1. Cardiff School of Engineering
Coursework Cover Sheet
Personal Details
Student No: 1056984
Family Name: Divecha First Name: Hiren
Personal Tutor: Prof Sam Evans Discipline: MMM
Module Details
Module Name: Surgical Practice Module No: ENT547
Coursework Title: Weekend 2 Coursework - Shoulder
Lecturer:
Submission Deadline: 10/1/2012
Declaration
I hereby declare that, except where I have made clear and full reference to the work of
others, this submission, and all the material (e.g. text, pictures, diagrams) contained in it, is
my own work, has not previously been submitted for assessment, and I have not knowingly
allowed it to be copied by another student. In the case of group projects, the contribution of
group members has been appropriately quantified.
I understand that deceiving, or attempting to deceive, examiners by passing off the work of
another as my own is plagiarism. I also understand that plagiarising another's work, or
knowingly allowing another student to plagiarise from my work, is against University
Regulations and that doing so will result in loss of marks and disciplinary proceedings. I
understand and agree that the University’s plagiarism software ‘Turnitin’ may be used to
check the originality of the submitted coursework.
Signed: …..…………………………………….………... Date: ……………………

2. Coursework 2 – Midshaft Clavicle
Fractures & ACJ Dislocations
Hiren Maganlal Divecha
Candidate Number: 1056984
ENT547 – Surgical Practice
Word count – 3402

3. Contents
1. Classify clavicle shaft fractures ....................................................................................................1
2. Discuss management of midshaft clavicle fractures with reference to biomechanics ...................3
a) Undisplaced ............................................................................................................................3
b) Displaced.................................................................................................................................3
3. Classify ACJ injuries .....................................................................................................................6
4. Critique this classification ............................................................................................................7
5. Describe the biomechanics of ACJ stabilisers ...............................................................................8
a) Static stabilisers.......................................................................................................................8
b) Dynamic stabilisers ..................................................................................................................9
6. Describe treatment options for Type IV/V ACJ injuries. Give biomechanical advantages/
disadvantages of these options ......................................................................................................... 10
7. With respect to ACJ injuries, review the literature and discuss treatment options for all groups 12
a) Type I/ II ................................................................................................................................ 12
b) Type III .................................................................................................................................. 12
c) Types IV/ V/ VI....................................................................................................................... 13
8. How would you have a Type III injury treated if it was your shoulder? How would you manage an
elite rugby player with the same acute injury? .................................................................................. 15
9. References ................................................................................................................................ 16

4. 1. Classify clavicle shaft fractures
One of the earliest clavicle fracture classifications was described by Allman (Allman, 1967) and simply
grouped the fractures according to location and in descending order of incidence:
 Group 1 – middle 1/3rd
 Group 2 – distal to coraco-clavicular ligaments (non-union common)
 Group 3 – proximal 1/3rd
Most modern classifications are based on this, but subdivide each group further. Craig’s (1990) and
Robinson’s (1998) classifications are commonly used (table 1) and take into account fracture
location, displacement, stability and joint involvement. This may make the day to day use of such
systems a bit more difficult, but including these variables allows for some guidance as to the risk of
delayed/ non-union (and of post-traumatic OA in the case of intra-articular involvement). In a
comparison of prognostic value in predicting delayed/ non-union between 5 classification systems,
O’Neill et al (2011) found that Craig’s classification had the greatest prognostic value for lateral third
fractures whilst Robinson’s classification had the greatest prognostic value for middle third fractures.
1

