Distal fracture clavicle and acromioclavicular dislocation: a case report and review the literature

Acromioclavicular dislocations and clavicle fractures are extremely common injuries. However, complete acromioclavicular dislocation combined with an adjacent clavicle fracture is very rare. Its recognition depends on a thorough assessment of the patient, including high-quality radiographs of the clavicle and acromioclavicular joint. This report describes an unusual injury: an acromioclavicular dislocation type III with a distal clavicle fracture type I in the same arm. The patient was treated conservatively with an immobilization for 6?weeks. After 9?months of follow-up, the patient had a pain-free shoulder with full range of motion.     

Floating clavicle after a high velocity biking accident: A case report of an acromioclavicular dislocation with simultaneous proximal clavicle fracture managed surgically

IntroductionClavicle fractures and acromioclavicular joint dislocations are very common injuries. However, the combination of both, known as “floating clavicle” is extremely rare, with approximately 40 cases reported.Presentation of caseWe report a case of a healthy 51-year-old male who suffered a high-velocity biking accident, with a bipolar clavicle injury (type IV acromioclavicular joint dislocation and proximal clavicle fracture), with concomitant rib fractures and pulmonary contusion. He received early surgical treatment by open reduction and osteosynthesis of the proximal clavicle (distal ulna plate, Protean®) and open reduction and stabilization with a MINAR® implant for the acromioclavicular joint. After an initial one-month immobilization, he started physical therapy. In the 10-month follow-up he presented with a pain-free full range of motion, a good cosmetic result, and radiological consolidation.DiscussionBipolar clavicle injury is a rare clinical entity that encompasses a spectrum of combined clavicle fractures, acromioclavicular or sternoclavicular joint dislocations. They are sustained in a high-energy context, and accompanying injuries must be sought. Diagnosis is made through X-Ray and CT. Despite the lack of clinical guidelines, most authors agree on surgical management of at least one of the injuries, with multiple surgical techniques available. There is an emphasis in surgical treatment of the young and active patient. Conservative treatment is associated with poorer results.ConclusionIt is advisable to have a high index of suspicion for floating clavicle in a high-energy trauma patient, given possible life-threatening injuries, and long-term shoulder sequelae. Surgery should be considered in a young and active patient.     

锁骨中段骨折合并同侧肩锁关节脱位：诊断要点分析研究

目的探讨锁骨中段骨折合并同侧肩锁关节脱位的诊断要点,为临床早期诊断该类损伤提供参考。 方法通过分析国内外文献报道的病例,并回顾性分析本科室随访病例,从年龄、性别、受伤原因、锁骨中段骨折及肩锁关节脱位分型等方面进行分析。 结果共检索到19篇锁骨中段骨折伴同侧肩锁关节脱位的英文病例报道、7篇中文文献病例报道,其中有清晰术前X线片的病例共22例。同时,回顾性分析了本院临床随访的2例该类病例,因此,最终有24例病例纳入分析研究。其中,男16例、女8例;最小年龄为19岁,最大年龄为65岁,平均年龄为37岁。大部分由高能量损伤所致（21/24, 87.5%）。锁骨骨折类型分型：19例（19/24,79.2%）属于A型骨折,5例（5/24,20.8%）属于B型骨折;肩锁关节脱位分型：IV型12例（50.0%）、III型6例（25.0%）,VI型4例（16.7%）,V型2例（8.3%）;9例（9/24,37.5%）患者有合并损伤。 结论对于高能量损伤导致的相对简单类型的锁骨中段骨折,需高度怀疑有无同侧肩锁关节脱位,诊断要点如下：（1）详细询问受伤原因,了解受伤机制;（2）对所有锁骨中段骨折病例,需观察肩锁关节处有无肿胀、皮下青紫,并对肩锁关节及喙突处进行压痛体格检查,如有压痛,则高度怀疑肩锁关节损伤;（3）需仔细观察术前X线肩锁间隙及喙锁间隙变化,如锁骨中段骨折为相对简单类型,且为高能量损伤者,需高度怀疑,建议加拍对照位片及患侧肩关节CT检查;（4）术中锁骨中段骨折固定后,常规透视同侧肩锁关节。     

