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Superior Shoulder Suspensory Complex injuries (SSSC)

Superior Shoulder Suspensory Complex injuries

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Superior Shoulder Suspensory Complex injuries (SSSC)

  1. 1. Zonal CME conducted at GSLMC DR.S.JAGANMOHAN M.S,D.N.B. ORTHO, FELLOW ARTHROPLASTY ASSISTANT PROFESSOR , DEPT. OF ORTHOPAEDICS GSL MEDICAL COLLEGE AND HOSPITAL
  2. 2.  Introduction  Definition  Related anatomy  Pathoanatomy  Investigations  Treatment options  Conclusion
  3. 3.  Ganz and Noesberger 1975 -The Floating Shoulder - the ipsilateral glenoid surgical neck and midshaft clavicle fracture  Goss 1993 introduced the concept Superior shoulder suspensory complex
  4. 4.  Described as a bony / soft tissue ring at the end of a superior and inferior bony strut  Bony struts : The superior strut The inferior strut  The ring is composed of the glenoid fossa, coracoid process, coracoclavicular ligaments, distal clavicle, acromioclavicular joint and the acromial process.  Function: This complex maintains a normal stable relationship between the scapula and the axial skeleton
  5. 5.  Double disruption: There should be injury to any two structures  Depending on the structure injured in SSSC that could lead to instability it is subdivided into 1. Clavicular - acromio clavicular joint - acromion strut 2. Clavicular – coraco clavicular ligament- coracoid C4 linkage 3. The three processes scapular body junction clavicular-acromioclavicular joint-acromial strut C4 The three-process-scapular body junction
  6. 6.  Fractures of the surgical neck of the scapula produce  D. Distal fragment consisting of the glenoid and the coracoid process and  P. Proximal fragment consisting of the acromion, scapular spine and scapular body. D P P Anterior view Posterior view
  7. 7.  The distal fragment is attached to the proximal fragment by coracoacromial ligament and to the axial skeleton, through the clavicular shaft, by the coracoclavicular ligament.  To produce a floating shoulder (scapula) - damage to these attachments is needed. D P P P
  8. 8. Surgical neck Lateral Clavicle acromial strut C4 coracoid , coraco clavicular lig and Its attachment to clavicle Surgical neck of scapula
  9. 9. AC joint C4 Acromion C4
  10. 10.  The scapular neck fracture is displaced inferiorly as well as anteromedially by the altered muscle forces and the weight of the upper extremity.  And If significant displacement occurs at either or both sites, there may be problems with healing, such as delayed union, malunion and nonunion  Malunion is common
  11. 11.  Drooping of shoulder- deformity  Brachial plexus pressure  Relationship of the glenohumeral joint with the acromion is altered, creating a functional imbalance  Decreased range of motion  Loss of normal lever arm of the rotator cuff (length)  Results in weakness on abduction and subacromial pain are common Drooping of shoulder
  12. 12.  Most are following Road traffic injuries  High energy injuries  Polytrauma associated with chest injuries pneumo/ haemo thorax, rib fractures
  13. 13.  Recommended views of shoulder 1. Anteroposterior view ( weight bearing) 2. Lateral view 3. Axillary view or trauma axillary view
  14. 14. Standard axillary Alternative axillary views
  15. 15. In ring structure concept, like the pelvis, it is more reasonable to think if the ring is broken in one area and the fragments displaced, then there must be a fracture or dislocation in another portion of the ring.
  16. 16.  Conservative treatment : supported by recent papers  Edwards (jbjs2000) : Reported excellent results in 20 treated nonoperatively by a shoulder immobilizer.They recommend conservative treatment, especially in patients with less than 5-mm displacement.  Van Noort et al ( injury and octa ortopaedica 2005, 2006) In a retrospective study, reported fair to good results in 28 patients treated conservatively with a well-aligned glenoid. The authors concluded conservative treatment leads to a good functional outcome in the absence of caudal displacement of the glenoid. Caudal displacement was defined as an inferior angulation of the glenoid of at least 20 degrees
  17. 17.  Surgical management:  Goss 1993, recommended stabilisation of both sides and stated that conservative treatment causes drooping of the shoulder  Ada and Miller reported a high incidence of rotator cuff dysfunction in patients with displaced clavicular and scapular fractures resulting in loss of the normal lever arm of the rotator cuff, and they recommended that the fractures be treated by open reduction  Romeo et al. reported a poor outcome after scapular neck fractures with malalignment; they measured the glenopolar angle to assess the rotational malalignment of fractures involving the glenoid . In their series patients with scapular fractures, which were displaced by more than 1 cm, had poorer results than those with undisplaced fractures.
  18. 18.  B.D.Owens &T.P. Goss jbjs2006 Surgical stabilisation of the clavicle alone could reduce the scapular fracture indirectly, and fixation of the scapular fracture was only required with displaced fractures
  19. 19. Case example quoted in wheeles textbook for conservative management With glenoid not much displaced
  20. 20. Case of SSSC with clavicle plate fixation with undisplaced scapula neck treated With clavicle plate alone
  21. 21. Case of Failure with clavicle plate fixation with displaced scapula neck treated With calvicle plate alone resulted in decreased ROM
  22. 22. Protocol to be followed clavicle plate fixation still scapula neck is displaced . scapula fixation is done
  23. 23. Double Plating done at the same time
  24. 24. Fixation of lateral clavicle (acromio clavicular ) and coracoid (c4)
  25. 25.  less than 5-mm displacement  No Caudal displacement Conservative management • Clavicle plating first • Scapula still unreduced • Scapula fixation SSSC yes No Operative management

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Superior Shoulder Suspensory Complex injuries

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