5. Robinson Craig
a1. Undisplaced - Extra-articular
a2. Undisplaced - Intra-articular
Type 1 (medial 1/5) Group I (mid. 1/3)
b1. Displaced - Extra-articular
b2. Displaced - Intra-articular
Type1: Minimal displacement (inter-ligamentous)
a1. Cortical alignment - Undisplaced Type 2: Displacement secondary to fracture medial to ligaments
a2. Cortical alignment - Angulated a. Conoid and trapezoid attached
Type 2 (mid. 3/5)
Group II (dist. 1/3) b. Conoid torn, trapezoid attached
b1. Displaced - Simple, wedge Type 3: Intra-articular
b2- Displaced - Multifrag, segmental Type 4: Ligaments attached to periosteal sleeve, displacement of prox. frag.
Type 5: Comminuted, ligaments attached to comminuted inf. frag.
a1. Undisplaced - Extra-articular Type1: Minimal displacement
a2. Undisplaced - Intra-articular Type 2: Significant displacement (ligaments ruptured)
Type 3 (lateral 1/5)
Group III (prox. 1/3) Type 3: Intra-articular
b1. Displaced - Extra-articular Type 4: Epiphyseal separation (paediatric)
b2. Displaced - Intra-articular Type 5: Comminuted
Table 1: Outline of Robinson's and Craig's classification systems of clavicle fractures
2

6. 2. Discuss management of midshaft clavicle fractures with reference
to biomechanics
The goal of treatment of these injuries is to restore shoulder function to (near) normal levels.
a) Undisplaced
Undisplaced midshaft clavicular fractures can be treated non-operatively (Khan, et al., 2009). Initially,
patients are immobilised in a sling for 2-4 weeks followed by physiotherapy and active motion
thereafter. Depending on radiographic signs of union, full mobilisation can begin at 6 weeks and
contact sports at 3 months (Khan, et al., 2009) (Preston & Egol, 2009). A figure of eight bandaging
technique used to be employed, however this has not been found to affect fracture healing outcome
and can be associated with patient discomfort, axillary pressure sores and neurovascular
compromise (Andersen, et al., 1987) (Stanley, et al., 1988). In a large systematic review, the non-
union rate with non-operative treatment in undisplaced fractures was reported at 5.9% (increasing to
15% in displaced fractures) (Zlowodzki, et al., 2005).
b) Displaced
Historically, displaced clavicular shaft fractures were treated non-operatively. Amongst reasons for
this was the reported increased non-union rates following attempted ORIF (Neer, 1968) (Rowe,
1968)). More recent studies (McKee, et al., 2006) including a large prospective randomised trial by
the Canadian Orthopaedic Trauma Society (2007), have shown lower non-union rates and better
functional outcomes following ORIF for displaced midshaft clavicular fractures. Indications for
operative intervention include:
1. Open fracture/ overlying skin compromise
2. High energy injuries with more than 2 cm displacement (increased non-union risk) 16
3

7. 3. Associated neurovascular compromise/ injury may necessitate exploration and repair followed
by fracture fixation
Relative indications include:
1. Polytrauma
2. Floating shoulder injury
3. Symptomatic mal/ non-union
Other studies have shown that non-union rates may be as high as 20% in displaced and comminuted
fractures after nonsurgical treatment and that strength and endurance deficits are more common in
these cases.36,52 These reports, in combination with a more prognostic classification system, have
led many authors to recommend acute surgical fixation for these fracture subtypes.53
Historically, K-wires and threaded pins (e.g.: Knowles pins) have been used to stabilise these fracture
types. These methods have been associated with significant complication rates, non-union and in
particular the risk of pin migration into nearby vital structures (Grassi, et al., 2001). Osteosynthesis of
midshaft clavicular fractures can be achieved with plate or intramedullary pin fixation.
 Plate fixation allows for accurate reduction and absolute fracture stability through rigid fixation.
This allows early mobilisation. Use of anatomically contoured plates obviates the need for
removal of prominent hardware, usually.
 Antegrade or retrograde IM pin fixation allows for relative stability but benefits from better
cosmesis and less periosteal stripping. As they are not locked, they have little rotational stability
(Golish, et al., 2008) (Renfree, et al., 2010).
Renfree et al (2010) compared IM pins with unicortically locked plates and bicortically non-locked
plates in synthetic clavicle fracture models under cantilever and 3-point bending. They concluded
that both plate constructs provided similar rigid fixation (added advantage of unicortical screws –
4