浮肩损伤的手术治疗

目的 探讨手术治疗浮肩损伤的方法和疗效.方法 2001年1月-2007年12月收治24例浮肩损伤患者.按黄长明等的分类:A型(同侧肩胛颈骨折+锁骨干骨折)14例;B型(同侧肩胛颈骨折+锁骨外侧端骨折)6例;C型(同侧肩胛颈骨折+肩锁关节脱位)4例.均行手术治疗,其中锁骨或肩锁关节固定7例,锁骨或肩锁关节和肩胛颈部固定17例.并对手术前后孟极角(GPA)进行测量.结果 术前GPA≥30°5例,GPA 20°～29°8例,GPA＜20°11例.术后GPA≥30°19例;GPA20°～29°5例,均为单纯固定锁骨者;术后GPA较术前有明显改善.随访时间为3个月至4年,平均16个月;骨折愈合时间为11～27周,平均15周.肩关节功能采用Hardegger功能评定标准评定:优13例,良9例,可2例.结论 浮肩损伤为肩关节悬吊复合体结构的严重损伤,积极切开复位内固定为早期功能锻炼提供基础,有利于肩关节功能的恢复.     

改良双Endobutton技术治疗肩锁关节脱位和锁骨远端不稳定性骨折的肩关节功能评定

目的对经典的双Endobutton技术进行改良,治疗锁骨远端不稳定性骨折和Rock—woodⅢ型以上的肩锁关节脱位,探索新术式的疗效。方法2010年3月至2011年1月就诊的18例锁骨远端不稳定性骨折和Ⅲ型以上的肩锁关节脱位的患者,予以改良的双Endobutton技术重建喙锁韧带,术后予以Constant—Murley评分。结果术后随访4～10个月,本组14例疗效为优,4例为良,优良率为100％。未发生并发症。结论改良的双Endobutton技术重构锁骨远端的生物稳定性,术式简单易行,手术时间短,疗效满意。     

锁骨钩钢板内固定术后肩部疼痛和外展受限的分析

目的探讨采用锁骨钩钢板内固定治疗锁骨远端骨折和肩锁关节脱位术后并发肩部疼痛和肩关节外展受限的原因。方法将60例锁骨远端骨折和肩锁关节脱位患者随机分为A、B两组。锁骨钩钢板外侧钩的安置采用两种不同方式：A组（30例）患者术中仅显露锁骨骨折断端及肩锁关节,不显露肩峰,锁骨钩钢板外侧钩于肩锁关节后方盲插入肩峰下进行固定;B组（30例）患者同时显露肩峰,将锁骨钩钢板外侧钩紧贴肩峰于骨膜下插入进行固定,以减少钢板钩部与肩峰之间软组织嵌入。对两组术后出现患侧肩关节疼痛不适及外展受限发生率进行组间对比分析。结果 55例患者获得12-24个月随访,5例失访。肩关节疼痛及外展轻度受限B组28例中出现3例,发生率为10.7%;A组27例中出现9例,发生率为33.3%,两组比较差异有统计学意义（P〈0.05）。结论术中充分显露肩峰,紧贴肩峰插入锁骨钩钢板外侧钩,使外侧钩部与肩峰紧密贴合,可减少其间软组织嵌入和肩峰与钢板钩部撞击,从而减少术后肩关节疼痛及外展受限等并发症的发生率。     

