Injuries of the Clavicle, Acromioclavicular Joint and Sternoclavicular Joint Andrew H. Schmidt, M.D....

Injuries of the Clavicle, Acromioclavicular Joint and

Sternoclavicular Joint

Andrew H. Schmidt, M.D.Revised October 2010

Andrew H. Schmidt, MD & T. J. McElroy, MD; Created March 2004; Revised January 2007 & October 2010

Goals

1) Review anatomy of clavicle, AC joint, and sternoclavicular joint

2) Review imaging of these areas.

3) Clavicle FracturesNonoperative RX

Surgical Repair

Nonunions and Malunions

4) AC Joint Injuries

5) Sternoclavicular joint injuries

Clavicle

“S”-shaped bone Medial - sternoclavicular joint

Lateral - acromioclavicular joint and coracoclavicular ligaments

Muscle attachments:– Medial: sternocleidomastoid

– Lateral: Trapezius, pectoralis major

AC Joint

Diarthrodial joint between medial facet of acromion and the lateral (distal) clavicle.

Contains intra-articular disk of variable size.Thin capsule stabilized by ligaments on all sides:

– AC ligaments control horizontal (anteroposterior ) displacement– Superior AC ligament most important

Distal Clavicle

Coracoclavicular ligaments– “Suspensory ligaments of the upper

extremity”– Two components:

• Trapezoid• Conoid

– Stronger than AC ligaments– Provide vertical stability to AC joint

Mechanism of Injury

Direct impact to the anterior - superior shoulder of moderate – high force.

1. Fall from height

2. Motor vehicle accident

3. Sports injury

4. Blow to the point of the shoulder

5. Rarely, a direct injury to the clavicle

Physical Examination

Inspection– Evaluate deformity and/or

displacement– Beware of rare inferior or

posterior displacement of distal or medial ends of

clavicle– Compare to opposite side.


PalpationEvaluate pain

Look for instability with stress


Neurovascular examination– Must be done thoroughly and documented!

Evaluate upper extremity motor and sensation

Measure shoulder range-of-motion

Radiographic Evaluationof the Clavicle

Anteroposterior View

30-degree Cephalic Tilt View

Radiographic Evaluation of the Clavicle

Quesana View– 45-degree angle superiorly and a 45-degree

angle inferiorly – Provide better assessment of the extent of

displacement

Radiographic Evaluation of the AC Joint

Zanca View– AP view centered at AC joint with 10

degree cephalic tilt– Less voltage than used for AP shoulder

Stress Views of the Distal Clavicle & AC Joint

Rationale: demonstrate instability and differentiate grade III AC separations from partial Grade I-II injuries.

Performed by having patient hold 10# weight with injured arm.

Rarely used today, since most Grade I-III AC joint injuries are treated the same anyway, and management of distal clavicle

fractures depends on initial displacement and location of fracture.

Radiographic Evaluation of the Medial One Third

X-ray: Cephalic tilt view of 40 to 45 degrees

CT scan usually indicated to best assess degree and

direction of displacement

S=sternumC= medial clavicleE= esophagus

Clavicle Fractures

Classification of Clavicle Fractures

Group I : Middle third– Most common (80% of clavicle fractures)

Group II: Distal third– 10-15% of clavicle injuries

Group III: Medial third– Least common (approx. 5%)

Treatment Options

Nonoperative– Sling– Brace

Surgical– Plate Fixation

– Screw or Pin Fixation– Titanium elastic nails (usually

inserted medial to lateral)

Nonoperative Treatment

“Standard of Care” for most clavicle fractures.

Unclear about the need to wear a specialized brace.

Simple Sling vs. Figure-of-8 Bandage

Prospective randomized trial of 61 patients

Simple sling– Less discomfort

Functional and cosmetic results identical

Alignment of healed fractures unchanged from the initial displacement in both groups

Andersen et al., Acta Orthop Scand 58: 71-4, 1987.


It is difficult to reduce clavicle fractures by closed means.

Most clavicle fractures unite rapidly despite displacement.

Significantly displaced mid-shaft and distal-third injuries have a higher incidence of nonunion.


There is new evidence that the outcome of nonoperative management of displaced

middle-third clavicle fractures is not as good as traditionally thought, with many patients

having significant functional problems.

