Clavicle fracture Gãy xương đòn Điều trị bảo tồn và phẫu thuật

Gãy xương đòn Điều trị bảo tồn và phẫu thuậtDiaphyseal multifragmentary, fragmentary segmental clavicle fracture The AOOTA classification does not further subdivide multifragmentary fractures of the diaphysis into subtypes (fragmented spiral,.

Diaphyseal multifragmentary, fragmentary segmental clavicle fracture

The AO/OTA classification does not further subdivide multifragmentary fractures of the diaphysis into subtypes (fragmented spiral, intact segmental, fragmented

segmental), but the treatment may vary depending of the fracture configuration

They are all classified as AO/OTA 15.2C fractures

Definition: The diaphysis of the clavicle extends from the attachment of the

coracoclavicular ligament laterally to the costoclavicular ligament medially

Diaphyseal multifragmentary, fragmentary segmental clavicle fracture

These fractures often results from high energy injury and a careful examination for

associated injuries should be performed The main choice of treatment is between

nonoperative treatment and bridging plate

Nonoperative treatment

Skill level

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Equipment

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Main indications

Shortening and displacement < 2 cm

Supporting indications

 Situations where larger interventions are contraindicated

Advantages

 No surgery

Disadvantages

 Immobilization up to 6 weeks

 Yield more incidences of nonunion or shortening

Contraindications

 Open fracture

 Neurovascular injury

 Risk of skin penetration by bone

Nonoperative treatment of clavicle fractures

Diaphyseal multifragmentary, fragmentary segmental clavicle fracture

4/4 – Phase 4: Beginning of week 13 after injury (remodeling and reintegration phase)

1 Phase 1: injury to the end of week 3 after injury (inflammatory phase)

Phase 1 principle: protection of the injured (operated) limb to facilitate uneventful healing

Phase 1 aim: healing without complications while facilitating early movement

External support - full time

Optimal shoulder immobilization is achieved when the upper arm and forearm are secured to the chest Traditionally, this has been done with a sling that supports the elbow and forearm and counteracts the arm's weight The simplest sling is a triangular bandage tied behind the neck

Additional support is provided by a swath that wraps around the humerus and the chest

to restrict further shoulder motion and keep the arm securely in the sling

Commercially available devices provide similar immobilization, with or without the circumferential support of a swath

Abduction brace

In the case of coracoid fractures or acromial fractures and rotator cuff surgery, one attempts to relieve tension by elevation and abduction of the extremity This can be achieved with the aid of a so-called airplane splint or an abduction cushion, as shown in this diagram

Mobilization of the upper extremity for general indications

It is essential to maintain optimal mobility of the unaffected joints to reduce arm swelling

by encouraging venous return and lymphatic drainage Active mobilization of the

unaffected joints promotes the preservation of the proprioception and therefore promotes optimal joint motion

The following exercises are recommended

 Opening and closure of the hand

 Squeezing of a soft ball

 Bending of the wrist forward, backwards and in a circular motion

 Movement of an open hand from side

to side

 Straightening and bending of

the elbow

 Squeezing the shoulder blades together while the shoulders remain relaxed

 Gentle side-to-side, forward-and-backward, and rotational movements of the neck

Mobilization of ipsilateral limb kinetic chain with no active motion of clavicle-scapula

Physical therapy instruction and supervision may be helpful for optimal rehabilitation or if the patient is not progressing satisfactorily

Active assisted range of motion exercises are started with gravity eliminated and as comfort permits:

 External rotation at waist level

 Internal rotation at waist level

 Forward flexion without scapular protraction with the forearm supported by the table (illustrated)

 Isometric strengthening of the rotator cuff and deltoid as comfort permits

X-rays should be checked to rule out secondary fracture displacement if unexpected pain occurs

Activities of daily living

At this stage, activities of daily living are limited to those needed to do personal care The patient is encouraged to use the ipsilateral hand for midline personal care

activities (eg eating and toileting)

Care should be taken when motions approach extremes of range, and taking the hand behind the back may not be safe until fracture union has been confirmed (by

radiographs and the absence of fracture-site pain)

