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In the following, I'll send you the surgery report for... Hello, we have a young BMX bike rider. He fell onto his right arm and was not wearing a helmet. I see, traumatic brain injury and clavicle. He reports, however, that he did not injure his head at all. Ok. I’ll be with you straight away. It is useful to observe the anatomy in order to gain an understanding of clavicular injuries. The clavicle is located directly under the skin. It has an S-shaped curvature and articulates in the acromioclavicular joint on the shoulder side. On the sternum side, it articulates in the sternoclavicular joint. The clavicle is closely associated with other neurovascular structures or the lungs. hese are the subclavian artery, the subclavian vein and the brachial plexus. Having knowledge of ligamentary structures is also very important in understanding the injury. The clavicle is suspended from the coronoid process by the coracoclavicular ligaments and from the acromion by the acromioclavicular ligaments. The clavicle forms the only osseous connection between the torso and the arm. Clavicular fractures form the fracture injury most frequently suffered by human beings after fracture of the radius. Between 2.6 and 4% of all fractures suffered by adults involve the clavicle. The lateral clavicle is involved in 15-20% of cases, 770-80% involve the medial and only about 5% the sternal third. The clavicle is involved in up to 44% of all shoulder girdle injuries. In order to be able to determine the optimum treatment to be administrated, it makes sense to classify the types of fracture. The classification of the OTA is the most widely used one in the international literature. To begin with, this divides clavicular fractures into the medial, central and lateral third. Lateral clavicular fractures are also distinguished according to Jäger-Breitner as well. There are approx. 15% in the lateral, 80% in the central and 5% in the medial third. This slide shows the OTA classification. Type A fractures are in the medial third, Type B in the central and Type C in the lateral third of the clavicle. In a similar way as with the AO classification, the number following the letter indicates the severity of the injury. The additional classification of lateral clavicular fractures according to Jäger-Breitner is shown on this slide. The influence of the ligamentary structures on this classification can be clearly recognised. It has been revealed that the stability of lateral clavicular fractures crucially depends on the ligamentary concomitant injuries sustained. Fractures of the medial end. The relationship to the ligamentary structures is likewise important for the classification of medial clavicular fractures. If the fracture gap is located on the lateral side of the ligamentary join, then there is the threat of any unstable situation occurring due to the traction exercised by the sternocleidomastoid muscle. Medial comminuted fractures rarely occur. They are usually found in extra-articular regions and are undisplaced. Stability depends on the costoclavicular ligaments. If surgical treatment has to be undertaken, then various implants are possible for this: fixation with mersilene tape, Cerclagen etc. The application of a fixed-angle plate must be carefully checked. The issue here is whether enough medial osseous material is available to provide sensible anchoring. These X-ray images show examples of a medial comminuted fracture without any marked dislocation having been incurred. Fractures of the central third are designated mid-shaft or diaphyseal fractures. The OTA classification makes a distinction in this regard between simple B1 fractures, B2 wedge fractures and B3 comminuted fractures. Examples of corresponding injuries are shown on the X-ray images, while the ways they are surgically treated can be seen on the right hand side. Lateral clavicular fractures. The key thing with lateral clavicular fractures is to watch out for any supplementary ligamentary injuries. So, I’ll help you take off your T-shirt. Then the doctor will be able to check things out. So. Kathi, whom do we have here? This is Mr. O'Brien. He fell off his BMX bike today. Hello, My name is Kirchhoff and I work in Trauma Surgery. So you fell off your bike, did you? How did that happen? I was riding along the trail, and jumped over a mound, but then somehow got tangled up with a root when I was landing. Ok. And then I fell off. Were you wearing a helmet? No. Ok. Did you get your chest or stomach caught up against the handlebars in some way? No. Not in any way. And then you just fell onto your shoulder? No, I stretched my arm out to protect myself from falling. Do you know what the date is today? Today is the twelfth. Ok. Do you feel unwell in any way? Have you got any headache? No, none at all. All that really hurts is my arm. Any ringing in your ears? No. Seeing double? No. Nothing at all. Do you also know why you are here and where you are? Yes. Do you also know whether this is a hospital or a post office? Yes. Ok. Good. I would like to examine your shoulder, chest and stomach. That needs to be done. Just lie down flat. Okay. I am going to place your shirt over here. Is that OK? Yes. Perfect, ok. Just place your arms next to your body. Perfect. Do you feel any pain if I press here? No. Do you feel any pain here if you take a deep breath? No. Ok. I’m going to have a quick look at your stomach using an ultrasonic device, just to make sure that no stomach organs have been injured. Ok. As far as I can tell, the stomach is all