Deficits following nonoperative treatment of displaced midshaft clavicular fractures

A patient-based outcome questionnaire and muscle-strength testing were used to evaluate 30 patients after nonoperative

care of a displaced midshaft fracture of the clavicle.

At a minimum of twelve months (mean 55 mos), outcomes were measured with the Constant shoulder score and the

DASH patient questionnaire. In addition, shoulder muscle-strength testing was performed with the Baltimore Therapeutic Equipment Work Simulator, with the

uninjured arm serving as a control.

McKee et al. J Bone Joint Surg Am 2006;88-A:35-40.

Deficits following nonoperative treatment of displaced midshaft clavicular fractures

The strength of the injured shoulder was:– 81% for maximum flexion, 75% for endurance of flexion,

– 82% for maximum abduction, 67% for endurance of abduction, – 81% for maximum external rotation, 82% for endurance of

external rotation, – 85% for maximum internal rotation, and 78% for endurance of

internal rotation (p < 0.05 for all).

Mean Constant score = 71 pointsMean DASH score = 24.6 points, indicating substantial

residual disability.

McKee et al. J Bone Joint Surg Am 2006;88-A:35-40.

Conclusion of McKee study

Displaced midshaft clavicle fractures can cause significant, persistent disability, even

if they heal uneventfully.

Definite Indications for Surgical Treatment of Clavicle Fractures

1) Open fractures

2) Associated neurovascular injury

Relative Indications for Acute Treatment of Clavicle Fractures

1) Widely displaced fractures2) Multiple trauma

3) Displaced distal-third fractures

Relative Indications for Acute Treatment of Clavicle Fractures

4) Floating shoulder5) Seizure disorder

6) Cosmetic deformity7) Earlier return to work.

Clavicular Displacement Literature

< 5 mm shortening: acceptable results at 5 years (Nordqvist et al, Acta Orthop Scand 1997;68:349-51.

> 20 mm shortening associated with increased risk of nonunion and poor functional outcome at 3 years (Hill et al, JBJS

1997;79B: 537-9)

Plate Fixation

Traditional means of ORIF

Plate applied superiorly or inferiorlyInferior plating associated with lower risk of

hardware prominence.

Used for acute displaced fractures and nonunions.

May dissect out supraclavicular sensory nerves

Courtesy T. Higgins

Nonoperative Treatment Compared with Plate Fixation of Displaced Midshaft Clavicular Fractures.

A multicenter, randomized clinical trial

132 patients– 67 ORIF

– 65 sling

Constant and DASH scores significantly improved in ORIF group.

Time to union 16 vs 28 weeks in favor of ORIF

9 patients in sling group had symptomatic malunion

9 patients in ORIF group had hardware complications

Canadian Orthopedic Trauma Society; JBJS Am;2007:89A: 1-10

Intramedullary Fixation

Large threaded cannulated screwsFlexible elastic nails

K-wiresAssociated with risk of migration

Useful when plate fixation contra-indicatedBad skin

Severe osteopeniaFixation less secure

Titanium Elastic Nails

Same as used in pediatric femur fractures.

Accommodate three-dimensional anatomy of the clavicle.

Typically inserted “retrograde” (from medial to lateral)

Best in fractures without comminution

Small incision at fracture site may be needed.

Minimally Invasive Intramedullary Nailing of MidshaftClavicular Fractures Using Titanium Elastic Nails

31 cases evaluated 26 mos avg (6-46 mos)

Three groups:Isolated, n=9

Additional injuries, n=15

Multiple injuries, n=7

Mueller M, et al. J Trauma 2008;64:1528-1534

Minimally Invasive Intramedullary Nailing of MidshaftClavicular Fractures Using Titanium Elastic Nails

No nonunions or refractures in any group.

7 cases medial migration; 1 case lateral perforation in 1 case req’d shortening of nail.

No differences in outcome between groups in subjective outcome and objective scores

(DASH, Constant and Murley).

Mueller M, et al. J Trauma 2008;64:1528-1534

30 patients: simple shoulder sling

90% union

2 symptomatic malunions req’d OR

30 patients elastic nail

100% union

7 cases medial nail protrusion

2 refractures

Better DASH and Constant outcome scores, significantly different during

first 18 weeks.

Patients more satisfied with cosmetic appearance and overall outcome.

Comparison of Techniques

No studies available that compare one operative technique to another.

Both elastic nails and plates seem equivalent in stable fractures; benefits of minimally invasive approach used in elastic nailing

awaiting study.

