manage my shoulder and an elite rugby player with an acute Type III ACJ injury the sameway. Whilst I am not a professional level athlete, my chosen career path (orthopaedic surgery)dictates that I maintain acceptable health and manual dexterity given the skilled (often fine/precision work) nature of surgery. Anything less than near-normal restoration of ACJ function couldpotentially affect my ability to operate as a surgeon now and in the future (in terms of latecomplications such as on-going pain/ instability and ACJ OA).I would have the injury fully assessed using USS (or MRI) to determine the extent of soft tissuedamage (including disruption of delto-trapezial fascia and deltoid/ trapezius muscle detachments)that would require surgical repair. Given the current evidence (Simovitch, et al., 2009) (whichunfortunately is based on small case series and controlled laboratory studies), I would support theuse of an anatomic double-bundle autograft (semitendinosus) reconstruction of the CC ligamentswith repair + superior augmentation of the ACJ followed by an appropriate early mobilisationphysiotherapy programme (pendular/ passive ROM till 8 weeks to allow graft maturation, activeROM thereafter). I would not allow resisted training to begin until after 3 months. In the case of anelite rugby player, I would anticipate a return to full contact by 6 months.15 19. 9. ReferencesAllman, F. L., 1967. Fractures and ligamentous injuries of the clavicle and its articulation. J Bone JointSurg, 49(4), pp. 774-84.Andersen, K., Jensen, P. & Lauritzen, J., 1987. Treatment of clavicular fractures. Figure-of-eigthbandage versus a simple sling. Acta Orthop Scand, Volume 58, pp. 71-4.Bergfeld, J. A., Andrish, J. T. & Clancy, W. G., 1978. Evaluation of the acromioclavicular joint followingfirst- and second- degree sprains. Am J Sports Med, Volume 6, pp. 153-9.Branch, T. P. et al., 1996. The role of acromioclavicular ligaments and the effect of distal clavicleresection. Am J Sports Med, 24(3), pp. 293-7.Cho, C.-H.et al., 2010. Operative treatment of clavicle midshaft fractures: Comparison betweenreconstruction plate and reconstruction locking compression plate. Clin Orthop Surg, Volume 2, pp.154-9.Corteen, D. P. & Teitge, R. A., 2005. Stabilisation of the clavicle after distal resection: A biomechanicalstudy. Am J Sports Med, Volume 33, pp. 61-7.Costic, R. S., Labriola, J. E., Rodosky, M. W. & Debski, R. E., 2004. Biomechanical rationale fordevelopment of anatomical reconstructions of coracoclavicular ligaments after completeacromioclavicular joint dislocations. J Sports Med, Volume 32, pp. 1929-36.Craig, E., 1990. Fractures of the clavicle. In: C. A. Rockwood & F. A. Matsen, eds. The Shoulder.Philadelphia: Saunders, pp. 380-3.Deshmukh, A. V., Wilson, D. R., Zilberfarb, J. L. & Perlmutter, G. S., 2004. Stability ofacromioclavicular joint reconstruction: Biomechanical testing of various surgical techniques in acadaveric model. Am J Sports Med, Volume 32, pp. 1492-8.Flatlow, E. L., 1993. The biomechanics of the acromioclavicular, sternoclavicular and scapulothoracicjoints. Instr Course Lect, Volume 42, pp. 237-45.16 20. Fukuda, K. et al., 1986. Biomechanical study of the ligamentous system of the acromiclavicular joint. JBone Joint Surg Am, Volume 68, pp. 434-40.Glick, J. M., Milburn, L. J., Haggerty, J. F. & Nishimoto, D., 1977. Dislocated acromioclavicular joint:Follow-ip study of 35 unreduced acromioclavicular dislocations. Am J Sports Med, Volume 5, pp. 264-70.Golish, S. R., Oliviero, J. A., Francke, E. I. & Miller, M. D., 2008. A biomechanical study of plate versusintramedullary devices for midshaft clavicle fixation. J Orthop Surg Res, Volume 3, p. 28.Grassi, F., Tajana, M. & DAngelo, F., 2001. Management of midclavicular fractures: comparisonbetween nonoperative treatment and open intramedullary fixation in 80 patients. J Trauma, Volume50, pp. 1096-100.Harris, R. I. et al., 2000. Structural properties of the intact and reconstructed coracoclavicularligament complex. Am J Sports Med, Volume 28, pp. 103-8.Heers, G. & Hedtmann, A., 2005. Correlation of ultrasonographic findings to Tossys and Rockwoodsclassification of acromioclavicular joint injuries. Ultrasound Med Biol, 31(6), pp. 725-32.Jari, R., Costic, R. S., Rodosky, M. W. & Debski, R. E., 2004. Biomechanical function of surgicalprocedures for acromioclavicular joint dislocations. Arthroscopy, Volume 20, pp. 237-45.Jiang, C., Wang, M. & Rong, C., 2007. Proximally based conjoined tendon transfer for