1 Clavicular injuries: mechanism of injury: Most (94%) clavicular injuries result from a direct blow on the point of the shoulder, generally from a fall on the side (A). Less commonly, force may be transmitted up the arm from a fall on the outstretched hand (B). Under the age of 30 years, road traffic and sporting injuries are the commonest causes.

Fracture: The central 3/5 (1) is involved in about 2/3 of cases, and within this group fractures at the junction of the middle and outer thirds (2) are commonest. Fractures of the outer 1/5 (3) are much less common, and of the inner 1/5 (4) even less so. Subluxations and dislocations: These may involve the acromioclavicular joint (5) or the sternoclavicular joint (6). Fractures of the clavicle involving the acromioclavicular joint are uncommon (2.8% of cases).

2 Common patterns of fracture (a): Greenstick fractures are common, particularly at the junction between the middle and outer thirds. Fractures may not be particularly obvious on the radiographs and it is often helpful in children to have both shoulders included for comparison. The only abnormality visible in many cases is local kinking of the clavicular contours. Healing of this type of fracture is rapid, and reduction is not required.

3 Common patterns of fracture (b): In the adult, undisplaced fractures are also common, and are comparatively stable injuries. Late slipping is rare. Symptoms settle rapidly and minimal treatment is required.

4 Common patterns of fracture (c): With greater violence, there is separation of the bone ends. The proximal end under the pull of sternomastoid often becomes elevated (1). The shoulder loses the prop-like effect of the clavicle, so that it tends to sag downwards and forwards (2). Note (3) the glenoid, (4) the coracoid, (5) the acromion.

5 Common patterns of fracture (d): With greater displacement there is overlapping and shortening, but union is usually rapid. Remodelling, even in the adults, is so effective that strenuous attempts at reduction are unnecessary. Rare non-union is nevertheless seen most often in highly displaced fractures and those of the outer third. Pathological fracture may result from radionecrosis (following radiotherapy for breast carcinoma) and may be mistaken for a local recurrence.

6 Diagnosis: Clinically there is tenderness at the fracture site; sometimes there is obvious deformity with local swelling, and the patient may support the injured limb with the other hand. In cases seen some days after injury, local bruising is often a striking feature. Diagnosis is confirmed by appropriate radiographs; a single AP projection of the shoulder is usually adequate in the adult.

7 Treatment (a): The most important aspect of treatment is to provide support for the weight of the arm in which the clavicular tie has been impaired. As a rule this is best achieved with a broad arm sling (1). Additional fixation may be obtained by wearing the sling under the clothes (2). No other treatment is needed in greenstick or undisplaced fractures.

8 Treatment (b): Where there is marked displacement of a clavicular fracture an attempt to correct the anterior drift of the scapula round the chest wall (1) and improve the clavicular shortening is sometimes made. There is no simple way of achieving this. All methods attempt to apply pressure on the front of the shoulder (2) and although they are comparatively ineffective in terms of reduction, are helpful in reducing pain.

9 Treatment (c):Ring or Quoit method: Narrow gauge stockingette is cut into two lengths of about a metre each (1). The central portions are stuffed with cotton wool (2). One of the strips is taken and the padded area positioned over the front of the shoulder and tied firmly behind (3).

10 Treatment (d): The second strip is applied in a similar manner to the other shoulder (4). The patient is then advised to brace the shoulders back and the free ends of the ring pads are tied together (5). A pad of gamgee (a sandwich of cotton wool between layers of gauze) may be placed as a cushion beneath the knots (6).

11 Treatment (e): Figure-of-eight bandage: Pads of gamgee or cotton wool alone are carefully positioned round both shoulders (1). The patient, who should be sitting on a stool, is asked to brace back the shoulders; a wool roll bandage is then applied in a figure-of-eight fashion (2). For added security the layers may be lightly stitched together at the crossover (3).

12 Treatment (f): Commercially available clavicle rings, covered with chamois leather, may be applied and secured with a strap. Many other patterns of off-the-shelf clavicular supports are available. With all of these care must be taken to avoid pressure on the axillary structures and the additional support of a sling is desirable for the first 2 weeks or so. Note also that elderly patients tolerate clavicular bracing methods poorly, and sling support only may be advisable. (For internal fixation see Frame 25.)

