In the interest of making sure that Jason has enough time to do his talk and making sure that we get people back to their clinics, I'm going to go ahead and start with the introductory slides at this point. Welcome to the fellow online educational series. We appreciate you joining us. This is a subcommittee that is sponsored by the AMSSM Education Committee and the Fellowship Committee, of which Jason is a co-chair, to try to improve the availability of education for our fellows that came from the COVID pandemic. And so when people were pulled from their programs and reassigned to different things in the hospital, the fellowship directors tried to get together and try to help nationally with making sure that fellows around the country were getting an appropriate education, even though it wasn't in a traditional type of format. And from that, the AMSSM liked the way that that was going and said, hey, why don't we try to incorporate that a little bit into what we're doing as an organization? And therefore came the subcommittee on online education for fellows. And it's co-chaired by Will Den, myself, and then Heather Staffel, she was the fellow representative, but she's now graduated and she's in practice in South Bend, Indiana. And then we have a great working committee of which Jason is a member as well. Today's topic is pearls and pertinent information for the AC joint, the SC joint, and clavicle injuries. So I look at it as the clavicle from east to west, or west to east, depending on which one you're looking at, I guess. Our presenter is Jason Zaremsky from the University of Florida. If you don't know Jason, you should get to know him. He's a fantastic guy, a tremendous speaker. He's been published in numerous, numerous publications for his basic science work and his clinical work. He was our representative on a traveling fellowship to Sweden in 2018. He is a PM&R trained physician, went to medical school and did his PM&R training at Tufts in Boston, then his fellowship at the Geisinger Health System. He's a current member of the board of directors of the AMSSM, and again, a co-chair of the fellowship committee. And he's also, as I said, a member of this subcommittee. Jason is one of our strong leaders in the AMSSM and sports medicine in general, not only now, but will be for years to come. And we're very excited that he is going to be providing us with this lecture today. To make sure you understand what the goals of this program are, it's to serve as an adjunct to your individual program's educational programming. We're not trying to take the place of what you're learning or take the place of the didactics that you get, but to add to what you're learning in a very positive way. It also provides the fellows with direct access to educational experiences with top members like Jason in a format that you would not otherwise have a chance to meet with him, get a chance to potentially ask questions here at the end. We can open up the mics and have a Q&A session at the end. The formal Q&A session will be through the chat function, so make sure that you use the chat function, and I'll compile the questions and we'll ask those at the end, but we can even open up the mics after that just for general conversation. Finally, it's to assist you in the CAQ preparation. We're trying to make sure that these lectures bring up particular points that are helpful for your CAQ prep. So if you would now make sure that all of your devices are muted from a microphone standpoint. We don't want to have side chatter coming in while Jason's giving his talk. Again, use the chat function to get your questions on board here, and then I'll try to make sure we address those questions at the end. Then again, we have an evaluation form on Collaborate that we ask that you fill out as well. So to start, to kind of get Jason going here, one of the things that you may be asking on the CAQ is a question such as, the axillary lateral X-ray projection is important in the workup of AC joint injuries. For what reason? And then you may have a variety of foils to answer that question. And instead of answering that question, I just encourage you to pay close attention to the lecture today, and you'll know the answer by the time the lecture is through. So without further ado, I'm going to stop my sharing and allow for Jason Zaremsky to provide us with his lecture. Jim, can you see this? Yes, absolutely. All right. So, thanks, Dr. Moeller, for the introduction. Thank you to everyone who has been part of this committee, in particular your leaders, Jim, Will, and Heather. And really, a big thank you to our AMS system staff in Kansas City, working either from their homes or from the office intermittently, to really set this up every single Wednesday. So, hopefully, this has been helpful, will continue to be helpful for those of you, for our fellows, and for those of you who are probably recertifying for CAQ next summer. So, what I've tried to do is combine everything in AC, SC, and clavicle injuries. It's really been pertinent for a primary care slash non-operative sports medicine fellow or network provider. There's a few topics, like the surgical techniques for a grade 5 AC joint reconstruction. We're obviously not going to talk about that because we're not surgeons, nor are we expected to know that. We are expected to know when something needs to go to a surgeon, however, and I will talk about that. As Jim mentioned, please, any questions, add them to the chat function, and I'm sure Jim or Andy Myers in the background will let me know. And for your colleagues who are in clinic and in different time zones, I believe this is also going to be re-shown on the YouTube channel. And I'm always happy to share these slides I can make in the PDF to make the data size much smaller. Okay. So, let's get started. So, as Jim mentioned, I am Jason Jermseen with the University of Florida. Let's start with the case. And this is not a case I made up or I heard about. This is my case last year. So, this is a 17-year-old right-hand dominant male. He's a running back football player. He presented to a Saturday morning clinic after sustaining a shoulder injury the night before. The mechanism, as was reported to me by the student athlete, as well as athlete trainer, was that an opponent landed on his right shoulder and lateral chest. Now, he didn't say if he got speared or not, but that was what I was told. So, I asked a couple questions. He didn't hear or feel a pop. He didn't have any noticeable swelling or bruising. He did complain of some shoulder pain with active range of motion. An athletic trainer told me that she had moved him from the game immediately. And