Dorsal Scapular nerve course and innervation Pierces middle scalene deep to Levator Scapulae. Innervates: Levator Scapulae, Rhomboid minor and major Long thoracic nerve course and innervation Anterior surface of serratus anterior w/ lateral thoracic artery Innervates: Serratus anterior Suprascapular nerve course and innervation Under transverse scapular ligament in suprascapular notch then spinoglenoid notch (area of compression) Innervates: Supraspinatus and Infraspinatus Lateral Pectoral nerve course and innervation Medial to Medial pectoral nerve with pectoral artery Innervates: Pectoralis major and minor Thoracodorsal nerve course and innervation With thoracodorsal artery deep to Lat Innervates: Latissimus dorsi Axillary nerve course and innervation Inferior to capsule, through quadrangular space, bends anterior ~5cm distal to acromion Innervates: Deep banch- Deltoid Superficial branch- Teres minor Deltoid innervation Axillary nerve Pectoralis major innervation Medial and Lateral Pectoral nerve (medial runs lateral to lateral) Pectoralis minor innervation Medial pectoral nerve Serratus Anterior innervation Long Thoracic nerve Subclavius innervation Nerve to the subclavius Rotator cuff muscles and innervation Supraspinatus- suprascapular nerve Infraspinatus- Suprascapular nerve teres minor- Axillary nerve Subscapularis- Upper and Lower Subscapular nerve Gerdy's tubercle Proximal lateral tibia Insertion of IT band Pubic diastasis Symphysis alone- <2.5 cm Symphysis and sacrospinous ligament- >2.5 cm Symphysis, sacrospinous, sacrotuberous, and posterior sacroiliac- unstable vertically, posteriorly, and rotationally Radiographic signs of Pelvic Instability Sacroiliac displacement of 5mm in any plane Posterior fracture gap (rather than impaction) Avulsion of 5th lumbar transverse process, lateral border of sacrum (sacrotuberous lig), or the ischial spine (sacrospinous lig) Equinus position fixed plantar flexion Pediatric ankle fracture classification Dias and Tachdjian: Lauge Hansen + Salter Harris Supination external rotation Pronation external rotation Supination plantar flexion Supination inversion- I- fibular physis.  II- tibial physis as talus wedges into articular surface (intraarticular and leads to growth disturbance) Toddler's fracture Spiral fracture of tibia in a patient < 2.5 yrs old boys > girls right > left Mechanism- ER of foot with fixed knee Tx: 2-3 weeks LLC --> 2-3 weeks SLC Pediatric Tibial Tubercle fracture classification and treatment Watson Jones: I- small fragment avulsed through 2° ossification center II- 2° ossification center coalesced, fracture at level of horizontal physis III- fracture line passing proximal through tibial epiphysis and into joint Ogden modification: A- minimally displaced/noncomminuted B- displaced or comminuted Tx: IA- LLC 4-6 weeks IB, II, III- Opperative- screws and pins Pediatric knee ossification centers Distal femur- Appears at 39th fetal week, closes at 16-19 yrs, growth of 9mm/yr Proximal tibia- Appears 2 mo, closes 16-19 yrs, growth 6mm/yr Tibial tubercle- Appears 9 yrs, closes 15-17 yrs Pediatric leg length discrepancy s/p femur shaft fracture treatment 2-10 years old: <2 cm shortened- spica cast (overgrowth of 1.5 - 2 cm common) >3 cm shortened- skeletal traction Acceptable angulation of Pediatric Femoral Shaft fracture Birth- 2yrs: Varus/Valgus- 30°, A/P- 30°, shortening- 1.5cm 2- 5yrs: Varus/Valgus- 15°, A/P- 15°, shortening- 2.0 cm 6-10yrs: Varus/Valgus- 10°, A/P- 15o, shortening- 1.5cm 11- mature: Varus/Valgus- 5o, A/P- 10o, shortening- 1.0cm Rotation: 10o, external better tolerated Pediatric femoral shaft fracture treatment <6mo: Pavlik harness or posterior splint 6mo- 4yrs: Immediate spica cast 4-12yrs: Flexible or elastic IM nails placed in retrograde fashion. Contraindicated if >100lbs or comminuted. Interlocked nails through greater trochanter is contraversial. 