Clavicle

An asymptomatic enlargement of the medial clavicle is a condition that is often both missed and misdiagnosed. We review the most common causes of an isolated and asymptomatic enlargement of the medial clavicle. Underlying aetiologies include osteoarthritis of the sternoclavicular joint, condensing osteitis, spontaneous dislocation of the sternoclavicular joint, and sternocostoclavicular hyperostosis. Key points in the history and physical examination as well as characteristic radiographic findings are sufficient for correct diagnoses. Treatment is conservative.

Background and Objectives. Brachial plexus block is clinically useful. Although the infraclavicular approach to brachial block is the less commonly used form it may offer advantages. We describe the results with three local anesthetic mixtures used during this observational study. Methods. Three hundred and sixty patients, ASA physical status I and II, scheduled for upper extremity orthopedic surgery, were anesthetized with an infraclavicular brachial plexus block. They were divided into three groups (120 patients each) by type of 40-mE anesthetic mixture: group I had even parts of 2 % plain lidocaine and 0.5 % bupivacaine with epinephrine 1:200,000; group II had even parts of 1% plain lidocaine and 0.25 % bupivacaine with epinephrine 1:200,000; and group III had even parts of 1.5% plain lidocaine and 0.37% bupivacaine with epinephrine 1:200,000. Plexus identification was made by nerve stimulator. The observational assessments were: adequacy and latency time of the block, tourniquet tolerance, postoperative analgesia, local anesthetics doses, sedative doses, complications, and side effects. Results. In groups I, II, and III, adequacy of the block was 95, 75, and 96%, latency time was 10.4, 12.9, and 10.9 minutes, tourniquet tolerance was 99, 84, and 98%, postoperative analgesia time was 663, 331, and 502 minutes, anesthetic doses of lidocaine/bupivacaine were 5.2/1.3, 2.9/0.7 and 4.i/1.i mg/kg, respectively. Differences were noted between group II and groups I and III (P range: .0I-.0001). Sedatives in adequate blocks were midazolam with/without fentanyl (2-3 mg/50-100 I~g) in all groups. There were two complication cases with no consequences: two vascular punctures that did not hold up or delay the anesthetic or surgical procedure. There were no clinical manifestations or side effects. Conclusions. The infraclavicular approach described is effective. It produced reliable anesthesia and is associated with minimal complications and side effects. The mixture of local anesthetics used in group II is not adequate for producing reliable anesthesia. Reg Anesth Pain Med 1999: 24:411-416.

We compared five classification systems for clavicle fractures. The aim of this study was to evaluate the prognostic value of each system. Over a two-year period we reviewed all new radiographs of the shoulder region and identified 487 clavicle fractures. Each radiograph was classified using five classification systems. We reviewed all subsequent X-rays and clinical records until the patient was discharged. We assessed each classification system's prognostic value in predicting delayed/non-union. Our data show that 79.3% of clavicle fractures occur in the middle third, 19.3% in the lateral third and 1.4% in the medial third. The overall prevalence of delayed/non-union was 7.3%, with 3.2% requiring operative management and 4.1% developing asymptomatic non-union. The incidence of non-union in the lateral third was 9.6%, but only 0.4% required operative management. Craig's classification had the greatest prognostic value for lateral third fractures, and Robinson's classification had the greatest prognostic value for middle third fractures. Fractures of the clavicle are common injuries but non-union is an uncommon occurrence. Non-union is more common in the lateral third, but we found these to be mostly asymptomatic. Middle third fractures are more likely to require operative fixation. Middle third fractures should be classified according to Robinson's classification system and lateral third fractures according to Craig's classification. We did not assess sufficient medial third fractures for the data to be significant.