her exam, which was documented, basically was nonconcerning except for pain. So, it abounds of caution. And it's at the high school level. So, obviously, a lot less resources. He was held out for the remainder of the game. So, in clinic, Saturday morning, physical exam, inspection. There was no bruising or deformities, palpation, tender to basically in that delto-pectoral region. Sometimes you might think it's like a pec minor area. It was tender, but nothing was hot, red, swollen, no bony tenderness. Range of motion was full, but some pain with active abduction greater than 90 degrees. Strength was fine. Neurovascular was fine. Shoulder radiographs were also normal. So, based on that, the recommendations were, let's keep you in a sling for just a couple days. But I definitely want to follow you back up because something seemed a little bit off about this. I spoke with the athletic trainer about the plan as well. So, the twist that gave me anxiety for a month afterwards was that we were told his pain had mildly improved. And he had been taking his arm out of the sling a few hours a day against medical advice. However, two days after he was evaluated, so that was the first day back at school for him on a Monday, pain had moved from kind of the axillary region to a sternoclavicular region. He denied any kind of red flag signs that we'd be concerned about. Was he messing around? Or did he go to practice? Did he get hit? Did he feel a pop? Was there any vascular issue, shortness of breath, chest pain, neurological? Everything was negative. And then he said one thing. He said, you know, I think I felt a pop when I turned over in bed on Sunday night. Okay. So, on physical exam, he had palpation, pain to palpation and the medial, not lateral now, pectoral muscle, a very tender right SC joint, and there was a palpable defect. So, we got sternoclavicular joint x-rays. It's called serendipity views, which typically, if you speak to any radiologist, are some of the worst sensitive and specific type of x-rays around. If you can't see anything, the x-rays are worthless. If you do see something, that means something bad has occurred. As you can tell with the arrows, because the image projection is a little tough, something is not symmetric here. So, Andy, this is the first question. I can get the poll up. So, the next question is, what do you do? MRI, CT, next available surgical consultation, or he would say, you know what, let's just keep you in the sling, you've been stable, and we're going to re-X-ray you again in a week. I'll give you about 30 seconds. And I think one of our fellows is on. She may have heard this case. So, that individual I will not call out. I hope you get this right. All right, Andy, how do I see the scoring? Ah. All right. So, two-thirds of you suggested a CAT scan. About 120% said next available surgical consultation, and then the rest kind of MRI and sling and re-X-ray. Okay. Let's talk about why CT scan is the best answer. So, I ordered a STAT non-contrast CT scan, and the stuff in white there is just being a little bit more specific. But the important point is a STAT non-contrast CT scan, and what it showed with it was there is a true posterior displacement of the right medial cavicular head at the SC joint with a small fracture fragment, concerning for a Salter-Harris II fracture. Now, remember, when you have physial or growth changes, the physes in the upper extremity, particularly the medial clavicle physis, it may not completely close until you're in your early 20s. So, it's still possible to have a Salter-Harris fracture if you are 17 years old. So, obviously, this is concerning. This is actually pretty cool imaging. This is a 3D reconstruction, if you haven't seen before, in what would be the upper left-hand part of your screen. And then this is a standard CT axial cut in the right-hand part of your screen. In both images, you should be able to see that there's an asymmetry. In the upper left, you can see where this is posterior. The SC joint is completely displaced or dislocated compared to the AC joint. And then if we flip it and we just do a straight axial cut, you can see the right proximal clavicle versus the left. Now, what's also important is you can almost see a little outline here of something. That little something is your superior vena cava, which for many of us may not have dealt with it since we were interns or even med students. So, that is why this is so concerning. So, what are the next steps? This person was sent to the emergency room stat, like his mother took him in his car and they went and show up in the ER. I made some calls, and he was in the operating room two hours later. Closed reduction failed, so it was converted to an open reduction internal fixation with one of my pediatric orthopedic colleagues. She also had carthoracic surgery on standby if need be. Now, that said, this is actually a very good outcome. Six months after the ORIF, no restrictions, shoulder range motion was great. There was no swallowing difficulties, no squeaking difficulties, no shortness of breath, chest pain, complete PT, and he was allowed to return to contact. But he did very well. So, sternoclavicular joint injuries. This injury, in particular the posterior one, is one you never want to see, but if you do see it, you're never going to miss it again. I have, in a weird way, gotten six of these, only one posterior, but I've had six SC joint injuries show up in my clinic in the last 12 months. And that's more than our trauma team, it's just luck of the draw. But if you know what to look for and you know the algorithm, you can be very calm about knowing how to go about treating these injuries and the type of injury it is. So, let's go through those. So, number one, these are very rare events. Less than 5% of all shoulder girdle injuries are a result of actually posterior sternoclavicular joint dislocations, less than 3% in athletes. So, this is what you have to be aware of, in particular, you know, we're in the fall right now in the United States at least, is this is a result of high-velocity collisions. This is not going to happen because you got bumped or you fell from standing. These are high-velocity collisions, and typically there's one of two mechanisms. One is a high-energy posterolateral compressive force to the ipsilateral shoulder, and then it translates force from the lateral to medial to the neoclavical. The other is a direct impact where it basically gets speared. Obviously, in this case, it was mechanism number one, except he was likely perched and would not have been able to be detected unless you got an automatic CAT scan, which we don't do because that's a lot of