12- mature: Flexible nail(if size and pattern present), or interlocked nails (avoid piriformis fossa), or locked submuscular plate Both bone forearm fracture deforming forces Proximal 3rd: Biceps and Supinator- flex and supinate proximal fragment. Pronator teres and Pronator quadratus- pronate distal fragment Middle 3rd: Biceps, Supinator and Pronator teres- Proximal fragment stays neutral. Pronator quadratus- Pronates distal fragment Distal 3rd: Brachioradialis- Dorsiflex and radially deviates distal fragment. Pronator quadratus, wrist flexors and extensors, thumb abductors also deform Both bone forearm fracture immobilization position by site Proximal 3rd: supination Middle 3rd: neutral Distal 3rd: pronation Juvinile tillaux fracture Salter Harris III of anterolateral tibial epiphysis 13-16 yrs old when central and medial portion fused External rotation Juvenile triplane ankle fracture transverse, coronal, and sagital Explained by physis fusion from central -> anteromedial -> posteriomedial -> lateral Carpal tunnel syndrome predisposing factors Female Obese Pregnant Hypothyroid RA Amyloidosis Carpal tunnel borders Medial: scaphoid tubercle and trapezium Ulnar: Hook of hamate and pisisform Palmar: Transverse carpal ligament Dorsal: Proximal carpal row Carpal tunnel contents 9 flexor tendons- FPL most radial Median nerve- between PL (palmaris longis) and FCR Recurrent motor branch- 50% extraligamentous, 30% subligamentous, 20% transligamentous. Cut transverse ligament far ulnarly to avoid cutting. Carpal tunnel syndrome treatment NSAIDS Steroid injection Carpal Tunnel Release- cut ulnarly Surgery Recovery- pinch strength- 6 wks, Grip 100%- 12 wks Extensor compartments 2,2,1,2,1,1 1st: Extensor Pollicis Brevis and Abductor Pollicis longus (effected in DeQuervains) 2nd: Extensor carpi radialis longus and Extensor carpi radialis brevis 3rd: Extensor pollicis longus (ruptured in distal radius fracture as it courses around Lister's tubercle) 4th: Extensor digitorum communis and Extensor indices proprius 5th: Extensor digiti minimi 6th: Extensor carpi ulnaris Vertical medial malleolus ankle fracture treatment Must plate Transverse/oblique medial malleolus fracture treatment cannulated screw Lateral malleolar fracture with medial clear space widening treatment Bimalleolar equivalent ORIF If you can't tell medial clear space widening- Dorsiflex and ER imaging ED ankle fracture treatment Consious sedation or intraarticular injection before reduction Reduce to 90o, 90o Short leg splint- 3 sided (posterior component) Repeat imaging to ensure no lateral talar displacement- medial malleolar skin breakdown Recognize fracture vs. fracture/dislocation Rotational ankle fracture classification Lauge-Hansen Supination Adduction: medial talar displacement I- fibula avulsion (low transverse) or LCL rupture II- verticle medial malleolus fx + I Supination External Rotation: most common I- ATFL disruption +/- tib or fib avulsion II- Spiral fx of distal fib (AI -> PS) III- PTFL disruption or posterior malleolus avulsion IV- II + medial malleolus fx or deltoid lig rupture Pronation Abduction: I- Medial malleolus fx or deltoid lig rupture II- I + ATFL rupture or Chaput's tubercle avulsion III- I + transverse or comminuted fibula fx Pronation External Rotation  I- same as P-AB I II- same as P-AB II III- I + high spiral distal fib fx (PI -> SA) IV- PTFL disruption or avulsion of posteriolateral tibia Distal radius normal measurements Radial inclination: 22o Radial length: 11mm Volar tilt: 11o Distal radius fracture criteria for risk of failure with closed reduction LaFontaine criteria Pre-Reduction Films Determines rate of failure- >2= fx collapse -Age > 60yrs -Dorsal comminution -Dorsal angulation >20o -Ulnar styloid involvement -Radiocarpal joint involvement Smith fracture Reverse Colles fracture Volar angulation Unstable fracture pattern Colles fracture 90% of distal radius fractures Dorsal angulation Dorsal displacement Radial shift Radial shortening Acromiohumeral interval Shortest distance between inferior cortex of acromion and humerus Normal: 1-1.5 cm Rotator cuff tear: <6mm Galeazzi fracture Radial shaft fracture @ junction of middle and distal 3rd with DRUJ disruption Fracture of necessity- needs ORIF Monteggia fracture and complications Proximal ulnar shaft fracture with radial head dislocation Complications - Radial nerve deep branch paralysis- Most common - Posterior Interosseous Nerve (PIN) palsy- constant pressure from radial head - Annular ligament tear Monteggia fracture classification and treatment Bado  I- Apex anterior w/ anterior dislocation II- Apex posterior w/ posterior dislocation III- fx at metaphysis w/ lateral dislocation IV- same level both bone fx w/ anterior dislocation Treatment I, III, IV- 110o flexion II- 70flexion Distal radius fracture- most influence on outcome Carpal