Retinoic acid has long been used to induce limb reductions defects in experimental animal studies. No limb malformations, however, have been reported among malformed retinoic acid-exposed human fetuses from case reports o r epidemiologic studies. We report a child and a fetus with limb reduction malformations following maternal use of isotretinoin (13-cis-retinoic acid) during the first trimester of pregnancy. The child had a unilaterally absent clavicle and nearly absent scapula, with a short humerus and short, synostotic forearm bones. He also had ventriculomegaly and developmental delay, minor dysmorphic facial features, and a short sternum with a sterno-umbilical raphe. The fetus had a unilaterally absent thumb with normal proximal bony structures. Other findings included hydrocephalus, craniofacial anomalies, thymic agenesis, supracristal ventricular septa1 defect, single umbilical artery, anal and vaginal atresia, and urethral agenesis with dysplastic, multicystic kidneys. Although the limb malformations were quite dissimilar, a number of anomalies that are frequently found among isotretinoin-exposed fetuseslinfants were present in both cases. This increases the probability that retinoic acid caused these limb defects, but a causal association cannot be conclusively drawn on the basis of these two retrospective case reports.

Background The coracoclavicular joint has been described as an articulation found inconstantly between the coracoid process and clavicle. We often observe a small space bordered by the fascia which covers the anterior surface of the subclavius muscle and the coracoclavicular ligament. The aim of this study was to observe the space in detail and to discuss the functional role of the coracoclavicular joint. Materials and methods Sixteen shoulder girdles from eight Japanese cadavers were used in this study. The scapula, clavicle, and anterior half of the Wrst rib were extracted en bloc together with the subclavius muscle and the surrounding fascia. After observing the motion of the scapula and clavicle, we investigated macroscopically the attachments of the coracoclavicular ligaments and the subclavius muscle, and the extension of the fascia. Results The fascia divided laterally into two sheets: the anterior sheet attached to the trapezoid ligament and the posterior to the conoid ligament. Among the two sheets, the coracoclavicular ligaments, coracoid process, and clavicle, a small space was observed. This small space can be recognized as a part of the coracoclavicular joint. When manually moving the inferior angle of the scapula with the sternal end of the clavicle Wxed, we observed that the clavicle collided with the trapezoid ligament on the superior surface of the coracoid process within the space and that the scapular motion was restricted by this collision. Conclusion The coracoclavicular joint could be much more recognizable than in previous papers and play an important role in the normal function of the shoulder joint. Level of evidence Basic science study.

• Cervical spine injuries sustained during impact events in sport activities such as rugby union can have devastating effects on players' welfare. • Dynamic simulations using musculoskeletal models, driven by in vivo biomechanical data, are effective tools to gain insight into injury mechanisms and can aid injury risk reduction.

Background: Several randomised trials have been published on the effect of lowintensity pulsed ultrasound (LIPUS) on fracture healing in both distal radius and tibia fractures. Most studies showed a positive effect on time to clinical and radiological healing. We hypothesised that LIPUS has a beneficial effect on the healing of fresh clavicle fractures as well and studied its effect in non-operatively treated shaft fractures. Methods: We conducted a randomised double blind, placebo-controlled multi-centre trial in 101 adult patients with a non-operatively treated fresh clavicle shaft fracture. Of these patients, 49 used a placebo transducer and 52 patients had an active transducer with ultrasound stimulation (Exogen 2000 1 ). Data were analysed on intention to treat basis. Baseline parameters of both groups were not significantly different. Results: There were no differences in time to subjective clinical fracture healing, resumption of daily activities, sports or professional work, Visual Analogue pain Scores (VAS) and use of pain medication. Conclusion: Our findings did not confirm that LIPUS accelerates clinical healing time of fresh clavicle shaft fractures. Level of evidence: Level 1 evidence that low-intensity pulsed ultrasound does not accelerate clinical fracture healing in non-operatively treated fresh midshaft clavicle fractures. #

Internal fixation of the clavicle is rarely necessary. When it is warranted, the clavicle's complex three-dimensional morphology and functional anatomy, proximity to vital structures, and the multidirectional biomechanical forces acting upon it place considerable demands on any implant used for skeletal fixation. We treated nine clavicles with the recently-introduced 3.5 mm low contact-dynamic compression plate (LC-DCP). Surgery was performed for symptomatic non-union in six patients, shoulder dysfunction following a malunited fracture in one, for an open fracture in one, and for an acute fracture associated with brachial plexus injury in one. After an average follow-up period of 17 months union was secured in each case. The advantages afforded by the 3.5 mm LC-DCP in internal fixation of the clavicle with its uniquely demanding anatomical and biomechanical characteristics are discussed.