8. avoid plunging into underlying neurovascular structures). The IM pin was less stiff (greater
displacements) and provided little rotational stiffness. Interestingly, a clinical comparison of union
rates and functional outcomes between plate and IM fixation has reported similar good results with
no differences in complication rates (Liu, et al., 2010). A clinical comparison between locked and non-
locked plates by Cho et al (2010) similar times to union and functional outcome scores between the 2
groups, with less evidence of screw loosening in the locked group.
It remains apparent that good results may be achieved operatively, but the ideal fixation device
remains uncertain. Future work should be directed at clinically based, comparative/ controlled,
functional outcome related research in this area. An example of this is the multicentre randomised
controlled trial in progress in the UK (Longo, et al., 2011).
5

9. 3. Classify ACJ injuries
Acromio-clavicular joint injures were originally classified by Tossy et al in 1963 (1963) and later by
Allman in 1967 (1967) into three groups. This was then expanded in 1989 to 6 groups by Williams et
al (1989) to describe the Rockwood classification (table 2), which remains in current use:
Type AC Lig CC Ligs Delto-trapezial fascia Instability Radiographic CC distance
I Sprained Intact Intact None Normal (1.1-1.3 cm)
II Torn Sprained Intact AP <25%
III Torn Torn Intact AP and vertical 25-100%
IV Torn Torn Torn Unstable (posterior displacement
into trapezius)
V Torn Torn Torn Unstable 100-300%
VI Torn Intact Torn Decreased
Table 2: Rockwood classification of ACJ injuries (AC – acromio-clavicular; CC – coraco-clavicular). Adapted from
(Simovitch, et al., 2009)
Physeal separations of the distal clavicle and fractures of the base of the coracoid (CC ligaments
remain intact and attached) may be falsely described as Type III injuries. In Type IV injuries, it is
important to exclude a concomitant anterior dislocation of the sterno-clavicular joint. In Type V
injuries, the delto-trapezial fascia tears and the resulting increase in CC separation is large. The
weight of the arm results in the scapula being pulled downwards and anteriorly (unopposed pull of
serratus anterior). Type VI injuries are rare and are seen in high-energy polytrauma scenarios. The
distal clavicle dislocates inferiorly into a subacromial or subcoracoid position (can result in brachial
plexus or vascular compression/ injury). Mechanism – hyperabduction and external rotation of the
arm combined with retraction of the scapula).
6

10. 4. Critique this classification
The Rockwood classification system defines injuries to the ACJ by increasing soft tissue damage
(table 2). Structures fail in sequence (AC ligaments, CC ligaments, delto-trapezial fascia) with
resulting increased disruption and instability of the ACJ. The classification system stratifies injuries
according to increasing energy and can therefore guide treatment (generally non-operative for Types
I-III; operative for some type III and all Types IV-VI). However, a diagnosis based on a single, static
sagittal radiograph may result in over-/under-estimation of the extent of the injury. For this reason,
attempts have been made to correlate radiographic classification with USS, MRI and intra-operative
findings.
Heers and Hedtmann (2005) found that USS was 80% sensitive and 100% specific for diagnosing
deltoid/ trapezial detachment and fascial disruption (intra-operatively confirmed). Interestingly, 9/31
Type III and 2/28 type II injuries were found to have damage to deltoid/ trapezius insertions or to the
delto-trapezial fascia. Nemec et al (2011) found that MRI findings were concordant with the
radiographic Rockwood type in 52% however, 36% were reclassified into a less severe type and 11%
into a more severe type. Additional ligamentous injuries were found in 25%.
Thus, whilst the Rockwood classification remains the main classification in use for ACJ injuries and is
easily used/ reproducible, investigative adjuncts such as USS and MRI may be useful in delineating
the extent of soft tissue damage, which is not apparent on static radiography. This may be
particularly important in Type III injuries in aiding the management decisions. Outcomes in both
conservative and operative treatment are mixed in this group and this could be due to poorer results
seen in those patients who have been conservatively managed that actually had more severe soft
tissue damage than appreciated radiographically.
7