Sleeping

The patient should sleep wearing the sling and lie either on his back or on the non-injured side

When sleeping on the back, the injured side should be supported by placing a pillow underneath the arm and shoulder Some patients may find it more

comfortable to sleep in a sitting or semireclined position

A pillow can be placed across the chest to support the injured side when sleeping on the side

Hygiene

improve safety The arm can hang

gently at the patient's side while

showering Axillary hygiene is

important If assistance is not available, a long-handled sponge can be used to wash the back and legs

2 Phase 2: Beginning of week 4 to end of week 6 after injury (early repair phase)

Phase 2 principle: continued protection of the injured (operated) limb with the promotion of directed tissue repair

Phase 2 aim: established healing of injured tissues with antigravity strength

External support - full time weaning to part-time or no support

Simple sling and abduction brace are used at night and for all activities when gravity is applied, both indoors and outdoors

Pillows may support the limb while seated at rest or when performing exercises

Mobilization for general indications

Phase 1 exercises are continued

Mobilization of ipsilateral limb kinetic chain with active motion of clavicle-scapula

All the exercises from Phase 1 can be continued

Actively assisted elevation to shoulder level can be introduced

Note: Avoid hand behind back and extreme across body adduction at this stage This avoids adverse rotation of the clavicle and scapula

Activities of daily living

All activities permitted in phase 1 are continued Activities for domestic purposes at the tabletop level are encouraged (eg short lever arm reaching and food preparation)

Radiographic control

Radiographic evidence of fracture union is expected at this time Confirmation of union with a concurrent reduction in symptoms permits progression to phase 3

3 Phase 3: Beginning of week 7 to end of week 12 after injury (late repair and early tissue remodeling phase)

Phase 3 principle: reestablishment of proprioception in the limb

Phase 3 aim: encourage normal tissue structure and reinnervation through daily

activities without secondary injury

External support – weaning from full time

to no support

A sling may be preferred for support at night and outdoor activities

Mobilization for general indications

Phase 2 exercises are continued

Mobilization of ipsilateral limb kinetic chain with motion of the clavicle-scapula

All the exercises from Phase 1 can be continued

Actively assisted elevation above shoulder level can be introduced

Note: Hand behind the back and across body adduction is permitted at this stage This facilitates rotation of the clavicle and scapula

Isometric and isokinetic strengthening of the rotator cuff, deltoid, and periscapular muscles are permitted

A "shoulder therapy set" might be helpful Typically included devices are:

An exercise bar lets the patient use the uninjured left shoulder to passively move the affected right side

Rope and pulley assembly With the pulley placed above the patient, the unaffected left arm can be used to provide full passive forward flexion of the injured right

shoulder

As passive motion improves and active assisted exercises progress satisfactorily and the fracture becomes fully consolidated, one can begin strengthening The first one strengthens by active motion against gravity To increase muscle strength, one must increase the resistance against which the muscles work Endurance training follows Elastic devices (therabands) are helpful in providing varying degrees of resistance Ultimately the athletic patient can progress to resistance machines and free weights

Activities of daily living

All activities permitted in phase 2 are continued with the addition of social activities, active elevation, and abduction of the injured limb as comfort permits

Radiographic control

Radiographic evidence of fracture consolidation is expected at this time Confirmation

of consolidation without adverse features (eg displacement, fixation failure, or

heterotopic bone) in the absence of symptoms permits progression to phase 4

4 Phase 4: Beginning of week 13 after injury (remodeling and reintegration phase)

Phase 4 principle: normalization of the proprioceptive function with optimal

biomechanics

Phase 4 aim: to establish normal tissue structure and reinnervation through training and practice for optimal endurance

Mobilization of ipsilateral limb kinetic chain with no limits of movement

Sport or occupational work hardening exercises are introduced under supervision

Activities of daily living

All activities, including sport and occupational activities requiring resisted elevation and abduction, is encouraged