alignment - Measured by intersection of 2 lines on lateral X-ray - parallel through middle of radius - parallel through capitate - should intersect within carpus Chauffeur's fracture Radial styloid fracture AKA- backfire fx, hutchinson fx Compression of scaphoid against styloid w/ wrist in dorsiflexion and ulnar deviation Associated with intercarpal ligament injury- scapholunate or perilunate dislocation Barton fracture Fracture dislocation of radiocarpal joint Shearing mechanism Fracture of volar or dorsal radial rim Unstable Die punch fracture Depression fx of lunate fossa of articular surface of distal radius Radial head fracture classification and treatment Mason I- Nondisplaced II- Marginal fx w/ displacement (impaction, depression, angulation) III- Comminuted fx involving entire head IV- Associated w/ elbow dislocation Treatment I- possible aspiration of radiocapitellar joint for pain relief II- only operative if fragment blocking motion or part of a complex injury III & IV- ORIF or prosthetic replacement, possible late excision of radial head   Hardware only in 90o "safe zone" Essex Lopresti lesion Radial head fracture dislocation Interosseous ligament and DRUJ disruption Olecranon fracture classification I- nondisplaced II- displaced w/o instability III- instability of ulnohumeral joint a- noncomminuted b- comminuted Ulnar nerve compression sites around elbow (cubital tunnel syndrome) Medial intramuscular septum- 8cm proximal to medial epicondyle Arcade of Struthers- aponeurotic band from medial IM septum to medial head of triceps Medial epicondyle (osteophytes) Cubital tunnel retinaculum (Osborne's ligament) Anconeus epitrochlearis- replaces Osborne's ligament in 11% of population causing static compression Aponeurosis of 2 heads of Flexor carpi ulnaris (often continuous with Osborne's ligament) Deep flexor/pronator aponeurosis- 4cm distal to medial epicondyle Cubital tunnel syndrome symptoms Predominantly hand symptoms Fibers to FCU and FDP run centrally Hand intrinsic fibers are peripheral Ulnar Tunnel syndrome Compression of ulnar nerve in Guyon's canal Most commonly Ganglia (triquitrohamate joint 50%) Does not involve dorsal cutaneous nerve, FDP of 4th and 5th, or FCU Zone 1: proximal to bifurcation, both motor & sensory symptoms caused by hook of hamate fracture and ganglia  Zone 2:  deep motor branch, motor symptoms only caused by hook of hamate fracture and ganglia  Zone 3: superficial sensory branch, sensory symptoms only caused by ulnar artery aneurysm or thrombosis Pelvic fracture classification LC: implosion secondary to lateral force - I- Sacral impaction on impact side - II- Posterior iliac wing fracture on impact side w/ posterior ligament disruption. Maintains vertical stability - III- additional contralateral external rotation injury w/ SI, ST, & SS ligament disruption APC: anterior applied force, external rotation - I- <2.5 cm symphyseal diastasis, vertical fx of rami, posterior ligaments intact - II- >2.5 cm symphyseal diastasis, SI widining secodary to anterior SI, ST, and SS ligament tear, Posterior SI intact -III- II + posterior SI lig disruption, extreme rotational instability and lateral displacement, highest rate of vascular injury and bleed VS: vertical displacement (cephaloposterior) - usually through SI joint - complete disruption of symphysis, ST, SI, and SS ligaments - Extreme instability - High rate of neuro and vascular injury CM: combined mechanism (crush) (VS&LC) Pelvic fracture treatment Nonoperative Rehab: LC-1, and APC-1 Operative indications: - Open fx or viceral perforation - Open book or vertically unstable fx w/ hemodynamic instability - Symphyseal diastasis >2.5 cm - Leg length discrepancy >1.5 cm - Rotational deformity - Sacral displacement >1 cm - Intractable pain Iliac wing: plate and lag screws Diastasis: plate Sacral: transiliac bar fixation Tibial plateau fracture surgery I-IV: percutaneous screws or lateral placed periarticular plate V-VI: percutaneous locked plate or hybrid fixator Open hand fracture rate of infection Clean- 1.4% Contaminated/bite/lake water/barnyard- 14% Coracoclavicular ligament distances Trapezoid- 30mm from distal tip Conoid- 45mm from distal tip When performing Mumford excision- 10mm removal Bennett fracture 1st metacarpal Intraarticular Separation from volar lip Pulled proximally and flexed Deforming forces- abductor