11. 5. Describe the biomechanics of ACJ stabilisers
The ACJ is a diarthrodial joint formed between the lateral end of the clavicle and the medial end of
the acromion. A fibrocartilaginous intra-articular disc may be found, though this degenerates by the
fourth decade. The clavicle rotates approximately 5° to 8° relative to the acromion because of
synchronous scapula-clavicular motion (Flatlow, 1993), which is probably why shoulder elevation
remains normal after CCJ arthrodesis. The ACJ stabilisers can be grouped into static and dynamic.
a) Static stabilisers
These include the following – ACJ capsule (thin, minimal contribution), AC ligaments, CC ligaments.
Fukuda et al (1986) studied the contribution of each structure to the overall stability of the ACJ. The
AC ligamentous complex is comprised of anterior, superior, posterior and inferior ligaments. The
posterior and superior AC ligaments are the strongest and provide the majority of stability in the AP
plane. Excision of more than 1 cm of distal clavicle results in increased posterior translation of the
clavicle (Branch, et al., 1996) (Corteen & Teitge, 2005).
The CC ligaments are comprised of the medial conoid ligament and the lateral trapezoid ligament.
The conoid ligament is the main vertical constraint, whilst the trapezoid resists compressive axial
loading of the ACJ (Fukuda, et al., 1986). Interestingly, the contributions to stability of these
structures differs with increasing loads (figure 1) – thus the AC ligaments are more important at small
loads whereas the conoid provided greater stability at larger loads.
8

12. Figure 1: Relative contributions of structures to ACJ vertical stability with increasing load (taken from pg 438
(Fukuda, et al., 1986))
b) Dynamic stabilisers
The anterior deltoid and trapezius muscles insert via the delto-trapezial fascia into the acromion/
superior AC ligament and provide dynamic stability to the ACJ and repair of these structures should
be considered as part of the reconstructive process (Lizaur, et al., 1994).
9

13. 6. Describe treatment options for Type IV/V ACJ injuries. Give
biomechanical advantages/ disadvantages of these options
Generally, Type IV/ V injuries require surgical management to reduce and stabilise the ACJ. The goals
of treatment are to reduce the ACJ, pain free movement and to restore strength to (near) normal.
There are numerous procedures in use that can be broadly grouped into primary fixation, CC interval
fixation and anatomic CC reconstructions (ACCR). Some surgeons will combine procedures in an
attempt to augment repairs performed.
Primary fixation involves an open reduction of the joint, which is then stabilised by either K-wires,
Steinmann pins or a hook-plate (passed under the acromion). The ligamentous structures are allowed
to heal primarily whilst the joint is held reduced. The problems with these methods include loss of
reduction, hardware migration, ACJ OA and secondary metalwork removal (Lemos & Tolo, 2003).
CC interval fixation can also be performed to hold the clavicle reduced whilst the ligaments heal.
Older methods involved a CC screw (such as the Bosworth and Rockwood screws) whilst newer
methods employ the use of synthetic loops (suture material, tape) placed around the coracoid
process and clavicle. Disadvantages of these methods include breakage, fracture of coracoid/
clavicle, foreign body reaction, clavicle osteolysis and cut-out/ loss of reduction (Stewart & Ahmad,
2004). If screws are used, secondary hardware removal is also required. The use of tight-rope/ endo-
button devices has also been described (Walz, et al., 2008). This cadaveric study found the
reconstructed ACJ had greater loads to failure and less displacement than the native ACJ. Potential
complications include failure of the button device, fracture and loss of reduction.
Ligament reconstruction techniques seem to give the best biomechanical results in restoring/
maintaining ACJ reduction and providing a strong enough fixation to allow early mobilisation and
10

