All Things Clavicle: From Acromioclavicular to Sternoclavicular and All Points in Between.

The clavicle is the most frequently injured bone in the human body. In most cases, fractures that occur in the midshaft of the clavicle can be managed nonsurgically. An increasing number of studies suggest that displaced midshaft clavicle fractures have improved outcomes after surgical management, and equivalent outcomes can be achieved with both plating and intramedullary techniques. Distal clavicle fractures are managed according to the disruption of the coracoclavicular ligaments. Fractures with disruption of the ligaments usually will require fixation, whereas fractures with intact ligaments may be treated with closed management. Multiple techniques of reconstruction appear to yield similar outcomes; however, hook-plating techniques result in the highest complication rates. The evaluation process for acromioclavicular joint injuries is moving from a static two-dimensional evaluation to a three-dimensional evaluation that involves an assessment for scapular dyskinesis. Surgical reconstruction is indicated for patients who exhibit scapular dyskinesis. Anterior sternoclavicular injuries can typically be managed nonsurgically, whereas posterior sternoclavicular dislocations always require urgent surgical management. Newer techniques of ligament reconstruction for sternoclavicular injuries yield improved biomechanical stability.

A Novel Intramedullary Locked Fixation Device for Treatment of Clavicle Shaft Fractures.

INTRODUCTION: An intramedullary nail (the Sonoma CRx) with a unique flexible anatomical design and locking system is a viable alternative for treatment of displaced and shortened clavicle shaft fractures. STEP 1 POSITIONING: Place the patient in the beach-chair position and drape the arm free so that you can obtain an exaggerated anteroposterior and an axial fluoroscopic view of the clavicle by manipulating the position of the arm. STEP 2 SKIN INCISION: The surgical technique necessitates opening the fracture site in order to implant the device. STEP 3 PREPARING THE MEDIAL FRAGMENT: The preparation of the medial fragment is of utmost importance as the intramedullary Sonoma CRx nail should be placed as far as possible into the medial fragment of the clavicle, to provide the highest level of stability and the lowest risk of device failure. STEP 4 PREPARING THE LATERAL FRAGMENT: Preparation of the lateral fragment is more challenging than preparation of the medial fragment because of its relative immobility and shorter medullary canal. STEP 5 PLACEMENT OF THE INTRAMEDULLARY NAIL: Use the longest possible intramedullary nail that the clavicle can accommodate and insert the nail as far medially as possible into the medullary canal of the clavicle bone. STEP 6 ACTIVATION OF THE LOCKING DEVICE: Lock the device at its medial end with distally deployed grippers and laterally with a locking screw placed through a jig. STEP 7 MANAGEMENT OF COMMINUTED FRACTURE FRAGMENTS: Comminuted fractures are not a contraindication to the use of the intramedullary device as they can be reduced by the nail and secured by using cerclage sutures. STEP 8 POSTOPERATIVE MANAGEMENT: Protect the affected shoulder in a shoulder immobilizer for six weeks. RESULTS: In our original study, forty-seven consecutive patients with a displaced and shortened clavicle shaft fracture were treated with open reduction and internal fixation using the Sonoma CRx device.

Fully uncemented glenoid component in total shoulder arthroplasty.

BACKGROUND: Loosening of the glenoid component remains the most common problem in total shoulder arthroplasty. It has been described that the round-backed, all-polyethylene components with cemented peg fixation perform better biomechanically and clinically than flat-backed, metal-backed, or keeled components. However, side effects of cementing have been described. We hypothesized that cementing of a specific type of all-polyethylene glenoid component with 3 peripheral pegs and 1 central anchor peg is not necessary to obtain good clinical and radiologic results. MATERIALS AND METHODS: Thirty-four shoulders (34 patients), with a mean follow-up of 28.3 months, were evaluated clinically with the Constant-Murley score and the SF-12 Health Survey score. The fixation of the glenoid component was evaluated with computed tomography scan. RESULTS: The Constant-Murley score increased from 40.2 points (range, 13-73 points) preoperatively to 72 points (range, 54-93 points) postoperatively. The SF-12 Physical Component Summary score was 45, and the SF-12 Mental Component Summary score was 50. No signs of loosening were seen around the pegs or glenoid in 30 shoulders. Signs of loosening were seen around the central anchor peg and the peripheral pegs in 4 shoulders. There was no statistical difference between the clinical outcome of patients with and without signs of loosening. CONCLUSION: The clinical and radiologic evaluation of an uncemented all-polyethylene glenoid is promising, with good clinical results and with no signs of loosening in 88% of the patients on computed tomography scans.