Plate fixation best in comminuted fractures, but again no evidence.

Does Timing of Surgery Matter?

Matched group comparison of 15 patients who underwent early compression plate

fixation to 15 other patients who had operative repair of a malunion/nonunion at

avg of 63 months.

Potter JM, et al. J Shoulder Elbow Surg 2007;16:514-8


Outcome Early Delayed

Strength = =

Endurance 109% 80% (p=.05)

Constant score 95 89 (p=.02)

DASH score 3.0 7.2 (p=.15)

Satisfaction exc exc



Conclusion: Late reconstruction provides outcome similar to acute repair, except for

subtle decreases in endurance strength.

Such information might be of value in initial decision-making.


Complications of Clavicular Fractures and its Treatment

Nonunion

Malunion

Neurovascular Sequelae

Post-Traumatic Arthritis

Risk Factors for the Development of Clavicular Nonunions

Location of Fracture – (outer third)

Degree of Displacement – (marked displacement)

Primary Open Reduction

Principles for the Treatment of Clavicular Nonunions

Restore length of clavicle– May need intercalary bone graft

Rigid internal fixation, usually with a plate

Iliac crest bone graft– Role of bone-graft substitutes not yet defined.

Correction of symptomatic nonunion with IM screw

Clavicular Malunion

Symptoms of pain, fatigue, cosmetic deformity.Initially treat with strengthening, especially of

scapulothoracic stabilizers.Consider osteotomy, internal fixation in rare cases in

which nonoperative treatment fails.

Correction of malunion with thoracic outlet sx

Neurologic Sequelae

Occasionally, fracture fragments or abundant callus can cause brachial plexus symptoms.

Treatment is reduction and fixation of the fracture, or resection of callus with or

without osteotomy and fixation for malunions.

McKee MD, et al. J Bone Joint Surg Am 2003;85-A(5):790-7

Osteotomy for Clavicular Malunion

15 patients with malunion after nonoperative treatment of a displaced midshaft clavicle fracture of the clavicle.

Average clavicular shortening was 2.9 cm (range, 1.6 to 4.0 cm).

Mean time from the injury to presentation was three years (range, 1 to 15 years).

Outcome scores revealed major functional deficits.

All patients underwent corrective osteotomy of the malunion through the original fracture line and internal fixation.

McKee MD, et al. J Bone Joint Surg Am 2003;85-A(5):790-7

Osteotomy for Clavicular Malunion

At follow-up (mean 20 months postoperatively) the osteotomy site had united in 14 of 15 patients.

All 14 patients satisfied with the result.Mean DASH score for all 15 patients improved from 32 points preoperatively to 12 points at the time of follow-up

(p = 0.001).Mean shortening of the clavicle improved from 2.9 to 0.4 cm

(p = 0.01).There was 1 nonunion, and 2 patients had elective removal of

the plate.

Rosenberg N, et al. J Shoul Elbow Surg 2007;16:510-513

Functional Outcome of Surgical Treatment of Symptomatic Nonunion and Malunion of Midshaft

Clavicle Fractures

13 cases plate fixation / autogenous grafting of a clavicle nonunion / malunion, followed mean 41 months.

All united46% returned to previous job and sport

Constant scores remained lower than opposite arm<25% free of pain.

Distal Third Clavicle Fractures

Classification of Distal Clavicular Fractures

(Group II Clavicle Fractures)

Type I-nondisplaced – Between the CC and

AC ligaments with ligament still intact

From Nuber GW and Bowen MK, JAAOS, 5:11, 1997


Type II– Typically displaced secondary to a fracture

medial to the coracoclavicular ligaments, keeping the distal fragment reduced while allowing the medial fragmetn to displace

superiorly– Highest rate of nonunion (up to 30%)

– Two Types

Type IIA

A. Conoid and trapezoid attached to distal fragment


Type IIB

Type IIB: Conoid torn, trapezoid attached



Type III:articular fractures


Treatment of Distal-Third (Type II) Clavicle Fractures

Nonoperative treatment– 22 to 33% failed to unite

– 45 to 67% took more than three months to heal

Operative treatment– 100% of fractures healed within 6 to 10 weeks after

surgery

Displaced Type II fractures of the distal clavicle are often treated more aggressively because of the increased risk of nonunion

with nonoperative treatment

Techniques for Acute Operative Treatment of Distal Clavicle Fractures

Kirschner wires inserted into the distal fragmentDorsal plate fixationCC screw fixation

Tension-band wire or sutureTransfer of coracoid process to the clavicle

Clavicular Hook Plate

For most techniques of clavicular fixation, coracoclavicular fixation is also needed to

prevent redisplacement of the medial clavicle.