浮肩损伤

目的探讨浮肩损伤（floating shoulder injuries,FSI）的临床特征及治疗方法.方法回顾分析1999年6月至2005年6月收治的36例FSI的临床资料,其中肩胛颈骨折合并同侧锁骨骨折31例、肩锁关节脱位5例.患者均有不同程度的合并损伤,其中肋骨骨折、血气胸和（或）肺挫伤占88.9%.伤后至手术时间为3～43 d,平均9.6 d.术中首先复位固定锁骨骨折或肩锁关节脱位,然后采用改良Judet后方入路处理肩胛颈骨折.肩胛颈骨折合并锁骨骨折或肩锁关节脱位行一期内固定33例,术中仅固定锁骨骨折3例.结果术后随访6～69个月,平均19.7个月.肩胛颈骨折在目标区上均获解剖复位.根据Constant和Murley的疗效标准,术后肩关节功能评分为9～100分,平均81.3分,中位数为93%.按照Herscovici的疗效标准,优25例（69.4%）,良6例（16.7%）,可4例（11.1%）,差1例（2.8%）,疗效优良率为86.1%.术后复发血气胸1例,肩关节外展受限、肩峰下间隙疼痛3例,迟发性肩胛上神经损伤1例,肩关节不稳定继发创伤性关节炎1例.结论FSI使肩胛颈的解剖结构及其上方悬吊装置受到双重破坏,非手术治疗难以纠正不稳定型FSI的三维移位,早期切开复位内固定可取得满意疗效.     

Treatment of an open infected type IIB distal clavicle fracture: case report and review of the literature

Clavicle fractures are common skeletal injuries that are typically managed nonoperatively, which results in a high rate of fracture union with few or no long-term sequelae. Type II distal clavicle fractures are an exception, with reported rates of nonunion ranging from 22% to 44%. This high rate of nonunion has led to controversy regarding the appropriate treatment of type II injuries. The following case report describes a type IIB distal clavicle fracture, in which nonoperative management was complicated by the breakdown of skin over the fracture site and the subsequent development of infection. This is a rare complication of conservative management. Thorough operative debridement, fracture stabilization via external fixation, and identification of the causative organism allowed for successful outcome in the management of this complex presentation.     

锁骨钩钢板治疗肩锁关节脱位和锁骨远端骨折

目的探讨锁骨钩钢板（CHP）治疗TossyⅢ型肩锁关节脱位和NeerⅡ型锁骨远端骨折的临床效果。方法应用锁骨钩钢板治疗肩锁关节脱位50例和锁骨远端骨折42例。结果88例获得随访,时间6～36（23．2±7．1）个月,复查X线片见骨折、脱位均复位满意。42例锁骨远端骨折均获得骨性愈合,时间6～18周,内固定物断裂3例,但骨折均愈合良好。46例肩锁关节脱位者中有36例取出CHP,1例术后4d再次受伤出现钢板近侧锁骨骨折,更换较长CHP固定后治愈,9例尚未取出CHP,但均无再脱位。按Karlsson疗效评定标准：优43．2％（38／88）,良50．0％（44／88）,差6．8％（6／88）,优良率达93．2％（82／88）。结论锁骨钩钢板设计合理,符合肩锁关节的解剖生理特点,具有固定确切和可早期功能锻炼的优点,是治疗TossyⅢ型肩锁关节脱位及NeerⅡ型锁骨远端骨折的较好选择。     

AC-Gelenkverletzungen

There is still controversy about the treatment for dislocation of the acromioclavicular joint classed as acute type III according to Tossy and Rockwood's classification.Good functional results have been reported following operative and also after nonoperative treatment. According to the literature the functional outcome is similar.Following surgical repair,however, complications are more frequent and the period of rehabilitation is longer.One complication found more frequently after nonoperative treatment is persisting prominence of the distal clavicle. According to the criteria of evidence based medicine,nonoperative treatment seems to be the method of choice for type III injuries of the acromioclavicular joint.     