pollicis longus and adductor pollicis Rolando fracture 1st metacarpal  Cominuted intraairticular Y or T fracture pattern Future DJD Hand PIP surgical indications Dorsal lip- >1mm displaced Volar lip- >40% articular involvement Mallet finger DIP joint Dorsal lip fracture disruption of terminal extensor tendon "Jamming" mechanism of injury Nonoperative Treatment- Volar splint 6-8 weeks Surgical indications- volar subluxation of distal phalynx, >50% articular surface, >2mm step off Operative Tx- CRPP vs. ORIF, tendon reconstruction if >12 weeks old Jersey finger DIP joint Volar lip fracture avulsion of FDP Ring finger 75% of time- 5mm more prominent during grasp so makes more vulnerable to pulling away <3 weeks- tendon repair (do not advance >1cm) ORIF for osseous fragments Complications- if tendon advanced >1cm, flexion contracture or quadralgia effect (adjacent finger lag in flexion) Metacarpal fracture surgical indications Neck: - >10o angulation for 2nd and 3rd - > 30-40o for 4th and 5th Shaft: - >10o 2nd and 3rd - > 20o 4th and 5th Thumb - Bennett (type I) - Rolando (type 2) Thenar compartment Opponens pollicis (median) Abductor pollicis brevis (median) Flexor pollicis brevis superficial head (median) Flexor pollicis braves deep head (ulnar) Adductor compartment Adductor pollicis oblique and transverse heads (ulnar) Hypothenar compartment Palmaris brevis (ulnar) Flexor digiti minimi brevis (ulnar) Opponens digiti minimi brevis (ulnar) Abductor digiti minimi (ulnar) Posterior compartment of forearm Superficial: ECU (deep branch of radial n) anconeus (radial n) Intermediate: Extensor digitorum (radial n) Extensor digiti minimi (posterior interosseous n) Deep: abductor pollicis longus (PIN) extensor pollicis longus (PIN) extensor pollicis brevis (PIN) extensor indicis (PIN) supinator (deep radial n) Dorsal interosseous artery Anterior compartment of forearm Superficial: Flexor carpi radialis (median n) Flexor digitorum superficialis (median n) Flexor carpi ulnaris (ulnar n) Palmaris longus (median n) Pronator teres (median n) Deep: Flexor digitorum profundus (ulnar and AIN) Flexor policis longus (AIN) Pronator quadratus (AIN) Median, AIN, Ulnar, and Volar antibrachial interosseous nerves Ulnar and Volar interosseous artery Mobile wad (of Henry) Brachioradialis (radial) ECRL (radial) ECRB (radial) Radial artery and nerve Quadriceps  Rectus femoris (only one with origin on ilium) Vastus lateralis Vastus intermedius (deep to rectus) Vastus medialis Genu articularis (deep to intermedius, pulls suprapatellar bursa superior) Femoral nerve (L2-4) Cubital tunnel borders Roof: Arcuate (Osborne's) ligament Floor: MCL Posterior: Triceps medial head Anterior: Medial Epicondyle Lateral: Olecranon Subclavian artery course, branches and extension Part I- origin to anterior scalene      - Vertebral       - Internal thoracic (caudally behind ribs)      -Thyrocervical trunk (neck)         - suprascapular (rotator cuff) Part II- behind anterior scalene      - Costocervical trunk         - superior intercostal a.         - deep cervical a. Part III- lateral scalene to 1st rib      - Dorsal scapular (Levator scapula,        rhomboids, trapezius) Axillary- from 1st rib to Teres major      I- proximal to pec minor          - Superior thoracic (seratus a. & pecs)     II- behind pec minor          - Thoracoacromial             - Clavicular (clavicle fx injury)             - Acromial (w/ CA lig, risk in                 Subacromial decompression)             - Deltoid (w/ cephalic v., risk with                Deltopectoral approach)             - Pectoral (w/ lateral pectoral n.)         - Lateral thoracic (w/ long thoracic n.)    III- distal to pec minor         - Subscapular             - Circumflex scapular (triangle space)             - Thoracodorsal (w/ thoracodorsal n.)         - Anterior circumflex             - Ascending branch (arcuate a.               supplies most of humeral head)         - Posterior circumflex (quadrangular sp) Brachial- at lower margin of Teres major Triangular space (Medial) Teres minor Teres major Triceps long head Contains: Circumflex scapular artery Quadrangular space Teres minor Teres major Triceps long head Humerus Contains: Axillary n., Posterior circumflex a., Humeral a. Triangular interval (Lateral) Teres minor Triceps long head Triceps lateral head Contains: Radial n., Deep artery of arm Lateral x-ray C-spine prevertebral swelling distance by level C1- >10mm C3,4- >7mm C5-7- >20mm Radiographic markers of C-spine instability Compression fx w/ 25% loss of height Angular displacement >11o Cobb angle between adjacent vertebrae Translation > 3.5mm Intervertebral disc space separation >1.7mm Odontoid distances Atlas-dens interval- <3mm (5mm in child) Space for cord (Posterior odontoid to anterior cortex of posterior arch of atlas)- >13mm Dens-basion interval- <12mm Posterior axis line- <4mm anterior to basion Lateral atlas-dens intervals- symmetric and 2mm or < McGregor's line (hard palate to most caudal occiput)- if dens >4.5mm above, then basilar invagination Powers ratio- Basion to posterior arch of atlas/ Opisthion to anterior arch of atlas <1 Atlas fracture classification Levine A- isolated bony apophysis B- Isolated posterior arch  C- Isolated anterior arch D- Comminuted, lateral mass, or burst E- 3 or more fragments Atlas fracture treatment Initial- halo traction/immobilization Stable (A,B,C)- rigid cervical orthosis Unstable- prolonged halo immobilization Chronic instability- C1-2 fusion  Odontoid process (Dens) fracture classification and treatment Anderson and D'Alonzo I- Oblique avulsion of the apex (5%) II- Fx at waist (junction of body and neck). Watershed area with high rate of nonunion which can lead to myelopathy (60%) III- Base, extending into cancellous body of C2 and possibly the lateral facets (30%) Tx I- immobilize in cervical orthosis II- screw fixation or C1-2 posterior fusion due to high nonunion rate III- halo immobilization Hangman's fracture Traumatic spondylolisthesis of C2 (pars interarticularis fracture) Effendi classification I- nondisplaced, no angulation, translation <3mm, C2-3 disc intact, relatively stable Ia- Unstable lateral bending, involves one pars interarticularis and extending to body on contralateral side II- Significant angulation, translation >3mm, C2-3 disc disruption, most common (56%) IIA- flexion- posterior longitudinal lig rupture, anterior intact, no translation, traction contraindicated III- C2 anterior dislocation with extension, most associated with spinal cord injury Joint of Luschka uncovertebral joints in cervical spine (uncinate process projects superiorly from lateral aspect of vertebral body) C3-7 fracture classification Allen-Ferguson I- compressive flexion- "teardrop" fracture (from anterior body through inferior subchondral plate) II- Vertebral compression- burst fx III- Distractive flexion- dislocations IV- Compressive extension V- Distractive extension VI- Lateral flexion VII- Misc. (Clay shovelers, sentinel, ankylosing spondylitis, gunshot) Clay shoveler's fracture Muscular avulsion of spinous process in lower cervical or upper thoracic Sentinel fracture Through lamina on either side of spinous process.  Loose element may impinge on cord Cervical distraction device placement Gardner-Wells tongs- one fingers width above pinna of ear in line with external auditory canal Halo ring    - 1 cm above ears.    - Anterior pins- below equator of skull above supraorbital ridge, anterior to temporalis muscle, over lateral 2/3 of orbit.     - Posterior pins- variable to maintain horizontal orientation    - 6-8lbs of pressure Indications for anterior upper cervical spine approach in trauma 1. Screw fixation of Type II odontoid fx 2. Fusion and plating of C2-3 for IIA or III hangman's fx 3. Arthrodesis of AA articulations after failed posterior fusion Lower C-spine approach indications Posterior- open reduction of dislocated facet joints Bilateral lateral mass plating- teardrop fx, facet fx, facet dislocations Anterior- vertebral body burst fx w/ cord compression Anterior approach to subaxial spine plane  Superficial- Sternocleidomastoid (lateral), Anterior strap (medial) Deeper- Carotid sheath (lateral), trachea/esophagus (medial) Conus medullaris end level L1-L2 Spine region with smallest ratio of spinal canal to spinal cord T2-T10 Most thoracic and lumbar injuries occur at what region T11-L1 (thoracolumbar junction) Sacral sparing triad Perianal sensation Rectal tone Great toe flexion Compression vs Burst fx Burst involves middle column in addition to anterior Burst and compression fx most common type Type B (superior endplate) Early stabilization of burst fracture indications Neurologic deficits Loss of >50% body height Angulation >20o Canal