The Hook Plate (Synthes USA, Paoli, PA) was specifically designed to avoid this problem of redisplacement.

Hook Plate - Results

Recent series of distal clavicle fractuers treated with the Hook Plate document high union rates of 88% - 100%. Complications

are rare but potentially significant, including new fracture about the implant, rotator cuff tear, and frequent subacromial

impingement.

Preferred technique for fixation of acute distal third clavicle

fractures

Horizontal incisionManual reduction of fracture

Dorsal tension band suture and reconstruction/augmentation of

coracoclavicular ligaments.

Look for avulsion fracture of CC ligament attachment

If present, this fragment can be sutured to proximal (eg. medial) clavicle to restore

stability, without need for hardware.

Jackson WFM, et al. J Trauma 2006;61:222-225

Indications For Late Surgery For Distal Clavicle Fractures

Pain

Weakness

Deformity

Techniques For Late Surgery For Distal Clavicle Fractures

Excision of distal clavicle– With or without reconstruction of coracoclavicular ligaments (Modified

Weaver-Dunn procedure)

Reduction and fixation of fracture

Case Example 1

Case Example 1

Distal Clavicle

Medial Clavicle

Case Example 1

Coracoclavicular fixation not visible

Fixation to Acromion

Case Example 2

This fragment likely has CC ligament attached; need to reduce and hold clavicle shaft to this piece.

Case Example 2


Sutures passed into this fragment (not visible)

Case Example 2



4 months

Case Example 2



2 years

Acromioclavicular Joint

Mechanism

Sports injury or trauma.

Impact to superior acromion, driving the arm down and rupturing the AC joint capsule (first) and then the the coracoclavicular

ligaments (second).

Physical Findings

Pain over lateral clavicle / AC joint

May have prominent distal clavicle

May have skin abrasions

Unwilling to lift arm.

Should have full passive ROM of the shoulder.

Radiographic Evaluation of the Acromioclavicular Joint

Proper exposure of the AC joint requires one-third to one-half the x-ray penetration of routine shoulder

viewsInitial Views:

– Anteroposterior view– Zanca view (15 degree cephalic tilt)

Other views:– Axillary: demonstrates anterior-posterior displacement

– Stress views: not generally relevant for treatment decisions.

Classification For Acromioclavicular Joint Injuries

Initially classified by both Allman and Tossy et al. into three types (I, II, and III). Rockwood later added types IV, V, and VI, so that now six types are recognized.

Classified depending on the degree and direction of displacement of the distal clavicle.

Allman FL Jr. Fractures and ligamentous injuries of the clavicle and its articulation. JBJS 49A: 774-784, 1967.

Rockwood CA Jr and Young DC. Disorders of the acromioclavicular joint, In Rockwood CA, Matsen FA III: The Shoulder, Philadelphia, WB Saunders, 1990, pp. 413-476.

Type I

Sprain of acromioclavicular

ligamentAC joint intact

Coracoclavicular ligaments intact

Deltoid and trapezius muscles intact


AC joint disrupted

< 50% Vertical displacement

Sprain of the coracoclavicular

ligaments

CC ligaments intact

Deltoid and trapezius muscles intact

Type II


Type III

AC ligaments and CC ligaments all disrupted

AC joint dislocated and the shoulder complex

displaced inferiorlyCC interspace greater than

the normal shoulder(25-100%)

Deltoid and trapezius muscles usually detached from the distal clavicle


Type III Variants

“Pseudo-dislocation” through an intact periosteal sleeve

Physeal injury

Coracoid process fracture

Type IV

AC and CC ligaments disrupted

AC joint dislocated and clavicle displaced posteriorly into or

through the trapezius muscle

Deltoid and trapezius muscles detached from

the distal clavicle


Type V

AC ligaments disrupted

CC ligaments disrupted

AC joint dislocated and gross disparity between

the clavicle and the scapula (100-300%)

Deltoid and trapezius muscles detached from

the distal half of clavicle


Type VI

AC joint dislocated and clavicle displaced inferior

to the acromion or the coracoid process

AC and CC ligaments disrupted

Deltoid and trapezius muscles detached from the

distal clavicle


Treatment Options For Types I - II Acromioclavicular Joint Injuries

Nonoperative: Ice and protection until pain subsides (7 to 10 days).