The cortical ring sign: a reliable radiographic landmark for percutaneous coracoclavicular fixation.

BACKGROUND: For treatment of acute acromioclavicular separations, we have been using a reproducible radiographic view of the coracoid-the cortical ring sign-that we believe allows for placement of percutaneous coracoclavicular fixation safely and reliably in the center of the coracoid base, while avoiding the coracoid tip. This study evaluates the coracoid anatomy that the cortical ring sign represents, its utility for guiding fixation trajectory, and the proximity of neurovascular structures to this proposed trajectory. MATERIALS AND METHODS: Kirschner wires were used to measure the orientation of the fluoroscopic beam in relation to the scapula and the proposed fixation trajectory using this radiographic view. RESULTS: The cortical ring sign is achieved by first directing the x-ray beam perpendicular to the medial border of the scapula in the parasagittal plane and 49 degrees off the axis of the scapular spine in the axial plane, then fine-tuning until the coracoid cortical ring becomes evident. The nearest neurovascular structures to the fixation trajectory are the suprascapular artery and nerve (< 2 cm). CONCLUSION: The cortical ring sign view targets the coracoid base and, as such, allows reliable, safe, percutaneous fixation in the center of the coracoid base. LEVEL OF EVIDENCE: Basic Science.

Anomalous biceps tendon insertion into the rotator cable: a case report.

An anomalous origin of the long head of the biceps tendon (LHBT) from the rotator cable has not been described in the orthopaedic surgery literature. This case report describes the intraoperative findings of this aberrant origin, found incidentally during diagnostic arthroscopy. The concept of the rotator cable and crescent is discussed, and a literature review of aberrant anatomy of the LHBT origin is included.

Incidence of major tendon ruptures and anterior cruciate ligament tears in US Army soldiers.

BACKGROUND: Although a rare event, the prevalence of major tendon rupture has increased in recent decades. Identification of risk factors is important for prevention purposes. HYPOTHESIS: Race is a risk factor for major tendon ruptures. STUDY DESIGN: Cohort study (prevalence); Level of evidence, 2. METHODS: All patients admitted for surgical management of a rupture of a major tendon at Womack Army Medical Center, Fort Bragg, North Carolina, in 1995 and 1996 were identified and evaluated for risk factors. RESULTS: The authors identified 52 major tendon ruptures: 29 Achilles, 12 patellar, 7 pectoralis major, and 4 quadriceps tendon ruptures. All patients were active-duty soldiers, and 1 was a female soldier. Forty-one tendon ruptures occurred among black soldiers, 8 occurred among white soldiers, and 3 occurred among Latino soldiers. The population at risk included 93,224 exposures during the 2-year period, of which 67.1% were white, 24.5% were black, and 8.4% were self-classified as other race. The rate ratio for tendon rupture, adjusted for gender and age, was 13.3 (95% confidence interval, 6.2-28.5) between blacks and whites and 2.9 (95% confidence interval, 0.8-10.9) between Latinos and whites. CONCLUSION: The rate of major tendon rupture was 13 times greater for black men in this study population when compared with whites. Interventions among those at a higher risk for injury should be considered.

The arthritic, cuff-deficient shoulder--when is hemiarthroplasty enough?

This article outlines the role of hemiarthroplasty in the treatment of cuff-tear arthropathy. Rotator cuff tear arthropathy, kinematics, and classification are reviewed.

The association of suprascapular neuropathy with massive rotator cuff tears: a preliminary report.