radiation to kind of thyroid region and to the cardiovascular region, and he didn't have any pain there. So, he likely was perched, and then when he turned over in bed two days later, he then dislocated going from subluxation to dislocation. So, typically the history is someone may complain of some anterior chest or shoulder pain, again, typically after a high-energy accident or collision. Things you need to ask or be aware of, dysphagia, shortness of breath, possibly temperature changes in the affected limb, tachypnea, paresthesias throughout the ipsilateral arm. There may or may not be a popping sensation associated with the injury, and like I said, definitely got to ask about swallowing, speaking, shortness of breath, things like that. You also have to be aware, while they are extremely rare, you do have to be aware of the serious vascular and pulmonary associated complications if there is a posterior injury. That is why this is such a concerning and emergent injury to diagnose and to treat. So, you can see with the picture here, this is actually an anterior SC joint injury in the right-hand side, but the physical exam is actually more straightforward. It's, is there a defect over the SC joint or not, is there a bulge? Typically, if there's a bulge, it's anterior. If there's a defect or concavity, you're thinking a posterior defect. Is the pain focal to that region? Is there localized swelling or bruising? Is a reduced range of motion of the ipsilateral shoulder? Remember, go back to your basics. Go back to your, what you're taught as first-year med students. Palpate both SC joints. Palpate both AC joints. Palpate the sternum. Be very thorough in your palpation and see if there's any pain in any of your bony landmarks. This is a video that Dr. Mohler was kind enough to share. This is my first video on Zoom, so let's see if I can get it to work. Okay. Right there. Very good. So you can see, obviously, this is, I'm guessing, and Dr. Mohler can chime in, but this is likely a little bit more of a chronic issue. You won't be able to do this if this was an acute issue. And obviously, what you're doing when you're abducting and circumducting your shoulder, you're trying to see if there's instability of either the AC or the SC joint. Those of you who have seen anybody with a chronic AC joint injury, particularly grade three and above, it almost seems like their AC joint's just flailing in the air, the concept holds with an anterior SC joint injury as well. So what about the type of imaging? One, when you're independent, particularly if you're not at a major institution, you need to know specifically what to order. You can't just say shoulder x-ray or AC joint x-ray. As a fellow, and even if there's any residents listening, understand what we're ordering and why we're ordering it. So if you're getting x-rays for your SC joints, you likely want to order bilateral clavicle as well as serendipity views. And I took a picture off of one of the websites, which I listed below. So that's what a serendipity view is. It's about 40 degrees of tilt view. And then you start thinking about, well, okay, we've got an SC joint injury, and if we're concerned about posterior, what sort of advanced imaging do we want? A CT versus CT angiogram versus an MRI? Well, typically, you're going to think about a CT because it's very time sensitive, especially if things are inconclusive. If a CT angiogram is supposed to be ordered, I suspect that your orthopedic trauma or cardiothoracic trauma colleagues will be the one directing that care. But if you have, let's say, a sports-related injury, it's a Friday night game and it's Saturday clinic, and you're concerned, you get a stat CT chest, no questions asked. So this is a pearl for, I guess, from the CAQ standpoint for our fellows and those we certify, when you're talking about anterior versus posterior SC joint injuries. Anterior, it's very conservative. If it's acute, typically start with a sling, might use some NSAIDs or some ice, some gentle range of motion based on pain. Once pain subsides, really the concern are more cosmetic. I actually had a patient with three years of a significant anterior SC joint dislocation, and she said it was just bothering her. So I actually sent her to one of our surgical colleagues after getting a CAT scan, but that was not an emergent issue. That was basically she failed everything conservatively. A posterior issue, if I have sufficiently scared everybody now and what I went through last fall, is this is an emergency. You need to know your protocols. You need to know what to look for. And this is one of those few times when you say you go to the emergency room, you alert people, and you get going right away. This is not getting an MRI and we wait five to seven days. The other thing I would mention, particularly if you're a younger junior attending, is just let your orthopedic colleagues know or let your car thoracic colleagues know, don't just send the patient to the emergency room, particularly at the high school level when there's less resources versus if you're talking at a collegiate level and above when there may be a lot more people aware and things may be facilitated a little bit easier. If you just have a 15-year-old kid coming from a local high school, the resources are tough to get. So if you can do anything to expedite the treatment, that is very much going to be appreciated by everybody involved. All right. Another CAQ question. Andy, can you load it up? So let's see here. I'll do it like that. Jim, can you see the verbiage of the question? Just let me know. If not, I'll read it. Eighteen-year-old left-hand dominant core back sacked and driven to the ground into his right shoulder. Has immediate pain evaluated in the sidelines. he's got elevation and tenting of skin near his AC joint. Radiographs in the tunnel reveal an AC joint injury, no fracture with a cortical clavicular distance greater than two times the elevation compared to the left shoulder. So what are your next steps? I'll give about 15, 20 more seconds. And in a few seconds, we will see what everyone said. Andy, can you load up the results? All right, 70% of us said choice B, which is the correct answer, and there are a few others. So let's go over why that is and more about AC joint injuries in a little more detail. So the AC joint is a diarthrobial joint. Everyone always asks when they're looking at x-rays for the first time, oh, is six millimeters too wide for the AC joint or 12 millimeters? Remember, this is sort of a average. If you have a six foot six individual who's very large and you have a five foot one dancer, they're gonna be a little bit different. But in