in order. I’m now going to have another look at your arm. Can you spread out your fingers? Yes. Good. Does everything feel normal here or is there any feeling of numbness? No, everything feels OK. The pulse rates there are also good. You have sustained a few grazes. Have you been vaccinated against tetanus? Yes, I have. Ok. Good. Is there any pain if I press here? No. Ok. Good. And up here on the shoulder itself? Yes, that pulls upwards a bit. I’m not going to examine any further at all up there. In the end, it can already be clearly seen that there is a very high level of probability that the clavicle is broken. We are now going to take an X-ray image of the clavicle and of the chest and then we’ll have a further talk. Ok. And otherwise, you feel completely well? Absolutely fine. No tablets, no illnesses? No. Everything otherwise OK? Ok. Good. Then hold your arm and walk over to the X-ray. Yes? All right. See you soon. 151 00:08:32,031 --> 00:08:32,901
Two primary injury mechanisms are possible for lateral clavicular fractures. On the one hand, falling directly onto the shoulder or, on the other hand, an indirect transfer of force onto the outstretched arm through falling. First of all, conducting a clinical examination is important for clavicle investigation purposes. This begins with an inspection and palpitation for vision or palpable swellings and step formations. Care must be taken, in particular, to note any compound fractures, as the clavicle is located directly under the skin. Examining and recording peripheral blood flow, motor function and sensitivity are again of crucial importancewith clavicular fractures, not least due to the anatomical proximity of the clavicle to the brachial plexus and the vascular structures named above. Imaging diagnostic investigation provides for standard X-ray imaging in a.p. and at 45°. Treatment of clavicular fractures 90% of non-dislocated clavicle fractures heal in response to non-operative treatment. Retention used to be carried out by means of rucksack bandaging. This method is largely no longer used these days due to the complications of the axillary nerve. Fractures therefore these days tend to be immobilised by means of arm slings such as a Gilchrist or Medi-sling. This non-operative treatment lasts between 10 and 14 days with children and between 3 and 4 weeks with adults. The indications for surgical treatment are listed on this slide. In the case of medial fractures, the indication is made based on the laceration of the ligaments with dislocation. In the case of mid-shaft fractures, the indication is made based on a dislocation exceeding the width of the shaft as well as with multifragment fractures or if there is a threat of indentation of the skin occurring. In the case of lateral fractures, the indication is made based on dislocation and simultaneous elevation as signs that the coracoclavicular ligaments are ruptured in a manner corresponding to a Type IIa injury according to Jäger-Breitner. The question as to whether medial clavicular fractures are to be treated non-operatively or operatively was clarified in 2007 on the basis of a prospective, randomised study. This prospective, randomised study by the Canadian Orthopaedic Trauma Society covered 132 patients. The criteria for inclusion were having a completely dislocated shaft fracture without the fracture ends having any contact as well as there being room for at least three cortical bone screws on each side of the fracture. The treatment made provision for six weeks sling treatment for the non-operative part. The patients were allowed to remove the dressing as soon as they were free of pain. In terms of the operation, ORIF was carried out using inter-fragmentary compression screws if possible. This entailed using 44 small fragment plates, 15 Reco plates, 4 pre-bent and 4 other plates. The Constant and the DASH Score served as target parameters. This slide shows the results of the follow-up examination. The continuous line represents the average Constant Score following surgical treatment, while the dashed line represents the Constant Score following non-operative treatment. What can be clearly recognised is the the fact that the average shoulder function values were significantly better following an operation when compared with the non-operative treatment provided. This slide shows the results of the DASH scores. The important thing to be aware of in this regard is that the DASH score is better, the lower the quantitative results are. The continuous line again represents the average DASH score of those upon which operations were conducted and the dashed line the average DASH score of the clavicular fractures which underwent non-operative treatment. It can be clearly recognised that the DASH score of the patients who underwent operations was better every time da follow-up examination was conducted than that of the patients who had undergone non-operative treatment. Lateral clavicular fractures, as was mentioned before, form special cases due to the relationship to the concomitant injuries of the ligaments which are incurred. Jäger-Breitner I and IIb injuries are deemed to be stable, but Jäger-Breitner IIa, III and IV injuries to be unstable. The outcomes of lateral clavicular fractures are linked to non-unions with a relatively high degree of frequency following non-operative treatment. Outcomes following surgical reconstruction, for example by means of hook plate, lead to impingement complaints in a not inconsiderable percentage of cases. Once the metal had been removed, the Constant Score could then