compromise >50% Scoliosis >10o Denis Three column model of spine stability Anterior- anterior longitudinal ligament, anterior half of vertebral body, and anterior annulus Middle- posterior longitudinal ligament, posterior half of body and annulus Posterior- Neural arch (pedicles, facets, and laminae) and posterior ligamentous complex ( supraspinous ligament, interspinous ligament, ligamentum flavum, facet capsules) Instability if 2 columns are disrupted Degrees of spinal instability 1st- mechanical 2nd- neurologic 3rd- mechanical and neurologic Thoracolumbar spine fx with incomplete neurologic injury approach to decompression Anterior (greater neurologic improvement than posterior or lateral) Predictor of dural tear in burst fx neurologic involvement Clavicle fracture classification Allman Group I- middle third (80%).  Group II- distal third (15%). - type I- Minimal displacement. Fx between conoid and trapezoid or CC and AC ligaments - type II- Displaced. Fx medial to CC ligament       A- Conoid and trapezoid attached distally       B- Conoid torn. Trapezoid attached distally - type III- Fx of articular surface of AC joint. No ligament injury. Confused w/ 1st degree sprain. Group III- proximal third (5%) Clavicle fx treatment Minimally displaced- sling immobilization 4-6 weeks Surgical indications - open fracture - associated neurovascular compromise - skin tenting - Controversy- midshaft "Z" deformity and type II fractures Operative techniques Plate and screw- anteroinferior has less prominent hardware than superior IM fixation- (Hagie pin, Rockwood pin) complications in 50% cases AC joint sprain classification I- AC ligament sprain II- AC lig tear w/ joint disruption; CC lig sprain III- AC and CC lig torn w/ AC dislocation IV- Distal clavicle displaced posteriorly through trapezius V- Distal clavicle displaced >100% superiorly VI- Distal clavicle displaced inferiorly Total Hip Arthroplasty- Posterior approach Split Gluteus maximus Cut external rotators - Piriformis - Superior Gemellus (SER) - Obturator Internus (SER) - Inferior Gemellus (SER) - NOT Quadratus femoris Repair Short external rotators (SER) to prevent dislocation Dangers - Sciatic nerve- reflecting Piriformis protects - Inferior Gluteal artery- injured in proximal extension - Medial Femoral Circumflex artery- under Quadratus femoris Total Hip Arthroplasty- Anterolateral approach Tensor fascia latae retracted anteriorly Detach Gluteus medius and minimus Danger - Descending branch of LFCA- under rectus femurs - Femoral nerve- caused by vigorous medial retraction. Lays on posts muscle w/ artery and vein.  Total Hip Arthroplasty- Anterior approach Retract Sartorius medially Retract Tensor Fascia latae laterally Retract Gluteus medius laterally Cut Rectus femoris Dangers - Lateral Femoral Cutaneous nerve- retract anteriorly - Femoral nerve- Damaged by vigorous medial retraction - Ascending branch of Lateral Femoral Circumflex artery- must be ligated Anterior approach to Clavicle Incision directly along clavicle Deppen incision through Platysma Dangers - Brachial plexus- passed directly inferior to middle 3rd of clavicle - Subacromial a. & v.(2nd part of subclavian)- passes directly inferior to middle 3rd Ligaments - Coracoclavicular- trapezoid and conoid Other muscle attachments - Sternocleidomastoid (CNXI)- superiomedially - Trapezius (CNXI)- superiolaterally - Deltoid (axillary)- inferiolaterally - Pectoralis major (lateral & medial pectoral)- inferiomedially - Subclavius (N. to subclavius)- inferior middle 3rd Osteomyelitis classification Cierny Host immune status: A- normal B- some compromise C- significant compromise Type 1 - medullary osteomyelitis w/ endosteal nidus - does not require bone graft Type 2 - superficial affecting outer surface of bone - examples: infected plate on fx, exposure 2o tissue loss, adjacent abscess to cortex - treatment:      - stabilization not required      - hardware removal      - debridement of avascular outer cortex down to bleeding bone (paprika sign)      - antibiotic beeds      - coverage      - bone grafting Type 3 - well marginated sequestration of cortical bone - can be excised but creates instability - Treatment:      - stabilization      - debridement      - abx beads      - coverage      - bone grafting Type 4 - permeative destructive lesion causing instability - example: infected tibial nonunion