14 Acromioclavicular joint injuries: Injury to the acromioclavicular joint usually results from a fall in which the patient rolls on the shoulder. Note that the clavicle is normally attached to the scapula by (1) acromioclavicular, (2) conoid and (3) trapezoid ligaments. The scapular component of shoulder abduction requires free acromioclavicular movement.

15 Pathology:Note that: (1) in subluxations and sprains, damage is confined to the acromioclavicular ligaments, and the clavicle preserves some contact with the acromion. In dislocations (2) the clavicle loses all connection with the scapula, the conoid and trapezoid ligaments tearing away from the inferior border of the clavicle. The displacement may be severe, and the ensuing haematoma may ossify (3).

16 Diagnosis (a): The patient should be standing and the shoulders compared. The outer end of the clavicle will be prominent, and in cases of damage to the conoid and trapezoid ligaments the prominence may be quite striking. Local tenderness is always present.

17 Diagnosis (b): Confirm any subluxation by supporting the elbow with one hand gently pushing the clavicle down with the other. Improvement in the contour of the outer end of the clavicle will confirm the diagnosis of subluxation or dislocation.

18 Diagnosis (c): Now stand behind the patient and abduct the arm to 90°. Flex and extend the shoulder while gently palpating the acromioclavicular joint. Failure of the outer end of the clavicle to accompany the acromion indicates rupture of the conoid and trapezoid ligaments.

19 Radiographs (a): Displacement of the clavicle by a diameter or more relative to the acromion (Illus.) suggests rupture of the conoid and trapezoid ligaments. The radiographs however are often fallacious in indicating the severity of the injury (and indeed may not show it). The reason is that spontaneous reduction tends to occur in recumbency – the position in which AP radiographs are normally taken.

20 Radiographs (b): It must be clearly indicated on the radiograph request form that the acromioclavicular joint is suspect. The radiographs should then be taken with the patient standing. The weight of the limb is often sufficient to show up the dislocation, but it is common practice to have the patient hold weights in both hands, and to include both shoulders for comparison.

21 Treatment (a): If there is no gross instability, treat by the use of a broad arm sling under the clothes for 4–6 weeks. Physiotherapy is seldom required and an excellent result is the rule.

NB: Subluxations are easily reduced and held by adhesive strapping, but this treatment should not be employed as early skin reactions will always force abandonment.

22 Treatment (b): In cases of gross instability, good results usually follow conservative management; complications are common after surgery, but this should be considered in patients who are engaged in work which is heavy or involves prolonged elevation of the arms. A common method is to hold the clavicle in alignment with the acromion, using a lag screw (1) run into the coracoid. A washer (2) is used to spread local stresses, and some advise reinforcement of the fixation with absorbable transarticular sutures (3) in the acromioclavicular joint. Any tears in the deltoid or trapezius should also be repaired.

Treatment (c): Other methods of internal fixation include figure-of-eight acromioclavicular wiring; PDS sutures (of polyglycolic acid) or polyester tape may be used in the form of slings passed round the clavicle and under the coracoid. Kirschner wires passed across the joint tend to migrate, and their use is not recommended. In all cases there is a strong tendency for the devices to cut out, and it is imperative that there is the additional support of a broad arm sling (under the clothes or with a body bandage) for 8 weeks. Internal fixation screws must be removed at 6–8 weeks before mobilisation.

23 Treatment (d): If a dislocation reduces with the arm in abduction, a shoulder spica for 6–8 weeks may be used as an alternative to surgery. Complications: Symptoms from acromioclavicular osteoarthritis may be relieved by excision of the outer 2 cm of the clavicle. Fascial reconstruction of the coracoclavicular ligaments can be used for persistent instability.

24 Fractures of the outer third of the clavicle: Displacement is generally minimal as the coracoclavicular ligaments are not usually torn. When these ligaments are damaged, however, displacement may be marked and give rise (rarely) to non-union. (It should be noted however in this context that non-unions in outer third fractures of the clavicle are often symptom free.)