We studied a prospective, consecutive series of 8 patients presenting with massive rotator cuff tears (>5 cm. in maximum dimension), all associated with severe retraction and fatty infiltration of the supraspinatus muscle on magnetic resonance imaging studies. All 8 patients had suprascapular neuropathy shown by electromyography (EMG) findings of denervation in the supraspinatus and/or infraspinatus muscles. Clinically, all patients had severe limitation of active motion, with no patient able to elevate their affected arm actively >40 degrees . Four patients elected débridement and partial surgical repair using margin convergence principles via a mini-open approach. Follow-up of these patients averaged 24 months. All 4 patients regained the ability to elevate their affected arm to >90 degrees , and to place their hand actively behind their head without assistance. Two of the 4 surgical patients consented to follow-up EMG studies that demonstrated, in both cases, that the suprascapular nerve had significant renervation potentials, with almost complete recovery of the nerve in 1 case. We conclude that suprascapular neuropathy may be associated with massive rotator cuff tears, and that partial rotator cuff repair may allow recovery of the nerve and improvement of function.

Muscle transfers involving the shoulder.

Muscle transfer provides a viable treatment option for several difficult problems involving the shoulder. Muscle transfer is often the only alternative to a salvage procedure such as shoulder fusion, and whereas salvage procedures provide pain relief at the cost of function, muscle transfer can provide pain relief while retaining acceptable function. The five most commonly encountered shoulder problems for which muscle transfer can be utilized are subscapularis rupture, irreparable rotator cuff tear, deltoid injury and dysfunction, trapezial paralysis, and serratus anterior scapular winging. Although numerous muscle transfer procedures have been described, the following procedures have proven the most reliable and are the focus of this article: 1) transfer of the pectoralis major for subscapularis rupture, 2) transfer of the latissimus dorsi for irreparable rotator cuff tears, 3) latissimus dorsi transfer for deltoid injury or dysfunction, 4) modified Eden-Lange procedure for trapezial paralysis, and 5) modified Marmor-Bechtol pectoralis major transfer for serratus anterior scapular winging.

Pullout forces of sutures in muscle lacerations.

The purpose of this study was to determine if complex suture techniques had higher pullout forces from muscle tissue than conventional stitching. Using transected cadaver muscle bellies, we performed repairs with various suture techniques and measured pullout forces. Epimyseal repair with conventional stitches (Kessler, figure eight, horizontal mattress) was inferior to complex stitches (modified Mason-Allen, perimeter). The combined complex stitches (perimeter and Mason-Allen) were strongest. Conventional stitches failed longitudinally through the muscle, whereas complex stitches failed transversely across the muscle. The complex combination of perimeter and Mason-Allen stitches had superior pullout resistance compared to conventional stitches.

The drop sign, a radiographic warning sign of elbow instability.

Persistent instability or redislocation is uncommon but of significant concern in treating elbow dislocations. Finding an objective, static radiographic sign that might correlate with the presence of instability was the purpose of this study. Pre- and post-reduction radiographs of 10 consecutive simple and complete adult elbow dislocations were reviewed and compared with radiographs of 20 consecutive adult elbows without any trauma history. A statistically significant measured increase in static ulnohumeral distance was noted on the routine unstressed post-reduction lateral radiographs of patients sustaining dislocation. We have termed this increased distance the drop sign. It differs from the radiographic ulnohumeral separation noted during O'Driscoll's test for posterolateral rotary instability, which is present only with axial compression. The drop sign becomes concerning only if persistent after the first reduction radiograph and may be a warning sign of the presence of instability.

Magnetic resonance imaging of the coracoclavicular ligaments: its role in defining pathoanatomy at the acromioclavicular joint.

Four patients with acromioclavicular joint injuries (one type II, two type III, one type V), two patients without acromioclavicular joint injury, and a fresh-frozen cadaver underwent magnetic resonance imaging (MRI) and plain radiographs. The normal conoid and trapezoid ligaments were easily identified in the cadaver and the two uninjured patients. Magnetic resonance imaging revealed disruption of both coraclavicular ligaments in the three patients with type II and type III injuries. However, the patient with the type V injury had disruption of the trapezoid ligament alone. Thus, the grade of injury, as determined by the change in the coracoclavicular interval onplain radiography and defined by the Rockwood classification system, failed to correlate with the pathoanatomy seen on MRI in two of the four injured patients. These findings suggest that improvements in the classification of these injuries may be necessary.

Primary coracoid impingement syndrome.