The surgical approach to the brachial plexus is of great importance during surgery for brachial plexus injuries-obstetric or traumatic. A number of different approaches have been described over the years for these injuries, with each 1 having its own advantages and disadvantages. We describe a novel approach to the supra-clavicular and infra-clavicular aspects of the brachial plexus, which has been used by senior author successfully for the past 15 years. It involves creation of 2 windows, 1 above and 1 below the clavicle in case of adult traumatic plexus injuries. A slight variation of joining the 2 incisions and creation of a laterally based cervicopectoral flap is used for obstetric brachial plexus injuries along with the use of clavicular osteotomy. The advantages of this approach are that it gives rapid access to the brachial plexus; wide exposure can be obtained for all regions of the plexus and donor nerves such as the spinal accessory nerve can be harvested in the same incision.

The furcula is a structure formed by the midline fusion of the clavicles. This is the element which is unique to theropods and is important for understanding the link between birds and other theropods. New specimens from basal theropods suggest that the furcula appeared very early in theropod history. We review furcula development, function, and morphology, as well as the anatomical terminology applied to it. Furcular morphology is highly variable in crown-group avians but is rather conserved among nonavian theropods. Here we review, or describe for the first time, the furculae in many nonavian theropods. Furculae occur in nearly all major clades of theropods, as shown by new theropod specimens from the Early Cretaceous of China and a close inspection of previously collected specimens. Informative phylogenetic characters pertaining to the furcula occur throughout Theropoda, though care should be take to consider taphonomic effects when describing furcular morphology.

This study investigates skeletal maturation and sexual dimorphism in the human clavicle in the American population. Specifically, traditional methods of age and sex estimation were compared to novel approaches. Transition analysis, or probit regression, was used to study secular trends in epiphyseal union of the medial clavicle. A Bayesian approach was used to develop age-at-fusion ranges that are less sensitive to the effects of developmental outliers and age mimicry. Linear regression was used to evaluate the sexing accuracy of three commonly-used clavicular measurements and six newly developed measurements. Additionally, a statistical clavicle atlas was used to explore size and shape dimorphism. For the epiphyseal union study, clavicles from 1,289 individuals from cohorts spanning the 20th century were scored with two scoring systems. A simple 3-phase scoring system proved the least subjective, while retaining accuracy levels.
Significant secular trends were apparent in the onset of skeletal maturation, with modern Americans transitioning to fusion approximately 4 years earlier than early 20th century Americans and 3.5 years earlier than Korean War era Americans. Consequently, the secular trend towards earlier maturation appears to have occurred primarily during the latter half of the 20th century. These results underscore the importance of using modern standards to estimate age in modern individuals. For the sexual dimorphism study, all analyses were performed on three dimensional models of CT scanned clavicles. Linear discriminant analysis was performed on nine computer-automated measurements from 1,414 clavicle models. Cross-validated accuracy rates of the best models hovered around 92%. Two new measurements of the lateral end proved to be useful sex estimators, whereas accuracy rates from the medial end were low.
Additionally, sex-specific statistical atlases were used to visualize areas of highest dimorphism. A statistical treatment combining Principal Components Analysis (PCA) and Fisher's Discriminant Ratio (FDR) showed high magnitudes of curvature difference between males and females, particularly in the anterior and superior curvature of the midshaft and the posteriorly oriented curvature of the lateral end. The areas highlighted by the PCA-FDR method show promise as new sexing criteria for the human clavicle.