There are two approaches to the treatment of outer third fractures of the clavicle. Good results are generally the rule with conservative management, which should follow the lines previously described for acromioclavicular injuries. Clavicular bracing is valueless and a sling under the clothes for 4–5 weeks is usually quite adequate.

Alternatively, to lessen the risks of non-union, some prefer to treat all outer third fractures by reduction and plating of the clavicle. If the ligaments are torn these should also be dealt with; PDS sutures or polyester tape in the form of slings passed round the clavicle and coracoid are particularly useful in this situation.

25 Complications of fractures of the clavicle: Non-union: This is an uncommon complication: although Neer reported 3 cases in 2235 fractures of the clavicle, the incidence is now believed to be higher (figures in the range 0.4% to 7% have been quoted). When it occurs it is commonest in severely displaced and comminuted fractures of the central 3/5th, in the elderly, and especially in females. In the vulnerable group of badly displaced central fractures in adults, internal fixation as a primary treatment for these fractures has been advocated, although few would reckon that this is justified in view of the risks of infection, failure of fixation and indeed the non-union it strives to avoid.

Treatment: As elsewhere, internal fixation and bone grafting are advocated for non-union. Dedicated, locked, anatomically contoured plates (e.g. the Acumed™ plate) are particularly useful in securing this slender bone.

Floating shoulder: This term applies to clavicular fractures associated with fractures of the proximal humerus or of the glenoid.

Treatment: These injuries are best dealt with by internal fixation of the clavicle.

Mal-union: Shortening of the clavicle with irregularity of the bone, sometimes with the formation of prominent spikes may give a poor cosmetic appearance, and cause local discomfort from the pressure of clothing and shoulder straps.

Treatment: Very occasionally a lengthening osteotomy with bone grafting and plating can be considered. Bony prominences may be readily trimmed with an osteotome, although few of those offered this procedure accept as they feel that their symptoms are not severe enough to merit this.

Functional impairment of the shoulder: Stiffness (especially in the elderly) of the shoulder, weakness and difficulty in carrying heavy weights, and local pain are usually amenable to physiotherapy.

26 Sternoclavicular dislocation: This is sometimes seen without any history of trauma, but generally the commonest lesion, a minor subluxation, follows a fall or blow on the front of the shoulder (1) or fall on the outstretched hand. There is asymmetry of the inner ends of the clavicles (2) due to the clavicle on the affected side subluxing downwards and forwards. There is local tenderness. The diagnosis is essentially a clinical one.

27 Radiographs: AP and oblique radiographs are difficult to interpret but are nevertheless usually performed; they may confirm the diagnosis when there is a major dislocation and the inner end of the clavicle is displaced onto the sternum. Note that in rare cases (illustrated) the clavicle passes behind the sternum where it may endanger the great vessels. As a rule tomographs or CT scans may be more useful in elucidating these injuries. (Clavicle: dotted line; sternal edge: arrows.)

28 Treatment (a): Minor subluxations should be accepted. The clavicle stabilises in the subluxed position; some prominence of the inner end of the clavicle may persist, with some asymmetry of the suprasternal notch, but a pain-free result is usual. The arm should be rested in a sling for 2–3 weeks until acute pain has settled.

29 Treatment (b): Gross displacements should be reduced under general anaesthesia. A sandbag (1) is placed between the shoulders which are firmly pressed backwards (2). Clavicular braces are then applied (see Ch. 6/Frame 9), along with a broad arm sling for 4–5 weeks. Should the reduction be extremely unstable, surgical repair with fascia lata slings should be considered. The rare irreducible dislocation may require open reduction (which may be hazardous).

30 Scapular fractures (a): Fractures of the blade of the scapula are usually caused by direct and often high energy violence, with sometimes an associated intrathoracic injury which merits overnight cardiac monitoring. Even when comminuted and angled (Illus.), healing is usually rapid and an excellent outcome is the rule. Treat with a broad arm sling and analgesics, and commence mobilisation as soon as the acute symptoms have settled (often by 2 weeks).