Return to sports as pain allows (1-2 weeks)

No apparent benefit to the use of specialized braces.

Type II operative treatment– Generally reserved only for the patient with

chronic pain.– Treatment is resection of the distal clavicle and

reconstruction of the coracoclavicular ligaments.

Treatment Options For Type III-VI Acromioclavicular Joint Injuries

Nonoperative treatment– Closed reduction and application of a sling and harness to

maintain reduction of the clavicle– Short-term sling and early range of motion

Operative treatment– Primary AC joint fixation

– Primary CC ligament reconstruction (usually with allograft, often with augmentation)

– Excision of the distal clavicle – Dynamic muscle transfers

Type III Injuries: Need for acute surgical treatment remains very controversial.

Most surgeons recommend conservative treatment except in the throwing athlete or

overhead worker.

Repair generally avoided in contact athletes because of the risk of reinjury.

Literature unable to support operative or nonoperative treatment as superior

Functional outcomes appear similar.

Cosmesis not different (scar vs bump)

Only 50% of surgical cases reduced at follow-up.

10% complications after surgery.

Ceccarelli et al. J Orthopaed Traumatol 2008;9:105-108.

Indications for Acute Surgical Treatment of Acromioclavicular

Injuries

Type III injuries in highly active patients

Type IV, V, and VI injuries

Surgical Options for AC Joint Instability

Coracoid process transfer to distal transfer (Dynamic muscle transfer)

Primary AC joint fixation

Primary Coracoclavicular Fixation

CC ligament reconstruction +/- distal clavicle excision.

Weaver-Dunn Procedure

The distal clavicle is excised.The CA ligament is transferred to

the distal clavicle.The CC ligaments are repaired

and/or augmented with a coracoclavicular screw or

suture.Repair of deltotrapezial fascia


Indications for Late Surgical Treatment of Acromioclavicular

Injuries

Pain

Weakness

Deformity

Techniques for Late Surgical Treatment of Acromioclavicular

Injuries

Reduction of AC joint and repair of AC and CC ligaments

Resection of distal clavicle and reconstruction of CC ligaments (Weaver-Dunn Procedure)

Case Example

AP View

Zanca View

Case Example

After Weaver-Dunnprocedure

Sternoclavicular Joint

From Wirth MA and Rockwood CA, JAAOS, 4:268, 1996

The Anatomy of the Sternoclavicular Joint

Diarthrodial Joint“Saddle shaped”Poor congruence

Intra-articular disc ligament. Divides SC joint into two

separate joint spaces.Costoclavicular ligament- (rhomboid ligament) Short and strong and consist of an anterior

and posterior fasciculus

Interclavicular ligament- Connects the superomedial aspects of each clavicle with the

capsular ligaments and the upper sternum

Capsular ligament- Covers the anterior and posterior aspects of the joint and represents

thickenings of the joint capsule. The anterior portion of the ligament is heavier and stronger

than the posterior portion.

Epiphysis of the Medial Clavicle

Medial Physis- Last of the ossification centers to appear in the body and the last

epiphysis to close.

Does not ossify until 18th to 20th year

Does not unite with the clavicle until the 23rd to 25th year

Radiographic Techniques for Assessing Sternoclavicular

Injuries40-degree cephalic tilt

view

CT scan- Best technique for

sternoclavicular joint problems


Injuries Associated with Sternoclavicular Joint

Dislocations

Mediastinal CompressionPneumothorax

Laceration of the superior vena cava

Tracheal erosion


Treatment of Anterior Sternoclavicular Dislocations

Nonoperative treatment

• Analgesics and immobilization

• Functional outcome usually good

Closed reduction

• Often not successful

• Direct pressure over the medial end of the clavicle may reduce the joint

Treatment of Posterior Sternoclavicular Dislocations

Careful examination of the patient is extremely important to rule out vascular

compromise.Consider CT to rule out mediastinal

compressionAttempt closed reduction - it is often

successful and remains stable.