general, the average is approximately nine millimeters in length from superior to inferior and about 19 millimeters in depth from anterior to posterior. There are static and dynamic stabilizers. I want you to really focus, in this case, on the static stabilizers. That's your AC joint capsule, your ligaments, as well as your coracocovicular ligaments. That includes the conoid ligament medially and the trapezoid ligament laterally. And that's important to understand when we talk about some fractures. With all due respect to Tony Romo, he had way too many clavicle and AC joint injuries. I apologize if anyone's a Cowboys fan on the call today. But typically, the mechanism of their direct trauma, so falling directly onto the superior lateral shoulder, is very similar to one of the two mechanisms of AC joint injuries. Or there's an indirect injury where you have a foosh or someone lands, but because the force is dissipated from distal to proximal, you feel it go directly into your AC joint. That is very similar to mechanism number two, I'm sorry, mechanism number one for the AC joints. The concept is very similar. Your physical exam, I think this should be second nature at this point, but to be thorough, we inspect palpate and then do range of motion. So inspection, is there a deformity, is there symmetry or asymmetry to the non-affected side? Obviously, you wanna palpate all your bony landmarks and you wanna do passive and active range of motion as long as the patient can. A little pearl here, if you ask the patient to shrug shoulders, that will reduce an AC joint type three injury. It will not reduce a type five. And we'll go over what that means if you don't know in a few minutes. Obviously, we're gonna wanna test strength. I personally would make sure you test from fingertips to shoulders. Don't just do shoulders and even biceps. I always do on any patient with a shoulder and a minimum wrist grip, radial pulse and flexion extension. It takes all five seconds to do, but occasionally you may pick something up. Special tests, there are lots of special tests. I'm not going to go into this in depth, but if I were a fellow, I would learn at least two or three good tests for each structure you're learning as opposed to trying to memorize 15 different tests for something. Learn something and learn it well. In this case, if we're talking about the AC joint, we wanna do a cross arm adduction maneuver. Sometimes it's just called the scarf test. There is also an active compression test. And honestly, just as simple as just looking at the shoulder and palpating if it hurts at the distal clavicle and AC joint. Lastly, neurovascularly, you wanna at a minimum do a light touch to your axillary nerve or lateral deltoid as well as checking pulses. I would also include your brachial pulses as well. So here is the very basics of AC joint imaging. We talked about serendipity view for SE joints. Well, for the AC joint, you wanna remember maybe a couple other things as well. There's something called a Zanka view, and that is about 10 to 15 degrees. You might wanna get bilateral views to compare if it is not an obvious injury. And also, again, as I mentioned, axillary view, and the way I explain it to patients is it's the armpit view. But the axillary X-ray will evaluate if there's a type four injury or not. The rest of this you can read, and again, the slides will be available if you wanna see where this comes from. So some examples of radiographs. We have an AP view. I think all of us have seen that at this point. We have an axillary view, and again, this is what Dr. Moeller asked at the very start of the talk. This is needed to diagnose a type four injury. And then we have the Zanka view, where the X-ray beam is aimed at the AC joint about 10 to 15 degrees phallic tilt. So this is the Rockwood classification of AC joint injuries. If you notice, I put a little pearl on the lower right-hand side of the screen. If you're gonna remember a couple things today for your CHQ exam, this slide will probably be helpful, very similar to the summary slide of the SC joint injuries. So some of you may have seen this before, some of you may not. But with a type one, type two, and type three injury, you really wanna start with understanding if there is any pathology to your acromioclavicular ligament, as well as your coracoclavicular ligament. So a type one, they're both intact. Type three, they're both ruptured. Type two, the CC ligament is only a partial injury. Why is that important? That will be helpful to understand why something looks like it looks, and we'll show you the X-rays in a moment. So if you're looking at a grade two injury, you have a complete AC tear, but your CC is not completely torn. So that way, you may have somewhere between 25 and 100% elevation in comparison to your acromion versus your distal clavicle, you can see right here, as opposed to a type three, your AC and CC are both torn. And if your CC is torn, because that goes from here to here, your clavicle now is not allowed to be stabilized. It's a stacked stabilizer, as we talked about. So it's gonna be elevated greater than 100% than the acromion. So you can see right here. So you see the difference of here versus here. So that's the difference between a grade two and grade three. That is something you'd be very comfortable with diagnosing in clinic because these are very common injuries. When we get to types four, five, and six, these are not non-operative injuries typically. These are surgical, but it is your job to understand what they are, diagnose them, and get them to the appropriate surgical colleague if that patient is a surgical candidate. So similar to one through three, here's four, five, and six. Four, five, and six, remember three, both of the ligaments are already torn. So you should already know four, five, and six, probably those ligaments are going to be torn. There's a little exception for type six. You also have to understand the difference between type four and type five. So this is where you have to know about your delto-trapezial fascia. In a type four, which remember an axillary view, an X-ray view of the axillary will be helpful. It's injured as the clavicle is displaced posteriorly. So if you think about that, it's a posterior view. That's the only reason that we can detect, the only way we can detect this is with an axillary X-ray. As opposed to a type five, it's injured, the fascia is injured and stripped off, and you see between 100 to 300% increase in the clavicle to acromion distance. So again, understanding some of the take-homes. Type four, you need an axillary. Type five, significant elevation, even greater than type three. So if