31 Scapular fractures (b): Fractures of the scapular neck lead to much bruising and swelling. Comminution is common. If involvement of the glenohumeral joint is suspected, check the position of the humeral head and any steps in the articular surface of the glenoid by CT scan, with a view to possible open reduction. In spite of frequently daunting radiographs, a good outcome usually follows conservative management with early mobilisation. Fractures of the scapular spine or coracoid may usually be treated conservatively.

32 Dislocation of the shoulder: When the shoulder dislocates, the head of the humerus may come to lie most often (1) in front of the glenoid (anterior dislocation of the shoulder), (2) behind the glenoid (posterior dislocation of the shoulder) or (3) beneath the glenoid (luxatio erecta). Anterior dislocation is by far the commonest of these.

33 Anterior dislocation (a): This most commonly results from a fall leading to external rotation of the shoulder (e.g. the trunk internally rotating over a fixed hand – the shoulder being vulnerable in abduction and external rotation). It is rare in children, common in the 18–25 years age group (from motorcycle and athletic injuries) and comparatively common in the elderly, where the stability of the shoulder may be impaired by muscle degeneration and where falls are common.

34 Anterior dislocation (b): The head of the humerus externally rotates out of the glenoid (1) and, having become free, comes to lie medially in front of the scapula (2). B = biceps tendons; C = capsule; G = glenoid; GT = greater tuberosity; H = head of humerus; L = glenoid labrum; LT = lesser tuberosity; S = subscapularis.

35 Anterior dislocation (c): Anterior dislocation is inevitably associated with damage to the anterior structures. Commonly the capsule is torn away from its attachment to the glenoid (1). (The Bankart lesion, although simultaneous displacement of the glenoid labrum (2) usually attracts this term.) The humeral head may suffer an impression fracture (Hill-Sachs lesion (see Ch. 6/Frame 71). Other damage may occur, especially humeral avulsion of the glenohumeral ligament (HAGL lesion).

36 Anterior dislocation (d): In the older patient especially, there may be tearing or stretching of the anterior capsule (3), sometimes with associated damage to the shoulder cuff, especially subscapularis (4). The greater tuberosity may fracture (5) and occasionally there is damage to the axillary artery or brachial plexus (6).

37 Diagnosis (a): The shoulder is very painful: the patient resents movement, and to prevent this often holds the injured limb at the elbow with the other hand. The arm does not always lie into the side, appearing to be in slight abduction. The outer contour of the shoulder may appear to be slightly kinked due to the displacement of the humeral head.

38 Diagnosis (b): Palpate under the edge of the acromion. The usual resistance offered by the humeral head will be absent. If in doubt, compare the two sides. The displaced humeral head, lying anteriorly, may be palpable at the front of the joint.

39 Diagnosis (c): Nevertheless the presence of the acromion and clavicle may make examination difficult. In the doubtful case, it may be helpful to try to assess the relative positions of the humeral head and glenoid by palpation in the axilla.

40 Diagnosis (d): Axillary (circumflex) nerve palsy is the commonest neurological complication. Test for integrity of the nerve by assessing sensation to pin prick (1) in its distribution over the ‘regimental badge’ area. (The shoulder is usually too painful to assess deltoid activity with certainty.) Look for other (rare) involvement of the radial portion of the posterior cord (2) and involvement of the axillary artery (3).

41 Radiographs (a): The majority of anterior dislocations of the shoulder show quite clearly on the standard AP radiographs of the shoulder. The humeral head is displaced anteriorly and medially; in its final position it may be described as lying (i) preglenoid (ii) subcoracoid, (iii) subclavicular. This classification is of little practical importance; the important diagnostic feature is the loss of congruity between the humeral head and the glenoid as illustrated.

42 Radiographs (b): A second radiographic projection is essential if the diagnosis is in doubt. Note that if the humeral head has minimal medial displacement the AP view may appear normal. (This is especially the case in posterior shoulder dislocations.) The most useful additional projection is the axial lateral (sometimes called the tangential lateral). (Illus.: the normal appearances in such films.) In recurrent dislocation especially this view may show a defect in the posterior aspect of the humeral head (see Frame 69).

