AC Separations & Distal Clavicle Fractures. Joshua M. Abzug, MD

Transcription

1 AC Separations & Distal Clavicle Fractures Joshua M. Abzug, MD

2 Introduction Account for 10-30% of pediatric clavicle fxs Result of direct blow to shoulder or fall onto distal clavicle Mechanism Collision type sports Football/Lacrosse

3 Anatomy Based on Injury to periosteum, AC and CC ligaments Direction of displacement

4 Anatomy Stability of the clavicle Horizontal/AP plane CC ligaments Permits the definition of the CC space (space between the clavicle and coracoid process) which should be cm

5 AC separation Classification Dameron and Rockwood Type I nondisplaced Type II Partial tear of AC ligaments and lateral periosteum Type III Clavicle displaced superiorly (25-100% clavicle width) with complete tear of AC ligaments and superolateral periosteum Type IV Clavicle displaced posteriorly and entrapped in trapezius Type V Complete displacement (>100%) Type VI Inferior displacement beneath the coracoid

6 Distal clavicle separation Classification Neer classification modified by Craig Type I Fx distal to CC ligament not involving the AC joint Minimal displacement bc proximal fragment is stabilized by AC joint capule and AC ligaments Type II Subdivided IIA Fx medial to CC ligament Proximal fragment loses stability provided by CC ligaments and displaces superiorly out of periosteal sleeve but the distal fragment remains stable bc of AC joint capsule, AC ligaments, & CC ligaments IIB Fx between CC ligaments with concomitant injury to the conoid ligament Same as IIA bc even though conoid ligament is disrupted, trapezoid ligament remains intact

7 Distal clavicle separation Classification Neer classification modified by Craig Type III Fx distal to the CC ligaments and extends to the AC joint Minimal displacement since ligaments are not disrupted Type IV Fx medial to the physis Significant displacement can occur between the physis and metaphyseal fragment, esp. of periosteal sleeve is disrupted Type V Fx that leaves a free-floating inferior cortical fragment attached to the CC ligaments with an additional fracture line dividing the distal clavicle from the remainder of the clavicle End result is instability bc neither the proximal nor distal fragment is attached to the CC ligaments

8 Type I non or minimally displaced Type II Fractures medial to CC ligament Type III Intra-articular fractures Classification Alternative Method

9 Imaging Plain radiographs true AP and axillary lateral Sufficient for Types III, V and VI Poor visualization of Type IV Need good PE to recognize displaced clavicle palpable in the suprascapular region

10 Imaging Zanca view Permits better assessment of AC joint to determine intra-articular involvement Aim beam degrees cephalad

11 Permits best visualization of AC joint Imaging - CT

12 Treatment Nonoperative Type I & III Operative Type II, IV, V

13 CZ 8 yo male fell of a slide CC: R Shoulder pain NVI

14 11/21/2018 Initial radiographs

15 12/3/ weeks post injury

16 12/17/ weeks post injury

17 1/14/ months post-injury

18 8 yo male Hurt playing football CC: R shoulder pain

19 4/26/2017 Initial radiographs

20 5/15/ weeks post-injury

21 6/12/ weeks post-injury

22 Treatment Nonoperative Type I & III Operative Type II, IV, V

23 Operative indications Older adolescents Highly competitive athletes Severe posterior or superior displacement Open fractures Displaced intra-articular extension Associated operative neurovascular injuries

24 Tretament - Operative - Suture repair - Tension band - Transacromial K-wire Typically avoided due to potential for breakage/migration - Plates - Small plates and screws (mod hand, micro/mini frag) - Hook plate removed after 3-6 months Aggregate scores improved from 16.1 to 18.6

25 Operative Technique - Modified beach chair position Modified Mallet Scores

26 Operative Technique - Incision in skin lines over distal 1/3 of clavicle and AC joint - Elevate skin and subcutaneous flaps - Must protect cutaneous nerves Modified Mallet Scores

27 Operative Technique - Reduce distal clavicle to acromion - Can utilize temporary transacromial pinning - Stabilize fracture utilizing 1 or more of above options - Suture periosteum and ligaments - Subcuticular closure Modified Mallet Scores

28 Outcomes Limited data for pediatrics and adolescents Vast majority have excellent outcomes

29 Complications Nonunion/Hardware failure Ensure adequate fixation in distal fragment/don t allow excessive activity early Screw penetration into AC joint Use direct visualization and fluorscopy in multiple planes

30 Thanks!!!