we look at some X-rays, so here's a type four, and this is an axillary view. So usually what I do with our residents and fellows, we have some med students as well, is the first question I ask them is where is the coracoid? That's how you can orient yourself. On this picture or this radiograph, it is actually quite difficult to find it. It's actually hidden, basically the way we're looking here, you have your humeral head, acromion, and your coracoid. So that way we can tell that this is now posterior, and this is a type four, as your AC joint is disrupted and it's posterior. So your coracoid is anterior or to the slight left where my arrow is, and here is where the distal clavicle is, which means this has gone posterior. And then if you look here, I don't think I put a number at the top, but this is a type five. Now again, understanding type three versus type five is a subtlety you do need to become aware of, but it is still something that you should understand that there's more than 100% elevation off of the acromion versus clavicle plane. It's just significantly greater than a type three. And again, here's a type five to show you how significant, this is probably two and a half to three times elevation. So type six is a direct, again, understand where the directionality is. So a type six is where the clavicle is inferior below the coracoid process. So you should actually be able to see that here. And while I'm not going to ask anybody to write in or chat in, there actually is more than just a AC joint injury. There is an avulsion right here, and hopefully someone else caught it. You have a non-display scapular body fracture on the lateral aspect of the cortex right here, and that's just on one view. So this is a type six AC joint injury. So what are the treatments? So for grade one and two, it's very straightforward. Typically, we're going to use a sling. Sometimes for type one, you don't even need a sling, but if they're in pain, you can use a sling. My rule of thumb, and honestly, I've had a lot of very experienced athletic trainers like to give this advice, type one, one to two weeks, type two, two to three weeks, but we really like to begin some gentle range of motion, some pendulums as soon as possible. We don't want to develop any form of capsulitis. If possible, start a rotator cuff strengthening program with some tubing, at least below eye level. Don't have to go above eye level, but at least at waist level. So there are some considerations. Is it the dominant arm or non-dominant arm if it's an overhead athlete? So obviously, we were talking about Tony Romo before. If this was his left arm, he can come back much sooner. If it was his right arm, it's going to be much more difficult to come back sooner. I think the most recent example of this was, I think it was Zach Rehnke had a clavicle fracture and was still with the Royals, and it was on his throwing side. So he had to have surgery as opposed to trying to have it healed non-operatively. Just to be aware, even though grade one and grade two AC joint injuries seem like almost just bad bruises, things can happen. This was, I think, two weekends ago. Someone correct me if I'm wrong, I think it was two weekends ago, one of the cornerback safeties for the, I guess, Las Vegas Raiders now, suffered a grade two AC joint sprain. However, a small piece of his collarbone chipped off, and he ended up having some internal bleeding. So this is extremely rare, but always be thinking, always keep, especially for our fellows, keep your differential open, just in case something out of the ordinary occurs. So grade three, grade three injuries are controversial. There really is no clear treatment algorithm. There's some expert recommendations from some surgeons that are out there, but typically what we're gonna do is begin with non-operative management and repeat radiographs at three to six weeks after the initial injury. I would, my personal opinion is, keep your surgical colleagues involved, whether it's general orthopedics or shoulder surgeons, or the head orthopedic surgeon for your team, because grade three are a little bit controversial. Just to be thorough, though I do not expect this to be on the CAQ, the International Society of Arthroscopic Knee and Orthopedic Surgery, one of their committees actually provided some specifications and made type three injuries into type 3A versus 3B. I'm not going to go into it, and again, I do not expect a non-operative physician to have to know this, but I'm pointing this here just to be thorough. Again, considerations are the same as before. Now with the type three injury, if you have a football lineman, and they have rehab for six to eight weeks, and they think they can play using padding, then we can try to play. But if it's a dominant overhead athlete, such as a swimmer, javelineer, baseball, softball, et cetera, that may be a little more difficult to return to play quickly. Again, this is just a cartoon of the Rockwood classification of AC joint injuries. And this is the summary from OrthoBullets, which I know a lot of you, if you're not aware of it, this is a nice site for summaries. It's also a little off-the-cuff humor. It's definitely a little bit more accurate than maybe going to Wikipedia sometimes, which I know some of you do. But this is a very nice summary of AC joint injuries. Clavicle injuries. And by clavicle injuries, I'm talking about fractures. Management's a little bit controversial. It seems to kind of ebb and flow over the years. You have to consider a couple things. Is this a mid-shaft fracture? Is this a distal fracture? Is your patient skeletally mature versus immature? Is it the non-dominant versus dominant side? Does this patient play a contact sport, a collision sport? Are they older or not? Is this a first-time injury or a repeat injury? Neurovascular status, open or closed? And one thing I did not put on this list, but to consider also, is there tinting of the skin? These are just a couple suggested manuscript reviews that are fairly new. The research kind of keeps changing, but one of them just came out in the last few months, the other in the last couple, few years. So I list them here. If you have access to PubMed and your medical center has subscriptions, you should be able to get these without any difficulty. All right, Andy, last question. If you can load it up, please. All right. So you have a 14-year-old left-hand dominant girl comes to clinic for shoulder pain, and her date of injury was yesterday. Outside x-rays revealed a distal clavicle fracture, and the radiologist stated that the fragment is concerning for the fracture being distal to the conoid ligament, and there's