Injuries of Clavicular Complex Key Points

• Most clavicle fractures can be definitively treated nonsurgically with a sling or a figure-eight dressing if they are minimally or nondisplaced.

• Grade 1 (tenderness) and grade 2 (tenderness and displacement with intact coracoclavicular ligaments) acromioclavicular injuries are managed conservatively with ice, pain control and a sling for comfort.

• Anterior shoulder dislocations are common, whereas posterior dislocations are less common but more dangerous with risk of compressing the great vessels.

The diagnosis of clavicle, acromioclavicular, and sternoclavicular injuries is straightforward; direct palpation along the clavicular complex should lead to an area of focal pain. Imaging studies should include the entire clavicle and a clear view of the targeted area from at least two planes. All injuries around the shoulder should include examination of the cervical spine and distal neurovascular evaluation. The brachial plexus, subclavian vein, and axillary artery lie immediately beneath the clavicle and can be at risk of injury.

Clavicle fractures account for 5% to 10% of all fractures and can be classified as either displaced or nondisplaced as well as by their specific location (proximal-distal) on the clavicle. Most fractures involve the midshaft (80%); however, distal third (15%) and proximal third (5%) fractures are also possible. Fortunately, most clavicle fractures can be definitively treated nonoperatively with a sling or a figure-of-8 dressing if they are minimally displaced or nondisplaced. Figure-of-8 bracing has been linked with skin necrosis over the fracture site, indicating the need for careful observation of skin integrity when used. In most cases, a simple sling for comfort is adequate over the first few weeks, followed by progressive range of motion (ROM) activities. More significant displacement (>100%), any tenting of the skin, significant comminution, or excessive shortening (>2 cm) may warrant surgical intervention, and referral to an orthopedist is recommended. Distal clavicle fractures have a higher rate of nonunion with nonsurgical treatment than midshaft or medial fracture patterns, so careful follow-up is necessary (Kahn et al., 2009; McKee et al., 2004).

Acromioclavicular Joint

Acromioclavicular (AC) joint injuries are classified by the ligamentous structures involved and the degree of separation of the AC joint (Fig. 30-3). A grade 1 injury involves only a partial injury to the AC ligaments, no displacement occurs, and the coracoclavicular (CC) ligaments are intact. A grade 2 injury involves the complete injury of the AC ligaments, and therefore mild superior translation of the distal clavicle occurs (<100% translation), and CC ligaments are intact. Both grade 1 and grade 2 injuries have an excellent prognosis with conservative treatment, which includes local application of ice, reduction of stresses, and a sling for comfort. Most patients will have substantial active motion and functional use of the arm within 6 weeks. A grade 3 involves the complete rupture of both AC and CC ligaments. The distal end of the clavicle and acromion are now separated by more than a full clavicular width (>100% displacement). Stress radiographic views may magnify this separation even further; however, stress views rarely alter the treatment plan and are painful to patients and thus no longer considered required diagnostic images.

Treatment of grade 3 AC injuries is controversial and ranges from surgical to conservative treatment with a sling. With conservative treatment, the distal clavicle may ultimately heal in a superiorly translated position, leaving a prominent bump over the lateral aspect of the shoulder. However, nonelite athletes can function well and have a full return to activities. Acute repair of grade 3 injuries is suggested more for elite athletes, but has not been proved in randomized, controlled trials (RCTs) because subtle changes occur at this important point in the kinetic chain. Chronic reconstructions have been suggested in patients who have grade 3 injuries but with residual pain or dysfunction. The more severe injuries of the AC joint have significant posterior, superior, or inferior displacement and require surgical reduction and repair.

A grade 4 AC separation is a complete injury of both AC and CC ligaments with a posterior subluxation of the distal clavicle relative to the acromion. These are frequently missed on routine anteroposterior (AP) radiographs but can be easily identified if routine axillary shoulder views are obtained. Fundamental management of bone and joint injuries requires a view from two perspectives. Grade 5 injuries are basically equivalent to severe grade 3 injuries where the distal clavicle is riding so high that it either buttonholes through the fascia or tents beneath the skin (300% translation). The fascial injury prevents reduction, and the pressure on the undersurface of the skin risks skin slough or an open injury. Finally, grade 6 AC injuries are extremely rare and are associated with an inferior dislocation of the distal clavicle beneath the coracoid.

Sternoclavicular Joint

Patient with sternoclavicular (SC) injuries present with a history of trauma (e.g., landing on lateral aspect of shoulder) or a history of chronic overuse that has led to popping and pain over the medial aspect of the clavicle (Matave et al., 2005). Acute SC joint dislocations can be identified clinically with localized tenderness over the medial clavicular aspect, and gross deformity may be present. More often, however, patients present with a subtle chronic situation caused by esthetic findings with a palpable or gross asymmetry. The examination should always include an assessment of the patient's airway and circulation, including cervical venous distention, because the great vessels and trachea lie immediately posterior to the SC joints (Fig. 30-4). Imaging studies should include an AP radiograph of the chest, views of the entire clavicle, and a tangential or serendipity view of the SC joint (Fig. 30-5). Because of overlapping shadows, these studies may be difficult to interpret. When suspicious, the best test is computed tomography (CT).

Traumatic SC joint dislocations can be either anterior or posterior. Anterior dislocations are generally easily palpated, with the proximal clavicle anteriorly displaced and painful. Anterior injuries may be reduced by placing a rolled towel or beanbag between the shoulder blades, then creating a distraction force along the arm in extension. Anterior dislocations tend to be unstable and to redisplace after attempted reduction. Fortunately, anterior injuries usually heal uneventfully, leaving an asymptomatic medial prominence and occasional popping, with minimal effect on the patient's activities of daily living. Posterior dislocations can be dangerous because of proximity to the great vessels posteriorly. If patients have venous engorgement in the neck and difficulty breathing, closed reduction may be attempted. A towel clip is used at the medial end of the clavicle, pulling anteriorly and creating the reduction. If this is attempted, a vascular surgeon should be available in case the proximal clavicle was actually tamponading an injury to the great vessels. This reduction should never be performed on the sideline in the absence of immediate cardiothoracic surgical response, unless the patient's life is at risk and there is no other option.

When treating injuries to the proximal clavicle, age of the patient and normal maturation of the proximal epiphysis are also important considerations. The medial clavicle epiphysis is one of the last to appear, at 19 to 23 years of age, and then the last to fuse, at 23 to 25 years of age. In patients younger than 23, these injuries are generally physeal injuries and not true dislocations, reducing the need for aggressive treatment (Fig. 30-6).

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