14. return to function. Furthermore, they provide a scaffold for revascularisation to occur. Disadvantages
include donor site morbidity.
 The Weaver Dunn procedure describes transfer of the CA ligament to the distal clavicle (with
excision of the distal end of the clavicle). This technique has been extensively modified since its
description. Suture loops (CC) can be used to strengthen the construct. However, this still only
provides 25% of the strength of the intact CC complex with significant translations compared to
the normal ACJ (Harris, et al., 2000)
 A similar procedure has been described using the lateral half of the conjoined tendon that is
harvested distally (left attached to coracoid) and then attached to the distal clavicle to hold it
reduced. This has been found to be stronger than using the CA ligament (which may be of
variable quality) (Jiang, et al., 2007)
 ACCR using semitendinosus (or anterior tibialis) autograft can be used in a double bundled
fashion to anatomically recreate both components of the CC ligament. The graft is passed
through a coracoid bone tunnel, crossed into a figure-of-eight, secured with interference screws
in 2 separate clavicular bone tunnels, the anterior limb of the graft is sutured over the repaired
ACJ and the repair augmented with a suture loop. Mazzocca et al (2006) performed a cadaveric
comparison of this technique to a modified Weaver-Dunn repair (with suture loop augmentation)
and to an arthroscopic CC screw fixation (with suture loop augmentation). They reported that
only the anatomic double bundled repair provided AP and superior stability similar to the intact
ACJ.
11

15. 7. With respect to ACJ injuries, review the literature and discuss
treatment options for all groups
a) Type I/ II
These injuries are treated conservatively: analgesia, rest in broad arm sling for 1-3 weeks, ROM/
strengthening exercises thereafter and return to activity when a pain-free ROM is achieved (usually
3-6 weeks). This may be extended to delay return to heavy manual work or contact sports until 8
weeks. Surgical intervention in these injuries is not supported although there are associated
mid/long-term complications. Minor symptoms (clicking, mild pain) may be found in 30% of Type I
and 42% of Type II injuries; severe symptoms (pain, limitation of activity) can be found in 9% of Type I
and 23% of Type II injuries (Bergfeld, et al., 1978). The same study reported the presence of
radiographic ACJ OA in 50%. Moushine et al (2003) reported that 27% of Type I/ II injuries treated
conservatively developed chronic ACJ symptoms (at mean of 6 months) requiring later surgery.
b) Type III
The majority of Type III injuries should probably be treated conservatively given the findings of
equivalent satisfaction (87%-conservative; 88%-operative), return to activity, pain relief, ROM and
strength in the meta-analysis of conservative vs. operative management by Phillips et al (1998).
Furthermore, surgically treated patients will have potential complications. Wojtys & Nelson (1991) et
al found a statistically insignificant reduction in strength and endurance in labourers and athletes
with conservative management. Although they concluded that adequate strength could be recovered
with conservative treatment, they felt that patients involved in activities requiring high-level
shoulder function might benefit from surgical intervention. This view is held by other authors
(Simovitch, et al., 2009), though the lack of conclusive evidence is noted. Furthermore, the risk of
late sequale (distal clavicle osteolysis, persistent pain/ instability and ACJ OA) should be discussed
12

16. with patients during the decision making process as surgery may be required later for these
complications.
An adequate structured rehabilitation programme (focus on strengthening deltoid, trapezius,
sternocleidomastoid, subclavius, rotator cuff and periscapular stabilizers (Simovitch, et al., 2009)) is
essential to proper conservative management of these injuries. Glick et al (1977) found no residual
pain in professional and competitive amateur athletes managed in this fashion.
The patients that do not do well with conservative treatment may represent a group with greater
soft tissue injury (than is appreciated by a single static radiograph) and therefore greater instability
that would do better with surgical intervention. This is an area that needs more clinically directed,
outcome-based research to define the role of acute imaging in guiding acute treatment of these
injuries.
c) Types IV/ V/ VI
These can be grouped together as they all require surgical intervention, along with some acute type
III injuries. There are numerous methods in use in the surgical management of these injuries (see
Question 6 for an overview of specific surgical methods and table 3). Ultimately, the aims of
treatment should be to reduce and stabilise the ACJ to allow pain-free ROM and return to (near)
normal strength. Jari et al (2004) suggest that methods that preserve the ACJ articulation are
preferable as they reduce the joint contact forces. What is apparent is that, biomechanically, ACCR
methods most closely recreate the normal CC ligament strength and stability. However, long-term
comparative/ controlled clinical results are lacking in the literature.
13