coracoclavicularreconstruction in the treatment of acromioclavicular dislocation. J Bone Joint Surg Am, Volume 89,pp. 2408-12.Khan, L. A., Bradnock, T. J., Scott, C. & Robinson, C. M., 2009. Fractures of the clavicle. J Bone JointSurg Am, Volume 91, pp. 447-60.Lee, S. J. et al., 2003. Reconstruction of the coracoclavicular ligaments with tendon grafts: Acomparative biomechanical study. Am J Sports Med, Volume 31, pp. 648-55.Lemos, M. J. & Tolo, E. T., 2003. Complications of the treatment of the acromioclavicular andsternoclavicular joint injuries, including instability. Clin Sports Med, 22(2), pp. 371-85.17 21. Liu, H. H. et al., 2010. Comparison of plates versus intramedullary nails for fixation of displacedmidshaft clavicular fractures. J Trauma, Volume 69, pp. 82-7.Lizaur, A., Marco, L. & Cebrian, R., 1994. Acute dislocation of the acromioclavicular joint: Traumaticanatomy and the importance of deltoid and trapezius. J Bone Joint Surg Br, Volume 76, pp. 602-6.Longo, U. G. et al., 2011. Conservative management versus open reduction and internal fixation formid-shaft clavicle fractures in adults - The Clavicle Trial: study protocol for a multicentre randomizedcontrolled trial. Trials, 12(57), pp. 1-6.Mazzocca, A. D. et al., 2006. A biomechanical evaluation of an anatomical coracoclavicular ligamentreconstruction. Am J Sports Med, Volume 34, pp. 236-46.McKee, M. D. et al., 2006. Deficits following nonoperative treatment of displaced midshaft clavicularfractures. J Bone Joint Surg Am, Volume 88, pp. 35-40.Moushine, E., Garofalo, R., Crevoisier, X. & Farron, A., 2003. Grade I and II acromioclaviculardislocations: Results of conservative treatment. J Shoulder Elbow Surg, Volume 12, pp. 599-602.Neer, C. S., 1968. Fractures of the distal third of the clavicle. Clin Orthop Relat Res, Volume 58, pp.43-50.Nemec, U. et al., 2011. MRI versus radiography of acromioclavicular joint dislocation. Am JRoentgenol, 197(4), pp. 968-73.ONeill, B. J. et al., 2011. Clavicle fractures: a comparison of five classification systems and theirrelationship to treatment outcomes. International Orthopaedics, 35(6).Phillips, A. M., Smart, C. & Groom, A. F., 1998. Acromioclavicular dislocation. Conservative or surgicaltherapy. Clin Orthop Relat Res, Volume 353, pp. 10-17.Preston, C. F. & Egol, K. A., 2009. Midshaft clavicle fractures in adults. Bull NYU Hosp Joint Dis, 67(1),pp. 52-7.Renfree, T., Conrad, B. & Wright, T., 2010. Biomechanical comparison of contemporary claviclefixation devices. J Hand Surg, Volume 35, pp. 639-44. 18 22. Robinson, C. M., 1998. Fractures of the clavicle in the adult. Epidemiology and classification. J BoneJoint Surg Br, 80(3), pp. 476-84.Rowe, C. R., 1968. An atlas of anatomy and treatment of midclavicular fractures. Clin Orthop RelatRes, Volume 58, pp. 29-42.Simovitch, R. et al., 2009. Acromioclavicular joint injuries: Diagnosis and management. J Am AcadOrthop Surg, Volume 17, pp. 207-19.Society, C. O. T., 2007. Nonoperative treatment compared with plate fixation of displaced midshaftclavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am, 89(1), pp. 1-10.Stanley, D., Trowbridge, E. & Norris, S., 1988. The mechanisms of clavicular fracture. A clinical andbiomechanical analysis. J Bone Joint Surg Br, 70(3), pp. 461-4.Stewart, A. M. & Ahmad, C. S., 2004. Failure of acromioclavicular reconstruction using Gore-tex graftdue to aspetic foreign-body reaction and clavicle osteolysis: A case report. J Shoulder Elbow Surg,Volume 13, pp. 558-61.Tossy, J. D., Mead, M. C. & Sigmond, H. M., 1963. Acromioclavicular separations: Useful and practicalclassification for treatment. Clin Orthop Relat Res, Volume 28, pp. 111-19.Walz, L. et al., 2008. The anatomic reconstruction of acromioclavicular joint dislocations using 2TightRope devices: a biomechanical study. Am J Sports Med, 36(12), pp. 2398-406.Williams, G. R., Nguyen, V. D. & Rockwood, C. A., 1989. Classification and radiographic analysis ofacromioclavicular dislocations. Appl Radiol, Volume 18, pp. 29-34.Wilson, D. R., Moses, J. M., Zilderfarb, J. L. & Hayes, W. C., 2005. Mechanics of coracoacromialligament transfer augmentation for acromioclavicular joint injuries. J Biomech, Volume 38, pp. 615-9.Wojtys, E. M. & Nelson, G., 1991. Conservative treatment of grade III acromioclavicular dislocations.Clin Orthop Relat Res, Volume 268, pp. 112-9.Zlowodzki, M. et al., 2005. Treatment of acute midshaft clavicle fractures: systematic review of 2144fractures. J Orthop Trauma, Volume 19, pp. 504-7. 19 23. 20