less than two centimeters of displacement. Weighted x-rays were performed and revealed about a centimeter and a half change in relation to the corcoid. She's a softball player. It is her dominant shoulder I forgot to mention, so my apologies. When can she return? So here are your choices. I'm gonna give you about 30 seconds. And when everyone answers, Andy, if you can throw up the percentages, please. Okay. So our toughest question yet, 44% said refer to surgery, 44% said, eh, let me re-X-ray you in four weeks, 10% said, eh, let's start some range of motion because I don't want you to get a frozen shoulder. But everyone did not select MRI, and even though MRI is my favorite imaging site, that is correct. Well, let's talk about what the right answer is. The right answer is actually not only pairing with sling, but then refer for an unstable distal clavicle fracture. We will go over that in the next couple of slides. So clavicle fractures, the mechanism, very similar to what we've talked about already. Even though they're traumatic, in the younger population, there are high energy mechanisms such as MVA or sports-related injuries. Our older geriatric population may be due to falls such as from standing. Fall onto shoulder, direct blows, foosh, exact same thing as AC and SE injuries. Our exam, everything we've already talked about, we always want to compare to the contralateral side, really want to palpate and get a good neurovascular exam as well. Radiographs. So again, we want to have a comparison view. If anything is not confirmed, if you have a scalpely immature person and you're unsure if there is a fracture, by all means, get the contralateral side. So there's different types of clavicle fractures. There's type 1, type 2, type 3. Type 1 is the middle one-third. This is an extremely common fracture. Then you have type 2s and type 3s. Type 3, if you remember, was associated with that SE joint case that I presented at the very start of this talk. So let's talk about the middle one-third. I would suspect most of you already in your fellowship and even some of the older residents have probably seen acute middle clavicle fractures or mid-shaft fractures. These are, as I said, the most common, somewhere around 80-85%, I believe, maybe a little bit less or more depending on which data you look at, databank. Typically, if they're non-displaced, you're going to use a sling, rest, non-operative management. There really is no consensus on duration of the sling. I've seen anywhere from two to six weeks. But what is really important, you want to really avoid contact and collision sports for at least three months, maybe as much as five months, depending on the sport, the age, the athlete, the dominant side or non-dominant, as I mentioned before. Why? Again, let's use Tony Romo as an example. If you had an injury there and you're playing a contact collision sport and you fall on that side again or if you get speared, until that callus is solidified at least three months, the likelihood of re-injury is much higher than someone who has not sustained a bony injury on that side. So lateral one-third. These fractures are less common depending where you look and go from 12% to 28% of clavicle fractures. So there's type one, type two, and type three. Type one injuries are distal to the coracocovicular ligaments. These are minimally displaced that are stable versus type two, the medial fragment, so in this case, the long bone, is discontinuous with the coracocovicular ligaments. The medial fragment often exhibits vertical instability. So if you look in the picture here from one of the reviews, you can see that the conoid ligament is ruptured, which would make this part of the clavicle unstable and can rise up. So that is why the question that I asked before, the correct answer indeed is, while you do want to sling somebody, this is one where you want to get a second opinion sent to a shoulder and elbow surgeon to see if they're going to need surgery or not. You're not going to see these too frequently, but it is very important and it would be very impressive to recognize these when you get the x-rays and if you're suspecting instability, so you get them over to one of your surgical colleagues in a timely manner. And finally, the medial fractures, these are extremely rare, and as you notice with my case, that's the first one I have ever seen associated with that injury. There's different classifications. I have never seen anyone either in a practice test or the actual test been asked to give a classification of a medial clavicle fracture, but what is most important with a medial clavicle fracture is assessing the SC joint, is assessing neurovascular status, pulmonary status, and if you need to get advanced imaging, just like we talked about the SC joint injuries, you do that. So here are the very basics for surgical referral recommendations for clavicle fractures. Number one, if anything is displaced and or shortened greater than two centimeters, it does not mean they're having surgery, but that is sort of the guideline that has been kind of taught over the years. Is there involvement of the AC joint, and in particular, that's medial to the coracoclavicular ligament, as I just mentioned? If there's any neurovascular compromise, this becomes more of an acute issue. Same with the open fracture. If there's significant tension in the skin, such as in this picture, that is another reason, and if there's something called a floating shoulder, if there is basically a concomitant ulenoid fracture, and I put the website on here in case you're curious to look in that picture in a little more detail. So that took us just shy of 45 minutes. Let me unshare, and I will let—there's no questions in the chat, so if anyone wants to write in questions, or if Dr. Mohler got anything, or wants to ask me questions, I'm more than happy to stay on. We got a few more minutes before at least the East Coasters have to go back to clinic. All right, Jason, fantastic job. I always love listening to you talk. I always pick up something new, and I really appreciate the time you put into putting together such a great lecture for us. I've got a few questions for you. First of all, were you apologizing to Dallas Cowboy fans because they're Dallas Cowboy fans, or were you apologizing to them because of the injury that took place to Tony Romo? I mean, I can't complain, because my wife's from Boston, so I had the Patriots for 20 years before Brady left, so I like Romo, he's a good announcer. I just feel bad he got injured so much. The Cowboys are one of the—when you look at teams that are the most hated and the most beloved, Dallas makes both lists every