be identified as being at 92 points. Compound clavicular fractures occur relatively rarely. They occur in cases of high energy traumas, for example in polytraumatised patients. Concomitant injuries of the vessels and nerves frequently occur with compound clavicular fractures. This means that how these injuries are treated strongly depends on the overall status of the patient. Mr. O’Brien. Are you back already? Come over here and please sit down. Unfortunately, the truth can now be revealed. I don’t like being right in cases like this, but I am afraid your clavicle really is broken. I didn’t see anything wrong in the chest area, but the clavicle has been broken into several parts. If you would like to have a look yourself, here is the X-ray image. This is outside and this is inside. You can then see that the external end has been shifted to a quite considerable degree compared with the internal end. Yes. Exactly. Why is the clavicle important? Please take a look at this. This is a model of the shoulder. This is your upper arm and that is your shoulder joint. That is your shoulder blade, the part lying against the chest at the back. This is then the clavicle. The clavicle is the only bony connection between your entire arm and the rest of your body. This means that if this connection is broken, then the shoulder is left dangling without any bony connection to the body. You need your clavicle just for this reason alone. It is the case that not everything requires an operation when it comes to trauma surgery. It has, however, been maintained for many decades lready that any fractures which have led to shifts occurring which are wider than the shaft must be treated surgically, and there is also a relatively new study from last year showing that even with fractures with fewer shifts, surgical treatment, that is to say the precise setting and securing of the bone, is considerably better when compared with deferring action or non-operative procedure, if the ability to use the arm and shoulder for sporting activities are taken into account and also in terms of functionality, together with the pain experienced by the patient, months after the operation or months after the fracture occurred. Mhm. It must be admitted that it has already been known for many years that in the case of fractures involving dislocations exceeding the width of the shaft, the probability is very, very high of what is termed a false joint forming, i.e. the ends of the bone simply closing without taking each other into account and not having any contact with each other any more. In summary overall, therefore, after having talked a lot, I recommend that, when it comes to clavicles and in the event of these being fractured, surgical treatment should always be considered in the first instance. OK, but I will then be able to ride my BMX bike again shortly afterwards, I hope? Yes, no problem. That is what we want to achieve with the operation. Ok. To carry out an operation which will be as free of pain as possible and fully restore all functions. If you would like to know how the operation is carried out as a whole: really specially made anatomical plates exist, and I think I even have an example of one here, i.e. plates which have been designed just for this bone alone. They are placed on the bone and then secured in the bone using various screws. People usually find that this plate also then causes them some bother after a few weeks or months. We then remove it, but only after three quarters of a year to a year after the operation has been conducted,... Ok. ...depending on the X-ray images. Ok? This is how things now look: you can see there is an enormous swelling there for yourself. That cannot just be left alone for several days and we wait for the operation to take place. There is a relatively high level of danger that the bone could actually pierce the skin. For this reason, I would actually advise you to undergo an operation in the very near future, and in fact, to be honest, even today. Have you eaten or drunk anything yet today? Yes, at noon today. Noon, ok. That means 6 hours have already passed until now, which in turn means we could actually operate at any time from now onwards. Yes, but is it a life-threatening intervention, or ...? A calculation of probabilities is always involved in life-threatening situations. If you were to leave this hospital now, you could be run over crossing the street. About 3,000 people lose their lives in traffic accidents in Germany every year. There is such a low rate of risk, such a low rate of complications, with this operation, precisely among young patients, that you really do not need to worry about that. We operate on patients aged 100 every day who have suffered considerably more difficult fractures with considerably higher potential complications. To that extent, the risk of your dying from this operation ultimately tends towards 0. Ok. There are basically what are referred to as general and specific risks. General operation risks are ultimately the same over the entire body. We cannot place a plate on the bone without making a skin incision and the skin incision will leave a scar. We try to do this in a minimally invasive manner, i.e. to operate using small skin incisions, but you nevertheless need to know that you will be left with a scar afterwards. Such a scar can also become somewhat broader and in the worst case will also not be too pleasant to look at. This is because every wound can possibly become infected, whether you cut yourself whilst peeling a cucumber in your kitchen or undergoing an