Clavicle Fractures
AC SC Case 79 year old active female fell while skiing
“These do well without surgery”
Questions: 1. Treatment: – A. Operative – B. Non-operative
Questions 1. Operative Treatment Choices: A. Transacromial Fixation B. Suture anchor(s) C. Plate D. Plate + CC fixation E. Coracoclavicular fixation
2 weeks later
“I thought these were supposed to do well without surgery???”
Questions: 1. Treatment: – A. Operative – B. Non-operative
Questions 1. Operative Treatment Choices: A. Transacromial Fixation B. Suture anchor(s) C. Plate D. Plate + CC fixation E. Coracoclavicular fixation
CC Fixation
8 weeks postop – clinically healed
Case 1
CASE 1 • 20 y.o. sophomore Starting QB • Goes down on shoulder during 3 rd game of season in 1 st quarter • Already has thrown for 700 yards in 1 st two games
CASE 1
CASE 1 On field • Unable to raise arm • Tender diffusely anterior shoulder and around AC Joint • Neck with normal rom • NVI distally
CASE 1 Take to Locker Room and Re-examine • Shoulder Pads off • Moderate deformity at AC joint • Tenderness around AC joint and anterior shoulder • Now able to Raise arm and resist in all planes with discomfort
CASE 1 Xrays:
CASE 1 Xrays:
CASE 1 NEXT STEP?
CASE 1 NEXT STEP? Done for the game? Injection? MRI?
CASE 1 Discussion with athlete A shared decision was made and injection was chose
CASE 1 Athlete went back out in 2 nd quarter Unable to play, too painful to throw Sat out rest of game
CASE 1 NEXT STEP?
CASE 1 MRI
CASE 1 NEXT STEP? Done for the year? Surgery? Rest and see if able to come back?
Acromioclavicular Joint injuries Results from survey from NCAA Div. I ortho docs • Type III AC joint injuries: Treat non-operatively 2008 67% 2016 92% Fix 2008 22% 2016 8% Fix in QB 2008 11% 2016 33%
Case 1 • Treated with rest and progressive motion and strengthening • Improved every week • Came back 3 weeks later • Finished year and threw for 2,000 yards • Story done?
Case 1 End of season exam • Significant deformity • Scapular dyskinesis • Cross arm adduction with elevation of clavicle over acromion
Case 1 Not the Athlete but example of the mechanics of the AC joint
CASE 1 NEXT STEP?
CASE 1 Called Russ Warren & Rich Hawkins
CASE 1 Ultimately decision was to rehab and strengthen and do surgery if did not improve
CASE 1 Scapular mechanics remained abnormal but he felt fine was able to return to play 2 more years and became all-time leading passer for University of Colorado
Case presentation Complex AC joint injury
• 45 y.o. worker • MVA, multiple injuries, resolved • AC soreness, deformity, dysfunction • Scope “AC joint repair”, technique unknown • Continued symptoms, deformity- “no change”
Post op 1 - What caused repair failure - What is current pathoanatomy, pathophysiology - Treatment options
Post op 2 - Anatomic CC- graft, sutures, 4.5 mm holes - AC- graft docked to acromion, 2.4 mm holes, tension band - Native ant, post AC repair, suture anchors Kibler et al Arthroscopy April 2017
Case 2 • 20 year old quarterback tackled and thrown on to one of his shoulders and sustained a significant injury
20 yo with football injury
Weighted views
20 yo with football injury
20 yo with football injury Cross body adduction AP radiographs
20 yo with football injury
20 yo with football injury 19 year follow-up: Patient is now a practicing orthopedic surgeon and feels his right shoulder is “normal”
What Would the Panel Do????
6 months postop
6 months postop
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