year, as do the New York Yankees. Just a little point for everybody. That means nothing to do with this lecture. I have a question about weighted views for you on x-ray. I don't do weighted views for AC joint injuries because it doesn't change my clinical management in most cases. What do you feel about weighted views for AC joint injuries? I don't do AC joint injuries also. The way I think of weighted views for the AC joint injury is similar to a stress view with a Weber B fracture in the ankle, is if you think that there's a concomitant injury in the syndesmosis or proximal fibula or medial side ankle, and you get a stress view, you're just going to worsen that injury. If you're already concerned that there is an AC joint injury that's more severe than a type 2, telling me if it's type 3 versus type 5, it still needs to go over to see the surgeon anyways. If it's a type 4 versus type 6, it still needs to be seen by a surgeon anyways. So I personally, this is not Evan's base, this is just my opinion, I don't do stress views for AC joint injuries for the exact reason you just mentioned. Yeah, and a 4 and a 6, the stress view is not going to add anything because it's only depressing the shoulder. It's not taking it further into a posterior plane or into an inferior plane. Having suffered a type 2 AC sprain, which are quite painful, quite honestly, and again, I'm kind of wimpy anyway, but back when I did it 20 years ago, the weighted views were part of the general series. It's painful just to do the view. For the patient perspective, you're not helping make your decision and you're making them more uncomfortable. So Ahmad Bazi, who's actually one of my fellows at Henry Ford, has a question. He first says, thank you for your lecture. Is a CT always warranted for SC joint dislocations, including anterior dislocations, to rule out fracture? All right. So Ahmad, thank you for the question and for putting up with your fellowship director, number one. Appreciate that. Yeah. So part of it's the timing. So I will give you an example. I think I mentioned before, I had a patient come in about two or three weeks ago with a chronic anterior SC joint injury. It was chronic. It was three years out, but she can move it back and forth, but she said she was sick of dealing with this. So I was going to eventually send her on and she's going to see one of my surgical colleagues. They may want the advanced imaging for surgical planning purposes, but does that person need a CT? No, not necessarily. You can tell it's out. But if you have any suspicion in an acute SC injury, I would get it, particularly if you can't see an anterior bulge, because that means it's either a kind of, it was a impact where there's going to be almost like a bone bruise, or there can even just be a simple posterior subluxation, which I had one of those a couple of months ago, right before all the shutdown started. So that was in February, I think it was. And there still can be a little bit of bruising or a hematoma that forms posterior to that SC joint. So for me, particularly because of all the neurovascular structures that are back there, acute injury, and there's not an anterior bulge, I'm getting the CAT scan. And even if there's an anterior, and if you've got a high level athlete, if you want to see if any of that capsule is torn, it's always helpful to know. If it's anterior, do you have to get it stat? No, you don't. You could even get an MRI if you want to look at the soft tissue. But for me, it's really understanding and recognizing that you get an SC joint injury, and that there's a possibility of a posterior injury. They're extremely rare. You see one, you'll never forget it. And like I said, I saw one last year, and that's my only one in nine years for a true posterior, but you will never forget it. The video that we shared, and I appreciate that you used it, I have these videos and don't end up using them for more than my fellow lecturers, that individual, there's a question as to whether or not it was an acute or a chronic injury, because he only really relayed a single injury event around the time that he came in with pain in that area as a hockey player, and he basically got crushed up against the boards, which is a great way also to get your AC injuries. It's kind of a badge of courage for hockey players to have AC joints that look a little bit abnormal. But as a hockey player, you take a lot of hits, and he says, well, I hurt my shoulder once, but I don't really remember what it was, and that was probably the original injury event. The team physician for the school was an orthopedic surgeon, and we called just to kind of let her know that we saw the athlete, and our plan was to do conservative management because it did not seem grossly unstable. She wanted to see him and ended up getting additional imaging, both CAT scan and an MRI scan, and ended up treating him conservatively just to kind of finish off that case. Just a reminder to everyone, Jason did mention that the proximal growth plate in the clavicle stays open quite long, and it's considered to be one of potentially the last closing growth plates in the body. The ischial tuberosity also closes in the early to mid-20s, as does the proximal clavicle. So I had a question for you, too, on radiographs and determining grade two versus three AC joint injuries. The coracoclavicular distance, measuring that distance and comparing it to the non-injured side, what is your cutoff for saying this is a two versus a three? Is it a millimeter difference, or is it a percentage difference, and what would be those numbers? I usually use, well, so I do it two different ways. One is, do I see that there's a doubling? So can I see that if you have your coracoid and clavicle, that it's doubled, so it's more than 100%? To me, that's a three. If it's anything that is less than 100% but it's elevated, it's a two. If you go to the Rockwood classification, I believe they say it's 25 to 100%, and a three is 100% above. So for me, visually, as long as you have a very good x-ray, you're basically looking straight on. So if you have something like this, then that's a three, and you have this, it's a two. So 25 to 100% elevation with respect to the plane of the chromium is a two, 100% and up would be a three. But some people now are actually measuring from the top of the coracoid process of the scapula to the superior margin of the coracoid to the inferior margin of the clavicle itself, as opposed to looking at the acromion to, I still use the acromion to clavicle orientation and do it the way you did it, but some people are now actually measuring the distance from the superior margin of the coracoid to