operation with us. Bacteria can enter into such a wound. If bacteria reach the bone, this can be catastrophic and follow-up operations need to be undertaken for as long as it takes to ensure the wound is clean once again. This needs to be qualified, however, by saying that in our hospital we have a rate of infection which is almost in the vicinity of 0. To that extent, this is a risk which, in all conscience, you really do not need to worry about much. Ok? Ok. The clavicle is arranged in such a way that, directly beneath the clavicle, the major vessels run which supply the arm or flow out from the arm again respectively. These vessels can already have been injured by the fracture and in the worst case they can, however, also be injured by an operation. In such a worst case, the vessel has to be stitched up, which has various consequences. Ok. Such plates can become loose and the screws can loosen and fall out of the bone. This will then mean the bone will not heal. That will then mean that another operation will need to be undertaken. If your shoulder really bashes against something while a plate is inserted, i.e. if you do not stick to what I ask you to do, but instead prefer to ride your BMX before the bone has become firm again, then the whole construction can fail, i.e. the bone break, the plate bend or break. Having to undergo another operation is something you really want to try and avoid if you possibly can. Ok? Therefore, please be sensible in the first 12 weeks. Mhm Ok? Yes. In the worst case, pain can be experienced after any operation. You then just need to report to the nurses on the ward in the course of treatment and ask them to provide you with pain-killers. Mhm. And you also certainly need to take pain-killers again for the first few days after you get back home. Ok. Ok? Good. Right, in that case, it is now time for me to send you to the ward. A colleague will meet you there and quietly talk you through the whole procedure once again. You then just need to sign the patient information sheet. WWe now just need to take a blood sample and then send you to the anaesthetist. Ok. No eating, drinking no smoking. Everything understood. Best wishes. Good, OK. Good bye, Mr O’Brien. Good bye. Complications linked to clavicular fractures can be pseudarthroses, paraesthesias in the dependent arm, vascular thromboses or the risk of having to undergo another operation and infections. The following is intended to show the risk of pseudarthrosis. In this study, the frequency of pseudarthroses occurring following the surgical treatment of clavicular fractures was examined within the framework of a case control investigation. After a bent Reco plate had been inserted, complete healing was ascertained in 93% of all cases. Surgical treatment nowadays is undertaken either by means of intramedullary stabilisation, designated as TEN in this context, or by means of plate osteosynthesis. A dedicated fixed-angle plate is available for the lateral clavicle, while for fractures of the medial third and for medial fractures specially anatomically designed pre-bent clavicular plates are likewise available. At least 3 bicortical screws need to be anchored per fragment. This slide, for example, shows surgical treatment being undertaken by means of TEN. In image No. 1, the patient can be seen with his mid-shaft fracture. In Image No. 2, both fragments are being captured with the use of disimpaction forceps and as can be seen in image No. 3, repositioned. As can be seen in image No. 4, the lateral clavicle is then opened by means of using an awl. As can then be seen in image 5, a TEN nail with a strength of 2.5 or 3 mm is introduced into the medullary cavity of the clavicle and, as can be seen in Image 6, shifted in the direction of the fracture. This slide shows the intraoperative illustration by means of image converters in a schematic manner. It can be seen in image No. 7 how the nail is shifted in the direction of the fracture, in image 8 how the lateral fragment can be manipulated by means of nails and in image 9, how the medial fragment is threaded. Image No. 10 shows that the nail is locked in the medial fragment. Image No. 11 shows that the nail is then cut off and image No. 12 shows the postoperative situation. This intramedullary bracing can be removed after 3 months at the earliest. The follow-up treatment for clavicular fractures which have been surgically treated envisages mini-sling treatment being administered for approx. 2 weeks. Exercising up to 90° abduction adapted according to pain is then undertaken for 6 weeks. An X-ray check should be conducted directly postoperatively after 3 and 6 weeks, the metal of the intramedullary nail removed after 4 months at the earliest and that of the plate after 12 months at the earliest. It can be stated in summary that open repositioning and internal fixation by means of plate osteosynthesis or nails can be considered for diaphyseal shaft fractures in cases where dislocation exceeds the width of the shaft. DBeyond that, this form of treatment should be administered with compound fractures, with pseudarthroses or with pathological fractures within the context of compound osteosynthesis. Patients with insufficient compliance for TEN treatment should likewise be treated by means of plate osteosynthesis. Treatment by means of internal fixation with a locking-compression plate makes sense for medial and lateral fractures. Long-term results are still awaited, however, in this regard. 423 00:25:09,545 --> 00:25:17,542 425 00:25:25,548 --> 00:25:31,423 427 00:25:37,298 --> 00:25:43,165