浮肩损伤的分类与治疗

目的 :探讨浮肩损伤的分类与治疗。方法 :回顾性分析自 1995年 5月～ 2 0 0 3年 2月共收治的 14例浮肩损伤病例 ,将浮肩损伤分为 3型。A型 :同侧肩胛颈骨折 锁骨干骨折 ;B型 :同侧肩胛颈骨折 锁骨外侧端骨折 ;C型 :同侧肩胛颈骨折 肩锁关节脱位。本组A型 9例 ,B型 3例 ,C型 2例。本组非手术治疗 6例。手术治疗 8例 ,其中A型损伤 4例 ,B型损伤 3例 ,C型损伤 1例。均只手术固定锁骨或肩锁关节。采用AO重建钢板 3例 ,AO锁骨钩钢板 3例 ,克氏针 2例。结果 :14例均得到随访 ,时间 6～ 3 6个月 ,平均 18个月 ,肩关节功能根据Herscovici标准进行评定。本组非手术 6例 ,优 1例 ,良 5例。手术 8例 ,优 3例 ,良 4例 ,可 1例。结论 :对于浮肩损伤进行分类 ,有利于浮肩损伤的诊断和选择治疗方法 ,手术中仅牢固固定锁骨可达到肩关节上部悬吊复合体稳定。     

Special status of lateral clavicular fracture]

Fractures of the lateral clavicle have different biomechanical conditions compared with fractures of the medial and central third; they therefore demand different therapy. Some 237 patients with fractures of the clavicle were followed, of which 75 (33%) were located in the lateral third of the clavicle. At the 5-year follow-up after exclusively conservative treatment, good results were found for Neer types I and III and 3 J?ger/Breitner type IIb fractures, while 4 out of 13 J?ger/Breitner type II a fractures ended in pseudarthroses (31%). Conservative treatment is recommended for Neer types I and III, as well as for the more stable J?ger/Breitner type II b and old II a fractures. Therefore, a new bandage is presented. It prevents the posterior and upward dislocation of the proximal fragment by vertical compression and rotation of the distal fragment by fixation of the arm. Open reduction and internal fixation by preferably extraarticular implants is recommended for unstable and dislocated J?ger/Breitner type II a fractures. For fractures of the lateral clavicle, good results can be achieved when the instability is recognized and adequately treated.     

Schultergürtelverletzung im Kindesalter

The fracture of the clavicle is a very frequent injury to children and young adults. Using a figure-of-eight bandage for treatment leads to good functional result and acceptable cosmetical appearance. Indications for an open reduction are rare: they are confined to brachial plexus lesions, injuries to the subclavian vessels, open fractures or fractures of the outer third of the clavicle combined with an acromioclavicular separation. Fractures of the scapula merely require immobilization and subsequent physiotherapy to yield satisfactory results. Distorsions and subluxations of the joints of the clavicle are to be managed conservatively, too. Only in cases of complete ruptures of the acromioclavicular, coracoclavicular or sternoclavicular ligaments, it is necessary to perform an open reduction and repair of the ligaments.     

AC Joint Injuries

There is still controversy about the treatment for acute type III acromioclavicular joint dislocation according to Tossy and Rockwood's classification. Good functional results were reported on following operative and non-operative treatment. According to the literature the functional outcome is similar. Following surgical repair, however, complications occur more often and the period of rehabilitation is longer. The disadvantages of non-operative treatment include a higher rate of a persisting prominence of the distal clavicle. Currently available data in the literature indicate that based on the criteria of evidence based medicine non-operative treatment seems to represent the method of choice for type III injuries of the acromioclavicular joint.     

关节镜辅助下三束重建治疗急性Rockwood Ⅲ型肩锁关节脱位

目的探讨关节镜辅助下三束重建治疗急性Rockwood Ⅲ型肩锁关节脱位的临床疗效。 方法回顾性分析上海交通大学医学院附属新华医院骨科采用关节镜辅助下三束重建治疗21例急性Rockwood Ⅲ型肩锁关节脱位患者的资料,均为闭合性损伤。术后3、6、12个月对所有患者进行术后临床效果和影像学评价。根据术后影像学资料评估复位再丢失情况,采用Constant评分和上肢功能（disabilities of arm,shoulder and hand,DASH）评分评估患者肩关节功能。探讨术中关节镜辅助治疗的意义和价值。 结果术中关节镜探查发现4例合并软组织损伤,并进行一期镜下修复。所有患者术后均未发生喙突骨折和襻断裂。影像学评估提示术后6~12个月有6例患者（28.6%）出现轻度复位丢失,但与Constant评分和DASH评分无显著相关性,没有患者要求取出内固定。 结论关节镜辅助下三束重建治疗急性Rockwood Ⅲ型肩锁关节脱位是一种创伤小、安全、临床效果确切的手术方法。急性肩锁关节脱位通常由高能量损伤造成,在手术中关节镜探查肩关节能发现合并的软组织损伤,并进行一期修复,有利于肩关节功能的恢复,避免二次手术。     