ORIF - Bridge plate

Skill level

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Equipment

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Main indications

Shortening and displacement > 2 cm

Supporting indications

 Associated pathology of the shoulder girdle, scapula fractures or LSSS (floating shoulder)

 Added stability needed due to repaired lesions to neurovascular structures

Advantages

 Less stripping of soft tissues necessary, especially for the wedge fragments

 Less pain and quick recovery of function (early return to work)

Disadvantages

 General surgical risk

 Risk of compromising subclavicular neurovascular structures

 Prominent hardware necessitating hardware removal

 Potentially poor cosmetic outcome (scar)

Contraindications

 Infection

 Metal allergy

ORIF - Bridge plate

Diaphyseal multifragmentary, fragmentary segmental clavicle fracture

1 Introduction

Bridge plating

Bridge plating (or biological plating) is a technique to achieve relative stability by splinting This allows for indirect healing with preservation of blood supply and soft tissue attachments while bridging the fracture zone maintaining the correct length, rotation and alignment Anatomical reduction of each fracture fragment is not

necessary

Plate alternatives

A precontoured plate is useful in situations when normal anatomical landmarks are distorted or there is significant bone fragmentation We will here show the procedure with a precontoured clavicular plate which has both a bend and a twist built into it

However, if a precontoured clavicular plate

is not available, there are other options

A straight plate may be used if it fits the clavicle (conventional or angle stable) If it does not, then it needs to be contoured This is best achieved with a slight twist at the midportion of the plate This results in the lateral plate being applied superiorly and the medial portion anteriosuperiorly A reconstruction plate which is easier contour may

be used in smaller patients where the forces working on the plate are not as great

When the fracture location is more lateral or more medial, the bone quality near the metaphysis may not offer sufficient screw purchase In these instances, a plate offering additional screw fixation may be required (eg, longer plate, periarticular plate, locking head screws)

Plate length

The goal when choosing the plate length is to reduce the concentration of bending forces This typically requires a longer plate Care must be taken not to insert a screw

in each hole of the plate or rigidly fix fracture gaps

2 Patient preparation and approach Patient preparation

This procedure is normally performed with the patient either in a beach chair or a supine

Approach

For this procedure an anterior approach is normally used

3 Reduction and fixation Reduction

Fracture fragments should not be devitalized or stripped from their soft tissue attachments

Achieve reduction by indirect means where possible

The aim is to restore normal alignment and rotation as well as length At times some sacrifice of length may be acceptable in order to improve bone contact and avoid excessive gapping

Plate application

The plate can often assist as a reduction tool to restore the length and rotation

A properly contoured plate is usually fixed first

to the medial side as medial side malalignment

is less well tolerated The lateral fragment is then reduced by manipulation involving traction and rotation and is aligned

anatomically with the lateral side of the plate

The superior surface of the lateral fragment is flat and readily identified Reduction of the plate to the superior flat surface of the lateral segment will often restore the correct rotation

A push-pull device is often helpful in obtaining the appropriate clavicular length when manual distraction is unsuccessful

Once the fracture alignment, length, and rotation are satisfactory, the remaining screws can be inserted

4 Aftercare

The aftercare can be divided into 4 phases:

1 Inflammatory phase (week 1–3)

2 Early repair phase (week 4–6)

3 Late repair and early tissue remodeling phase (week 7–12)

4 Remodeling and reintegration phase (week 13 onwards)

MIO - Bridge plate

Skill level

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Equipment

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Main indications

Shortening and displacement > 2 cm

Supporting indications

 Associated pathology of the shoulder girdle, scapula fractures or LSSS (floating shoulder)

 Added stability needed due to repaired lesions to neurovascular structures

Advantages

 Less stripping of soft tissues necessary, especially for the wedge fragments

 Less pain and quick recovery of function (early return to work)

 Minimally invasive (smaller scar)

Disadvantages

 General surgical risk

 Risk of compromising subclavicular neurovascular structures

 Prominent hardware necessitating hardware removal

 Difficult surgical technique

 Potentially higher of lesion of the neurovascular structures

Contraindications

 Infection

 Metal allergy