17. Study Methodology Outcome
(Mazzocca, et al., 2006) Modified Weaver-Dunn procedure vs. Comparable vertical stability and load to failure
arthroscopic suture fixation vs. ACCR ACCR had least AP translation
(semitendinosus)
(Jari, et al., 2004) CA ligament transfer vs. CC sling vs. Rockwood Largest vertical translations with after the CA ligament transfer (>300%)
screw Largest posterior translations with CC sling (330%)
Rockwood screw most rigid construct, but results in increased joint forces
(Costic, et al., 2004) Intact ACJ vs. ACCR (semitendinosus) Stiffness and ultimate load to failure of the ACCR was significantly lower than in the
normal ACJ with clinically insignificant elongation following cyclic loading
(Deshmukh, et al., 2004) Weaver-Dunn vs. augmented Weaver-Dunn Greater load to failure in augmented Weaver-Dunn (319N vs. 177N) and less instability
procedure No significant difference between suture anchor choice for the augmentation
(Lee, et al., 2003) CA ligament transfer vs. CC Mersilene tape sling CA ligament transfer weakest, Mersilene tape better initial strength
vs. ACCR (semitendinosus, gracilis, long toe ACCR superior to both (similar ultimate load to failure among different grafts)
extensors)
(Wilson, et al., 2005) Weaver-Dunn vs. Weaver-Dunn augmented Augmented Weaver-Dunn better approximated normal ACJ stability
with CC suture anchor fixation
(Harris, et al., 2000) CA ligament transfer vs. CC sling vs. 2 CC suture CA ligament transfer weakest. CC slings had high tensile strength but elongated at failure.
anchors vs. unicortical Bosworth screw vs. Bicortical CC screws provided the highest tensile strength and stiffness
bicortical Bosworth screw
Table 3: Summary of ACJ reconstruction methods (adapted from pg 216-7 in (Simovitch, et al., 2009))
14

18. 8. How would you have a Type III injury treated if it was your
shoulder? How would you manage an elite rugby player with the
same acute injury?
I would manage my shoulder and an elite rugby player with an acute Type III ACJ injury the same
way. Whilst I am not a professional level athlete, my chosen career path (orthopaedic surgery)
dictates that I maintain acceptable health and manual dexterity given the skilled (often fine/
precision work) nature of surgery. Anything less than near-normal restoration of ACJ function could
potentially affect my ability to operate as a surgeon now and in the future (in terms of late
complications such as on-going pain/ instability and ACJ OA).
I would have the injury fully assessed using USS (or MRI) to determine the extent of soft tissue
damage (including disruption of delto-trapezial fascia and deltoid/ trapezius muscle detachments)
that would require surgical repair. Given the current evidence (Simovitch, et al., 2009) (which
unfortunately is based on small case series and controlled laboratory studies), I would support the
use of an anatomic double-bundle autograft (semitendinosus) reconstruction of the CC ligaments
with repair + superior augmentation of the ACJ followed by an appropriate early mobilisation
physiotherapy programme (pendular/ passive ROM till 8 weeks to allow graft maturation, active
ROM thereafter). I would not allow resisted training to begin until after 3 months. In the case of an
elite rugby player, I would anticipate a return to full contact by 6 months.
15

19. 9. References
Allman, F. L., 1967. Fractures and ligamentous injuries of the clavicle and its articulation. J Bone Joint
Surg, 49(4), pp. 774-84.
Andersen, K., Jensen, P. & Lauritzen, J., 1987. Treatment of clavicular fractures. Figure-of-eigth
bandage versus a simple sling. Acta Orthop Scand, Volume 58, pp. 71-4.
Bergfeld, J. A., Andrish, J. T. & Clancy, W. G., 1978. Evaluation of the acromioclavicular joint following
first- and second- degree sprains. Am J Sports Med, Volume 6, pp. 153-9.
Branch, T. P. et al., 1996. The role of acromioclavicular ligaments and the effect of distal clavicle
resection. Am J Sports Med, 24(3), pp. 293-7.
Cho, C.-H.et al., 2010. Operative treatment of clavicle midshaft fractures: Comparison between
reconstruction plate and reconstruction locking compression plate. Clin Orthop Surg, Volume 2, pp.
154-9.
Corteen, D. P. & Teitge, R. A., 2005. Stabilisation of the clavicle after distal resection: A biomechanical
study. Am J Sports Med, Volume 33, pp. 61-7.
Costic, R. S., Labriola, J. E., Rodosky, M. W. & Debski, R. E., 2004. Biomechanical rationale for
development of anatomical reconstructions of coracoclavicular ligaments after complete
acromioclavicular joint dislocations. J Sports Med, Volume 32, pp. 1929-36.
Craig, E., 1990. Fractures of the clavicle. In: C. A. Rockwood & F. A. Matsen, eds. The Shoulder.
Philadelphia: Saunders, pp. 380-3.
Deshmukh, A. V., Wilson, D. R., Zilberfarb, J. L. & Perlmutter, G. S., 2004. Stability of
acromioclavicular joint reconstruction: Biomechanical testing of various surgical techniques in a
cadaveric model. Am J Sports Med, Volume 32, pp. 1492-8.
Flatlow, E. L., 1993. The biomechanics of the acromioclavicular, sternoclavicular and scapulothoracic
joints. Instr Course Lect, Volume 42, pp. 237-45.
16