Closed Reduction Techniques

Abduction traction

Adduction traction

“Towel Clip” - anterior force applied to clavicle by percutaneously applied towel

clip

Operative techniques

Resection arthroplasty

– May result in instability of remaining clavicle unless stabilization is done.

– Suggest minimal resection of bone and fixation of medial clavicle to first rib.

Sternoclavicular reconstruction with suture, tendon graft.

Literature – For those interested in further review.

Clavicle Fractures

Andersen K; Jensen PO; Lauritzen J. Treatment of clavicular fractures. Figure-of-eight bandage versus a simple sling. Acta Orthop Scand 1987 Feb;58(1): p71-4.

Canadian Orthopaedic Trauma Society. Nonoperative Treatment Compared with Plate Fixation of Displaced Midshaft Clavicular Fractures. A multicenter, randomized clinical trial. J Bone Joint Surg

2007;89-A:1-10.

McKee MD, Pedersen EM, Jones C, et al. Deficits following nonoperative treatment of displaced midshaft clavicular fractures. J Bone Joint Surg 2006;88-A:35-40.

Mueller M, Rangger C, Striepens N, Burger C. Minimally Invasive Intramedullary Nailing of Midshaft Clavicular Fractures Using Titanium Elastic Nails. J Trauma 2008;1528-1534.

Nowak J, Holgersson M, Larsson S. Can we predict long-term sequelae after fractures of the clavicle based on initial findings? A prospective study with nine to ten years of follow up. J Shoudler Elbow

Surg 2004;13:479-486.

Potter JM, Jones C, Wild LM, Schemitsch EH, McKee MD. Does delay matter? The restoration of objectively measured shoulder strength and patient-oriented outcome after immediate fixation versus

delayed reconstruction of displaced midshaft fractures of the clavicle. J Shoulder Elbow Surg 2007;16:514-518.

Robinson CM, Court-Brown CM, McQueen MM, Wakefield AE. Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. J Bone Joint Surg Am 2004;86-A:1359-

1365.

Smekal V, Irenberger A, Struve P, Wambacher M, Krappinger D, Kralinger FS. Elastic Stable Intramedullary Nailing Versus Nonoperative Treatment of Displaced Midshaft Clavicular Fractures

—A Randomized, Controlled, Clinical Trial. J Orthop Trauma 2009;23:106-112.


Distal – Third (lateral) Clavicle Fractures

Jackson WF, Bayne G, Gregg-Smith SJ. Fractures of the lateral third of the clavicle: an anatomic approach to treatment. J Trauma;61(1):222-225.

Meda PV, Machani B, Sinopidis C, et al. Clavicular hook plate for lateral end fractures:- a prospective study. Injury;2006:37(3):277-283.


Acromioclavicular Joint Injuries

Calvo E, Lopez-Franco M, Arribas IM. Clinical and radiologic outcomes of surgical and conservative treatment of type III acromioclavicular joint injury. J Shoulder Elbow

Surg. 2006;15(3):300-305.

Ceccarelli E, Bondi R, Alviti F, et al. Treatment of acute grade III acromioclavicular dislocation: a lack of evidence. J Orthopaed Traumatol 2008;9:105-108.

Lizaur A, Marco L, Cebrian R. Acute dislocation of the acromioclavicular joint. Traumatic anatomy and the importance of deltoid and trapezius. JBJS 1994;76B:

602-606.

Mikek M. Long-term shoulder function after type I and II acromioclavicular joint disruption. Am J Sports Med. 2008;36:2147-2150.

Nadarajah R, Mahaluxmivala J, Amin A, Goodier DW. Clavicular hook—plate: complications of retaining the implant. Injury 2005;36:681-683.

Spencer EE. Treatment of grade III acromioclavicular joint injuries: a systematic review. Clin Orthop Relat Res. 2007;455:38-44.

Return to Upper Extremity

Index

E-mail OTA about

Questions/Comments

If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e-mail to [email protected]

mailto:[email protected]?subject=RSP%20Author%20Volunteer%20/%20Recommend%20Updates

http://www.ota.org/res_slide/index.html

mailto:[email protected]?subject=Resident%20Slide%20Presentation%20U01

Injuries of the Clavicle, Acromioclavicular Joint and Sternoclavicular Joint Andrew H. Schmidt, M.D....

Documents

Transcript of Injuries of the Clavicle, Acromioclavicular Joint and Sternoclavicular Joint Andrew H. Schmidt, M.D....