Clavicle

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Rotator Cuff Injury Alternative Treatments

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Clavicle fractures account for 5 percent of all fractures seen in the emergency department and for 44 percent of significant injuries to the shoulder girdle. This is the most common fracture of childhood, with almost half of these injuries occurring by the age of 7. The clavicle functions as a strut, connecting the shoulder girdle to the trunk, and provides support and mobility for upper-extremity function. The clavicle also protects the adjacent lung, brachial plexus, and subclavian and brachial blood vessels.

The most common mechanism of injury is a blow to the shoulder. Transmission of the compressive force results in a buckling of the clavicle, which fractures once a critical force is achieved. Children will often have a greenstick or buckle-type fracture or a bowing deformity without a definite fracture. Open fractures, due to extreme tenting of the overlying skin, may occasionally be seen.

Eighty percent of clavicle fractures involve the middle third, 15 percent the distal third, and 5 percent the medial third. Patients typically present with swelling, deformity, and tenderness localized to the clavicle. The arm is slumped inward and downward and is supported by the other extremity. Routine clavicle radiographs may miss fractures due to overlap of surrounding structures, particularly with fractures at either end of the bone. Diagnosis of these may require special views or specialized techniques, such as tomography or computed tomography (CT) scan.

Numerous forms of treatment have been described for this common injury. Simple immobilization with a sling is often successful, with displaced fractures often treated with a figure-of-eight brace. A shoulder spica or open reduction may be required for severely displaced fractures, poor patient compliance, or for complications. Healing may occur as rapidly as 2 weeks for infants, with most adults healing in a 4- to 6-week period.

Although the vast majority of these fractures have a benign course, serious associated injuries and complications may occasionally occur. Penetrating or blunt trauma may result in associated lung, neurovascular, or first-rib injuries. Injury to the adjacent vascular structures, usually the subclavian artery, subclavian vein, internal jugular vein, or axillary artery, may be life-threatening. Distal clavicle fractures with displacement typically are associated with rupture of the coracoclavicular ligament and may require operative intervention to avoid nonunion. Medial clavicle fractures may be associated with intrathoracic injuries or develop late complications, such as arthritis. Significant callus formation may result in subsequent compression of adjacent neurovascular structures and is cosmetically deforming.

The scapula links the axial skeleton to the upper extremity and serves as a stabilizing platform for motion of the arm. Fracture of the scapula is an infrequent occurrence, accounting for less than 1 percent of all fractures. Due to the high energy typically required to fracture this protected bone, there is a greater than 80 percent association of injuries to the ipsilateral lung, thoracic cage, and shoulder girdle.

Significant scapular injury occurs most frequently in men between 25 and 40 years of age, usually as a result of motor vehicle accidents, falls, or other severe trauma. The mechanism of injury is from a direct blow, trauma to the shoulder sometimes with injury of the acromion or coracoid, or a fall on the outstretched arm. An indirect axial load transmitted via the outstretched arm may result in a scapular neck fracture, while the indirect force of a shoulder dislocation may result in fracture of the glenoid. Scapular fractures may be classified by their anatomic location: body, glenoid neck, intraarticular glenoid, spine, coracoid, and acromion ( Fig 263^-2) Fractures of the body and glenoid neck are the most common.

FIG. 263-2. Sites of scapula fractures. A. Body. B. Glenoid rim. C. Intraarticular glenoid. D. Neck. E. Acromion. F. Spine. G. Coracoid.

A patient with an isolated scapular fracture typically will present with localized tenderness over the scapula and the ipsilateral arm held in adduction. The shoulder may have a flattened appearance. Radiographs consisting of an anteroposterior shoulder, lateral scapula, and axillary will identify most fractures. However, scapula fractures are often associated with other significant injuries, and hence diagnosis may be delayed or initially missed entirely. In Ada and Miller's series, 96 percent of scapular fractures had associated injuries, of which rib fractures were the most common, followed by pulmonary, humeral head, and shoulder girdle injuries. Other injuries may include neurovascular, abdominal, and spine trauma.

Rarely, significant trauma may result in scapulothoracic dissociation. This syndrome consists of lateral scapular displacement, clavicular disruption, and severe soft-tissue injury. This injury is sometimes associated with brachial plexus avulsion, subclavian artery disruption, or both. Its presence may be suspected by neurovascular findings or by lateral displacement of the scapula visualized on a nonrotated chest radiograph.

The vast majority of scapular fractures are treated nonsurgically, with a sling for immobilization, ice, analgesics, and early range-of-motion exercises. Surgical intervention may be necessary for significant or displaced articular fractures of the glenoid, angulated glenoid neck fractures, acromial fractures associated with a rotator cuff tear, and some coracoid fractures. Fractures of the glenoid, acromion, or coracoid are more likely to be associated with long-term disability.

Complications of scapular fractures themselves are uncommon. Although many of these fractures heal with some degree of malunion, typically this does not result in significant disability. Most long-term disability is a result of other, associated injuries.

The rotator cuff consists of the tendons of the supraspinatus, infraspinatus, subscapularis, and teres minor muscles (see also Chap...275). These tendons coalesce with the capsule of the glenohumeral joint and attach to the greater and lesser tuberosities of the humerus. The main function of the rotator cuff is to provide dynamic stability to the glenohumeral joint. This is accomplished by contraction of muscles that compress the humeral head in the glenoid and by selective contraction resist the actions of major shoulder girdle muscles. The end result is a stable scapulohumeral articulation with the ability to perform smooth, coordinated motion. Injuries to the rotator cuff occur as a result of acute trauma, such as from a dislocation of the glenohumeral joint and as a result of chronic injuries.

Tears of the rotator cuff after glenohumeral dislocation are common but unfortunately often missed. They should be suspected in all patients over the age of 40 years, in patients with luxatio erecta, and in patients who are unable to abduct or externally rotate the arm after a glenohumeral dislocation.

Chronic injuries occur as a result of impingement and decreased vascularity, both common with advancing age. Impingement is explained by the anatomic relationship of the rotator cuff to osseus and soft-tissue structures. It is "sandwiched" among the humeral head, acromion, coracoid, and the coracoacromial ligament. Compression of the rotator cuff between the humeral head and the coracoacromial arch (acromion, coracoid, and coracoacromial ligament) leads to tendon attrition and degeneration. Disease of the rotator cuff is a continuum of injury from mild inflammation to rupture. The initial stage is characterized by inflammation and edema, resulting in mild pain with activity. There is no limitation of motion or weakness. There may be mild tenderness over the greater tuberosity. This stage of disease is most common in patients less than 25 years of age and is completely reversible.

In the second stage there is increased tendinitis, and the pain is more intense and seems to be worse at night. Tenderness is more diffuse. Overhead motion is painful, and there is some limitation of abduction and external rotation.

The third stage of disease is characterized by significant rotator cuff degeneration and tears. Most patients are over the age of 40 with a long history of symptoms. They have more pain, limitation of motion, and weakness. Patients with complete rotator cuff tears have tenderness over the greater tuberosity and acromioclavicular joint. They also have limitation of motion and weakness, especially to abduction and external rotation. Disease at this stage is considered irreversible.

Treatment in the early stages consists of rest, with sling immobilization, nonsteroidal anti-inflammatory drugs, ice, and local injections. Treatment of rotator cuff tears

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