20. Fukuda, K. et al., 1986. Biomechanical study of the ligamentous system of the acromiclavicular joint. J
Bone Joint Surg Am, Volume 68, pp. 434-40.
Glick, J. M., Milburn, L. J., Haggerty, J. F. & Nishimoto, D., 1977. Dislocated acromioclavicular joint:
Follow-ip study of 35 unreduced acromioclavicular dislocations. Am J Sports Med, Volume 5, pp. 264-
70.
Golish, S. R., Oliviero, J. A., Francke, E. I. & Miller, M. D., 2008. A biomechanical study of plate versus
intramedullary devices for midshaft clavicle fixation. J Orthop Surg Res, Volume 3, p. 28.
Grassi, F., Tajana, M. & D'Angelo, F., 2001. Management of midclavicular fractures: comparison
between nonoperative treatment and open intramedullary fixation in 80 patients. J Trauma, Volume
50, pp. 1096-100.
Harris, R. I. et al., 2000. Structural properties of the intact and reconstructed coracoclavicular
ligament complex. Am J Sports Med, Volume 28, pp. 103-8.
Heers, G. & Hedtmann, A., 2005. Correlation of ultrasonographic findings to Tossy's and Rockwood's
classification of acromioclavicular joint injuries. Ultrasound Med Biol, 31(6), pp. 725-32.
Jari, R., Costic, R. S., Rodosky, M. W. & Debski, R. E., 2004. Biomechanical function of surgical
procedures for acromioclavicular joint dislocations. Arthroscopy, Volume 20, pp. 237-45.
Jiang, C., Wang, M. & Rong, C., 2007. Proximally based conjoined tendon transfer for coracoclavicular
reconstruction in the treatment of acromioclavicular dislocation. J Bone Joint Surg Am, Volume 89,
pp. 2408-12.
Khan, L. A., Bradnock, T. J., Scott, C. & Robinson, C. M., 2009. Fractures of the clavicle. J Bone Joint
Surg Am, Volume 91, pp. 447-60.
Lee, S. J. et al., 2003. Reconstruction of the coracoclavicular ligaments with tendon grafts: A
comparative biomechanical study. Am J Sports Med, Volume 31, pp. 648-55.
Lemos, M. J. & Tolo, E. T., 2003. Complications of the treatment of the acromioclavicular and
sternoclavicular joint injuries, including instability. Clin Sports Med, 22(2), pp. 371-85.
17