We measured treatment responses for patients with primary coracoid impingement syndrome to determine whether coracoplasty provided pain relief and improved function. Eleven patients (12 shoulders) were included in the primary group, and secondary cases were excluded. Symptoms included burning pain occurring at the site of the coracoid process aggravated by exercise (push-ups). Magnetic resonance imaging and computed tomography showed a narrow coracohumeral interval. Surgical findings confirmed the diagnosis. Follow-up averaged 2.7 years. After follow-up, coracoplasty responses showed significant relief of pain (P < 0.0001) and improved function (P = 0.006). Treatment responses were good in primary cases, as indicated by pain and function scores.

An anatomic study of the effects on the suprascapular nerve due to retraction of the supraspinatus muscle after a rotator cuff tear.

The purpose of this anatomic study was to assess the risk to the suprascapular nerve by measuring the tension on the nerve and the angle between the nerve and its motor branch at the scapular notch with medial supraspinatus tendon retraction. Twelve shoulders in six cadavers were dissected to evaluate the branching point of the first motor branch of the suprascapular nerve, the change in angle between the nerve and its first motor branch at the scapular notch with retraction of the supraspinatus tendon, and the resulting tension on the nerve. The first motor branch originated at the notch in 9 cadavers, just proximal in 1, and just distal in 2. With the supraspinatus muscle in its anatomic position, the suprascapular nerve and its first motor branch angle measured 142.6 degrees at the scapular notch. After retraction of the supraspinatus, the angle markedly decreased to 98.7 degrees and 34.6 degrees with 1 cm and 5 cm of medial retraction, respectively. The motor branch was taut in all specimens at 2 to 3 cm of retraction. Medial retraction of the supraspinatus tendon drastically changes the course of the suprascapular nerve through the scapular notch, creating increased tension on the nerve. The degree of rotator cuff muscle atrophy frequently observed after a massive tear may be explained by increased tension on the nerve due to muscle retraction.

Relationship of the axillary nerve to the proximal screws of a flexible humeral nail system: an anatomic study.

OBJECTIVE: To investigate the risk of axillary nerve injury during placement of the proximal interlock and tension screws of the Synthes Titanium Flexible Humeral Nail System (Synthes, Paoli, PA). DESIGN: Cadaver study. MAIN OUTCOME MEASURE: Anatomic relationships. METHODS: A titanium flexible humeral nail was inserted in an antegrade manner in 10 fresh-frozen cadaver shoulders. Proximal interlock and tension screws were inserted. The axillary nerve was carefully exposed, and the distance from the center of the nerve to each screw was measured. RESULTS: In 8 of 10 specimens, the nerve traversed the interval between the proximal interlock screw and the tension screw. The average distance from the axillary nerve to the closer of the two proximal screws was 2.6 mm. The proximal interlock screw transected the axillary nerve in one specimen. CONCLUSIONS: There is significant risk to the axillary nerve when inserting the proximal interlock screw and the tension screw of this flexible humeral nail system. We recommend blunt dissection through the deltoid, direct visualization of the lateral humeral cortex, and use of a soft tissue protection sleeve when predrilling and placing these screws.

Surgical repair of acute traumatic closed transection of the biceps brachii.

BACKGROUND: Effective techniques to repair transected muscles are not well described. We determined the outcome of surgically repaired closed transections of the biceps muscle with regard to strength, appearance, and patient satisfaction. METHODS: We conducted a study on surgical repair of acute traumatic closed transection of the muscle belly of the biceps brachii in paratroopers. Muscle fibers and epimysium were sutured with use of running interlocked stitches as well as modified Mason-Allen stitches. We gathered data on the supination torque, appearance of the arm, and patient satisfaction. Nine patients underwent surgical repair and were followed for a mean of 2.2 years. Three patients, who constituted a comparative group, had nonoperative treatment of complete transections of the biceps and were followed for a mean of eleven years. RESULTS: We found that the patients who had surgical repair had better results than did those who had nonoperative treatment, with respect to supination torque (a mean of 11.0 N-m compared with 5.8 N-m, p = 0.0005), appearance (a mean of 4.6 cm compared with 3.0 cm, according to the cosmetic visual analog scale; p = 0.000002), and satisfaction (excellent in all nine patients who had surgical repair and satisfactory in all three who had nonoperative treatment). CONCLUSIONS: The results after repair of acute traumatic closed transection of the biceps brachii with the new surgical technique described in the present study demonstrated a significant improvement in terms of function, appearance, and patient satisfaction compared with those after nonoperative treatment.