the inferior margin of clavicle, and I was wondering, I don't do that. And so I don't really have that data at my fingertips, but I was wondering if you knew. I don't do that. I know some of the shoulder surgeons may, but again, you then need to have, well, what was it before the injury? Because even, so the example is, if you compare it to the other side, well, that's great, but what if it's a dominant overhead athlete and that shoulder is lax to begin with? Is there an extra millimeter or two of laxity to begin with because you're a throwing athlete? So for me, the concept makes sense, but it's very similar to like talking about range of motion shoulder if you're a baseball pitcher, where you have significantly increased external range of motion on your throwing shoulder versus you're not, but if you just looked at the right shoulder, like, oh, wow, you have an extra 20 degrees. So for me, it's still looking at the comparison of the acromion on the clavicle, and my surgical colleagues I've sent over, that's how they have looked at as well, and my MSK radiology colleagues have also looked at that. And I approach it the same way. I just, again, I've read about it and I don't have the numbers committed to memory, but again, you also have to get a radiograph of the opposite side, which means you're not focusing your beam directly. If you're trying to get them both in the same picture, you're not focusing the beam in my eyes appropriately on the AC joint that you're trying to look at. So again, I tend not to use it as well. So I appreciate that input. We don't have any more questions in the chat right now. So if people want to open up their microphones and, you know, just say hello to us, we'd appreciate it. We're kind of by ourselves here a little bit. Part of the deal is we want to make sure that you feel comfortable in talking with folks like Jason, who's, again, a well-established sports doc and a board of director. I'm a former board of director as well. We don't want to pressure you to say hello or to open it up and ask any questions that have come about, but feel free to do so. Yeah, I, you know, my approach sometimes, Jason, and I don't know if this is being cavalier or not, maybe you can, you know, knock me in the head if I am being cavalier, but when people are doing well with regards to motion and strength, and so their shoulder function is good after an AC, especially an AC injury, because that's clearly what we see the most of, clavicle fractures and AC injuries. And you know, I have a patient with, let's say, a grade three injury. We decided to treat them non-operatively, which is most of the cases in my practice, and they have full range of motion, they have full strength, they have no neurologic findings, but they're still sore over the AC joint. That's going to take a long time for that soreness to go away. My feeling is if they can protect themselves on the field, and they have appropriate function to perform the tasks that they need to perform on the field, again, whether they're sore or not to me, I'll put them back in the game, because if you're waiting for that pain to go away completely, it could take a long, long time. And there's no guarantee, you don't get to decide which shoulder you get hit on, which shoulder you get driven into the boards or into the grass, those kinds of things. So I tend to say, look, if you can prove to me that you have a normal exam with aside from the discomfort, and potentially the deformity that you see, but everything else is normal, you can protect yourself adequately, and you can do your job on the field, even if you're sore, I'll still let you play. Yeah, I think that's the case too. Obviously, you know, the non-throwing athlete, it's a little easier to do that. But you know, we usually tell folks, the grade three injuries, you're going to hurt for three months. You know, I mean, that's, you know, and if it's a little bit less than that, fantastic. But I mean, you're still going to have this, you know, soreness here and there. What's interesting, the folks who come in with chronic grade three injuries, they say, I feel fine. I just, they go like this, and their AC joint is kind of flailing around, and they have no pain when they come back like a year later, two years later. Yeah, I think the toughest thing is, is what's the sport, and it's the dominant side. But if you have a lineman, and it's been eight weeks, and he or she can go, and kind of using a figure four, and then taping up that the AT can do, you can try it. Or if you want to try to gut out through the rest of the season, then you see the surgeon at the end of the season. I think that's okay. But they're going to probably need, well, most people need at least six to eight weeks if you're non-throwing, if you, you know, if you're a lineman or something like that, if you are a cross country runner, or maybe you just need your arms to pull, but you're not really going to hopefully have any collision at all. But that's also where, you know, for our fellows, developing good relationships and communication with your senior ATs, head ATs, and your head team surgeon, or your surgical colleagues, because, you know, every type three injury is not the same. You know, there's times when you may do something nonoperatively. The surgeon may say, you know what, maybe we're going to try orthobiologic treatment, try to tighten up that joint, because it's been so long, because they don't have surgery. You may not have thought of that. So there's basic principles in everything, but every now and then there's the art of medicine also. Yeah, I keep telling people it's the practice of medicine, not the perfect of medicine. So we keep learning as we go. So Jason, again, we appreciate the fine lecture that you provided us here today. Folks, if you were on board here, you can tune into the Collaborate webpage and fill out the evaluation form, that would be fantastic. If you need to review it, it will be up, visible on a recorded platform through the Collaborate website in the future as well. So keep an eye out for that, and also keep an eye out for all future lectures. And we'll start dropping recorded lectures at some point in the coming months as well. So Jason, again, really, really appreciate it. Fantastic job. Everybody, thanks for tuning in. And any final words, Jason, before we go? No. Everyone have a good day, enjoy the rest of clinic or whatever you're doing today. Thank you. All right. Bye, guys.

3rd Edition, CASE 10

3rd Edition

Chest

AMSSM

fellowship education

sports medicine

Jason Zaremsky

AC joint injuries

SC joint injuries

clavicle injuries

CAQ exam preparation

diagnostic techniques