43 Radiographs (c): The axial lateral is usually taken with the patient lying on his back with the arm abducted to 90°. The X-ray tube is adjusted so that it lies roughly parallel to the trunk; the central ray passes through the axilla to the plate which is placed above the shoulder. The bony features are easy to identify. 1 = glenoid; 2 = humeral head; 3 = coracoid; 4 = acromion; 5 = clavicle; 6 = vertebral body of the scapula; 7 = spine of scapula.

44 Radiographs (d): If the shoulder is too painful to allow an axial lateral, obtain an apical oblique projection; the landmarks are similar to those seen in the AP, but may be easier to interpret. Alternatively, if the patient is not overweight, a translateral projection, at right angles to the plane of the AP, may be helpful. This view is often difficult to interpret, but note that in the normal shoulder (Illus.) the posterior border of the humerus and the axillary border of the scapula form a shallow parabolic curve (see also Frame 61).

45 Radiographs (e): An associated fracture of the greater tuberosity is not uncommon (see Frame 36 for mechanism). This does not influence the initial treatment of the dislocation by reduction, but may require subsequent attention. The radiographs of an acute dislocation may show evidence of previous episodes, the presence of a Hill Sachs lesion being particularly suggestive even although this may occasionally be found after a first dislocation.

46 Radiographs (f): Subluxation of the glenohumeral joint This may follow prolonged rest of the arm in a sling from shoulder girdle wasting (requiring no treatment), but may develop insidiously as a result of inherited ligament laxity, often referred to as AMBR (atraumatic, multidirectional, bilateral, treated by rehabilitation or inferior capsular ligament shift in recalcitrant cases). This is best seen if the AP radiograph is taken with the patient erect, and frank dislocation should be excluded by a lateral projection.

47 Treatment: Reduction by Kocher’s method (a): This, one of the most popular of reduction methods, may often be successfully carried out after the administration of intravenous Midazolam (benzodiazepine), or in the young adult after a substantial dose of intramuscular pethidine. Severe pain, or if the patient is of muscular build, are indications for general anaesthesia. Apply traction (1) and begin to rotate the arm externally (2).

48 Kocher’s method (b): Take plenty of time over external rotation. In the conscious patient, if muscle resistance is felt, stop for a moment and then continue, distracting the patient’s attention with conversation. It should be possible to reach 90° of external rotation. (If severe pain and muscle spasm prevent rotation, general anaesthesia will be required.) Excessive force must be avoided in order to prevent fracture of the humeral shaft.

49 Kocher’s method (c): The shoulder frequently reduces with a clear ‘clunking’ sensation during the external rotation procedure, but if this does not happen, flex the shoulder (by lifting up the point of the elbow) and then adduct it, bringing the elbow across the chest. (These and the following movements may be carried out rapidly.)

50 Kocher’s method (d): Now internally rotate the shoulder, bringing the patient’s hand towards the opposite shoulder. If reduction has not occurred, repeat all stages, attempting to get more external rotation in stage 2. If doubt remains over the reduction, repeat radiographs should be taken. Complete failure is rare under general anaesthesia. In the sedated patient, failure is an indication for general anaesthesia.

51 Alternative methods of reduction: In this common and generally easy to reduce dislocation there is no shortage of alternative procedures. These include the following:

(a) Hippocratic method: The principle is that traction is applied to the arm and the head of the humerus is levered back into position. The stockinged heel is placed against the chest (without being pressed hard into the axilla) to act as a fulcrum, while the arm is adducted.

52 (b) Stimson’s method: The patient is given a powerful analgesic (e.g. 200 mg of pethidine in a fit athletic male) or lidocaine injected intra-articularly, with resuscitation facilities available. The patient should be prone, with the arm dependent, a sandbag under the clavicle and a weight of about 4 kg tied to the wrist. The joint normally reduces spontaneously within 6 minutes: if not, with one hand fix the superomedial angle of the scapula (a), and with the other push the inferior angle medially (b).