21. Liu, H. H. et al., 2010. Comparison of plates versus intramedullary nails for fixation of displaced
midshaft clavicular fractures. J Trauma, Volume 69, pp. 82-7.
Lizaur, A., Marco, L. & Cebrian, R., 1994. Acute dislocation of the acromioclavicular joint: Traumatic
anatomy and the importance of deltoid and trapezius. J Bone Joint Surg Br, Volume 76, pp. 602-6.
Longo, U. G. et al., 2011. Conservative management versus open reduction and internal fixation for
mid-shaft clavicle fractures in adults - The Clavicle Trial: study protocol for a multicentre randomized
controlled trial. Trials, 12(57), pp. 1-6.
Mazzocca, A. D. et al., 2006. A biomechanical evaluation of an anatomical coracoclavicular ligament
reconstruction. Am J Sports Med, Volume 34, pp. 236-46.
McKee, M. D. et al., 2006. Deficits following nonoperative treatment of displaced midshaft clavicular
fractures. J Bone Joint Surg Am, Volume 88, pp. 35-40.
Moushine, E., Garofalo, R., Crevoisier, X. & Farron, A., 2003. Grade I and II acromioclavicular
dislocations: Results of conservative treatment. J Shoulder Elbow Surg, Volume 12, pp. 599-602.
Neer, C. S., 1968. Fractures of the distal third of the clavicle. Clin Orthop Relat Res, Volume 58, pp.
43-50.
Nemec, U. et al., 2011. MRI versus radiography of acromioclavicular joint dislocation. Am J
Roentgenol, 197(4), pp. 968-73.
O'Neill, B. J. et al., 2011. Clavicle fractures: a comparison of five classification systems and their
relationship to treatment outcomes. International Orthopaedics, 35(6).
Phillips, A. M., Smart, C. & Groom, A. F., 1998. Acromioclavicular dislocation. Conservative or surgical
therapy. Clin Orthop Relat Res, Volume 353, pp. 10-17.
Preston, C. F. & Egol, K. A., 2009. Midshaft clavicle fractures in adults. Bull NYU Hosp Joint Dis, 67(1),
pp. 52-7.
Renfree, T., Conrad, B. & Wright, T., 2010. Biomechanical comparison of contemporary clavicle
fixation devices. J Hand Surg, Volume 35, pp. 639-44.
18

22. Robinson, C. M., 1998. Fractures of the clavicle in the adult. Epidemiology and classification. J Bone
Joint Surg Br, 80(3), pp. 476-84.
Rowe, C. R., 1968. An atlas of anatomy and treatment of midclavicular fractures. Clin Orthop Relat
Res, Volume 58, pp. 29-42.
Simovitch, R. et al., 2009. Acromioclavicular joint injuries: Diagnosis and management. J Am Acad
Orthop Surg, Volume 17, pp. 207-19.
Society, C. O. T., 2007. Nonoperative treatment compared with plate fixation of displaced midshaft
clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am, 89(1), pp. 1-10.
Stanley, D., Trowbridge, E. & Norris, S., 1988. The mechanisms of clavicular fracture. A clinical and
biomechanical analysis. J Bone Joint Surg Br, 70(3), pp. 461-4.
Stewart, A. M. & Ahmad, C. S., 2004. Failure of acromioclavicular reconstruction using Gore-tex graft
due to aspetic foreign-body reaction and clavicle osteolysis: A case report. J Shoulder Elbow Surg,
Volume 13, pp. 558-61.
Tossy, J. D., Mead, M. C. & Sigmond, H. M., 1963. Acromioclavicular separations: Useful and practical
classification for treatment. Clin Orthop Relat Res, Volume 28, pp. 111-19.
Walz, L. et al., 2008. The anatomic reconstruction of acromioclavicular joint dislocations using 2
TightRope devices: a biomechanical study. Am J Sports Med, 36(12), pp. 2398-406.
Williams, G. R., Nguyen, V. D. & Rockwood, C. A., 1989. Classification and radiographic analysis of
acromioclavicular dislocations. Appl Radiol, Volume 18, pp. 29-34.
Wilson, D. R., Moses, J. M., Zilderfarb, J. L. & Hayes, W. C., 2005. Mechanics of coracoacromial
ligament transfer augmentation for acromioclavicular joint injuries. J Biomech, Volume 38, pp. 615-9.
Wojtys, E. M. & Nelson, G., 1991. Conservative treatment of grade III acromioclavicular dislocations.
Clin Orthop Relat Res, Volume 268, pp. 112-9.
Zlowodzki, M. et al., 2005. Treatment of acute midshaft clavicle fractures: systematic review of 2144
fractures. J Orthop Trauma, Volume 19, pp. 504-7.
19

23. 20