Current concepts in the diagnosis and management of acromioclavicular dislocations

Not all complete dislocations of the acromioclavicular joint should be treated by one method alone. A classification of acromioclavicular dislocation is presented and is based upon the pathology of the injury. Grade I sprain results from a mild force that causes tearing of only a few fibers of the acromioclavicular joint. Grade II sprains are caused by a moderate force with a rupture of the capsule and acromioclavicular ligament. Grade III sprains result from a severe force that ruptures both the acromioclavicular and coracoclavicular ligaments and causes a dislocation of the joint. Grade IV dislocation may be associated with an avulsion fracture of the coracoclavicular ligament from the inferior lateral clavicle, severe tearing or other injury to the soft-tissue envelope about the lateral clavicle, or a buttonhole injury of the lateral clavicle. Grade V dislocation refers to a posterior displacement of the lateral clavicle from any cause, while Grade VI relates to an inferior lateral clavicle displacement. Grades I, II, and most Grade III injuries can be treated conservatively. The indications for open treatment of Grade III injuries are reviewed. It is recommended that Grade IV and most Grade V and VI dislocations be managed with open methods.     

Management of midshaft clavicle fractures in adults

Fractures of the clavicle are common injuries. The usual mechanism of clavicle fracture is a direct fall on the shoulder. There are 3 types of clavicle fractures, but type II or midshaft fractures make up the vast majority. Most clavicle fractures can be effectively treated nonoperatively. Rates of nonunion and poor functional outcome, however, may be higher than previously thought. Risk factors for nonunion include initial fracture displacement, comminution, shortening, and older age. The 2 main methods of operative management are plate-and-screws and intramedullary fixation. Study results for both methods have been good. Indications for operative management, however, remain controversial.     

Treatment of distal clavicle fracture using Kirschner wires and tension-band wires

BACKGROUND: Nonunion frequently follows distal clavicle fracture. Traditional pinning methods using the through acromioclavicular articulation may result in osteoarthritic changes or ankylosis. This study introduces a direct pinning technique in which the acromioclavicular joint is spared. METHODS: Twelve patients with displaced distal clavicle fractures received open reduction and fixation with Kirschner wires (K-wires) and tension-band wires, from May 1996 to March 1997. The indication for surgery was type IIa fracture or fracture with displacement. Unrestricted passive and active range of motion was performed as soon as possible after the operation. Stretching and exertional exercises were permitted after radiographs showed an osseous union and after the implants were removed. RESULTS: Eleven patients achieved osseous union with painless full motion. Union time ranged from 3 to 6 months. One patient suffered from more comminuted fracture because of a fall 2 months after operation. This patient received a revision surgery with distal clavicle resection and coracoclavicle reconstruction. Symptomless ossification around the coracoclavicle ligament was noted on radiographs in one patient. The ossification did not progress after the 9-month follow-up. CONCLUSION: Edwards reported a rate of 45% delayed union and 30% nonunion in type II fractures. Several techniques had been described in the relevant literature. In our practice, fixation with Kirschner wires and tension-band wires has been successful in the treatment for displaced distal clavicle fracture.     

Atraumatic osteolysis of the distal clavicle: histologic evidence of synovial pathogenesis. A case report

Osteolysis of the distal clavicle was diagnosed in a young male athlete following many years as a baseball pitcher with a supplementary weightlifting program. There was no history of ligamentous injuries, contusions, fractures or separation of the acromioclavicular joint. As such, this case was categorized as "atraumatic" osteolysis. Non-decalcified histologic sections from the resected clavicle suggest that the pathogenesis of this atraumatic osteolysis arose from the synovium.