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Superior shoulder suspensory complex injuries (SSSC)

Zonal CMEconducted at GSLMCDR.S.JAGANMOHAN M.S,D.N.B. ORTHO, FELLOW ARTHROPLASTYASSISTANT PROFESSOR , DEPT. OF ORTHOPAEDICSGSL MEDICAL COLLEGE AND HOSPITALIntroductionDefinitionRelated anatomyPathoanatomy Investigations Treatment optionsConclusion

IntroductionGanz and Noesberger 1975 - The Floating Shoulder - the ipsilateral glenoid surgical neck and midshaft clavicle fracture

Goss 1993 introduced the concept Superior shoulder suspensory complexDefinition of SSSCDescribed as a bony / soft tissue ring at the end of a superior and inferior bony strut

Bony struts : The superior strut The inferior strut

The ring is composed of the glenoid fossa, coracoid process, coracoclavicular ligaments, distal clavicle, acromioclavicular joint and the acromial process.

Function: This complex maintains a normal stable relationship between the scapula and the axial skeleton

The scapula is hung or suspended from the clavicle by the coracoclavicular ligaments and the acromioclavicular joint4Double disruption: There should be injury to any two structures

Depending on the structure injured in SSSC that could lead to instability it is subdivided into

Clavicular - acromio clavicular joint - acromion strut Clavicular coraco clavicular ligament- coracoid C4 linkageThe three processes scapular body junction

Superior shoulder suspensory complex injury

clavicular-acromioclavicular joint-acromial strutC4The three-process-scapular body junctionThe complex can be subdivided into three units: 1) the clavicular-acromioclavicular joint-acromial strut; 2) the three-process-scapular body junction; and 3) the clavicular-coracoclavicular ligamentous- coracoid (C-4) linkage Secondary support is provided by the coracoacromial ligament.

5Fractures of the surgical neck of the scapula produce

D. Distal fragment consisting of the glenoid and the coracoid process and

P. Proximal fragment consisting of the acromion, scapular spine and scapular body.Pathoanatomy

DPP

Anterior viewPosterior viewClavicle is the only bony connection between the upper extremity and the axial skeleton

The scapula is hung or suspended from the clavicle by the coracoclavicular ligaments and the acromioclavicular joint

6 The distal fragment is attached to the proximal fragment by coracoacromial ligament and to the axial skeleton, through the clavicular shaft, by the coracoclavicular ligament.

To produce a floating shoulder (scapula) - damage to these attachments is needed.

DPPPPathoanatomy Clavicle is the only bony connection between the upper extremity and the axial skeleton

The scapula is hung or suspended from the clavicle by the coracoclavicular ligaments and the acromioclavicular joint

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Surgical neck Lateral Clavicle acromial strut C4 coracoid , coraco clavicular lig and Its attachment to clavicleSurgical neck of scapula Patterns

AC jointC4 Acromion C4Patterns The scapular neck fracture is displaced inferiorly as well as anteromedially by the altered muscle forces and the weight of the upper extremity.

And If significant displacement occurs at either or both sites, there may be problems with healing, such as delayed union, malunion and nonunion

Malunion is common

What happens to distal fragment?Results of Malunion Drooping of shoulder- deformity

Brachial plexus pressure

Relationship of the glenohumeral joint with the acromion is altered, creating a functional imbalance

Decreased range of motion

Loss of normal lever arm of the rotator cuff (length)

Results in weakness on abduction and subacromial pain are common

Drooping of shoulder

Mechanism of injuryMost are following Road traffic injuriesHigh energy injuriesPolytrauma associated with chest injuries pneumo/ haemo thorax, rib fractures

RadiographsRecommended views of shoulder

Anteroposterior view ( weight bearing)Lateral viewAxillary view or trauma axillary viewAnteroposterior view

Scapula Y view

Axillary view

Standard axillaryAlternative axillary viewsVelpeau view

Axillary view

Radiographs

In ring structure concept, like the pelvis, it is more reasonable to think if the ring is broken in one area and the fragments displaced, then there must be a fracture or dislocation in another portion of the ring.

Radiographs Treatment optionsConservative treatment : supported by recent papers

Edwards (jbjs2000) : Reported excellent results in 20 treated nonoperatively by a shoulder immobilizer. They recommend conservative treatment, especially in patients with less than 5-mm displacement.

Van Noort et al ( injury and octa ortopaedica 2005, 2006) In a retrospective study, reported fair to good results in 28 patients treated conservatively with a well-aligned glenoid.

The authors concluded conservative treatment leads to a good functional outcome in the absence of caudal displacement of the glenoid. Caudal displacement was defined as an inferior angulation of the glenoid of at least 20 degreesTreatment optionsSurgical management:

Goss 1993, recommended stabilisation of both sides and stated that conservative treatment causes drooping of the shoulder

Ada and Miller reported a high incidence of rotator cuff dysfunction in patients with displaced clavicular and scapular fractures resulting in loss of the normal lever arm of the rotator cuff, and they recommended that the fractures be treated by open reduction

Romeo et al. reported a poor outcome after scapular neck fractures with malalignment; they measured the glenopolar angle to assess the rotational malalignment of fractures involving the glenoid . In their series patients with scapular fractures, which were displaced by more than 1 cm, had poorer results than those with undisplaced fractures.

B.D.Owens & T.P. Goss jbjs2006 Surgical stabilisation of the clavicle alone could reduce the scapular fracture indirectly, and fixation of the scapular fracture was only required with displaced fractures

Treatment optionsCase examples

Case example quoted in wheeles textbook for conservative management With glenoid not much displaced

Case examplesCase of SSSC with clavicle plate fixation with undisplaced scapula neck treated With clavicle plate alone

Case examplesCase of Failure with clavicle plate fixation with displaced scapula neck treated With calvicle plate alone resulted in decreased ROM

Case examplesProtocol to be followed clavicle plate fixation still scapula neck is displaced . scapula fixation is doneCase examples

Double Plating done at the same timeCase examples

Fixation of lateral clavicle (acromio clavicular ) and coracoid (c4)Conclusion less than 5-mm displacementNo Caudal displacementConservative management Clavicle plating first Scapula still unreduced Scapula fixationSSSCyesNoOperative management

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