The supraclavicular skin has been studied extensively and used as a pedicled flap for face and neck reconstruction. Its use as a free flap has not paralleled its use as a pedicled flap. The authors performed an anatomical investigation to assess the possibility of harvesting a free supraclavicular flap with the donor-site scar lying in the supraclavicular crease. In this article, the authors present the results of their anatomical study together with the preliminary clinical applications. Methods: Skin vascularization and feasibility of a free supraclavicular perforator flap were studied on 25 cadavers (15 fresh cadavers injected with colored latex at the Universiteé René Descartes in Paris; and 10 formalin-fixed, noninjected cadavers at the Innsbruck Medical University). The flap was used in two patients at the Plastic Surgery Department of the University of Palermo for a cutaneous facial reconstruction and intraoral reconstruction after cancer excision. Results: An average of four perforators were consistently found in the supraclavicular area coming from the transverse cervical artery. Venous perforators drain into the superficial venous plexus rather than into the venae comitantes of the transverse cervical artery. Two flaps were successfully used based on these vessels. Conclusions: The vascularization of the supraclavicular skin depends on skin perforators coming from the transverse cervical artery and draining into the superficial venous plexus. Based on these vessels, a reliable free supraclavicular flap seems to be safe to harvest, with the scar hidden in the supraclavicular crease. The preliminary clinical applications of such a flap gave promising results, suggesting its potential applications. (Plast. Reconstr. Surg. 122:

Objective: To determine the effects of shoulder external rotator muscle fatigue on 3-dimensional scapulothoracic and glenohumeral kinematics. Background: The external rotator muscles of the shoulder are important for normal shoulder function. Impaired performance of these muscles has been observed in subjects with impingement syndrome and it is possible that external rotator muscle fatigue leads to altered kinematics of the shoulder girdle. Methods and Measures: Twenty subjects without a history of shoulder pathology participated in this study. Three-dimensional scapulothoracic and glenohumeral kinematics were determined from electromagnetic sensors attached to the scapula, humerus, and thorax. Surface electromyographic (EMG) data were collected from the upper and lower trapezius, serratus anterior, anterior and posterior deltoid, and infraspinatus muscles. Median power frequency (MPF) values were derived from the raw EMG data and were used to indicate the degree of local muscle fatigue. Kinematic and EMG measures were collected prior to and immediately following the performance of a shoulder external rotation fatigue protocol. Results: After completing the fatigue protocol subjects demonstrated less external rotation of the humerus. Additionally, they had less posterior tilt of the scapula in the beginning phase of arm elevation, and more scapular upward rotation and clavicular retraction in the mid ranges of arm elevation. Conclusions: Performance of an external rotation fatigue protocol results in altered scapulothoracic and glenohumeral kinematics. Further studies are needed to investigate the effects of external rotator muscle fatigue on scapulothoracic and glenohumeral kinematics in subjects with shoulder pathology.

This study utilizes a forensic autopsy sample of twentieth century American Whites (the McCormick Clavicle Collection) to describe the morphology, variation, and fusion timing of the lateral clavicle epiphysis. Clavicles from individuals between 11 and 25 years at the time of death were used to document fusion of the lateral epiphysis (n=133, 38 females
and 95 males). The lateral epiphysis was scored as
unfused, fusing, or fused. A linear weighted kappa indicates
that this scoring method is highly replicable with almost perfect
inter-rater agreement (kappa=0.849), according to a
widely used standard for assessing kappa values. Transition
analysis, or probit regression, was employed to quantify fusion
timing of the lateral epiphysis. The transition from “unfused”
to Bfusing^ is most likely to occur at 16.5 years in females and 17.5 years in males. The transition from “fusing” to “fused” occurs at age 21 in females and age 20 in males. The earliest age at which fusion began was 15 years (n=1), but
the majority began fusing between 17 and 20 years. Most
individuals (98.5 % of the sample) aged >24 years had fused
lateral epiphyses. The epiphysis assumes one of two forms:
(1) a separate bony flake fusing to the diaphysis or (2) a mound of bone glazing/smoothing over the diaphyseal surface. As socioeconomic status has been cited as the most influential variable on skeletal maturation rates, the fusion ages offered here should not be applied to populations with a socioeconomic status different from the greater US population

ócrates (469 -399 a.C.) a diferencia de los sofistas no cobraba y era ateniense. Su método de enseñanza era el diálogo y en realidad no creía ser portador del saber, por el contrario hace suya la frase del Oráculo de Delfos, sólo sé que no sé nada. Además no dejó escritos propios y todo lo que nos ha llegado de él ha sido a través de sus discípulos, principalmente Platón. No le interesaba la naturaleza ya que pensaba que no se podía extraer un conocimiento de ella, tal y como demostraba la diversidad de teorías de los presocráticos. Este rechazo generalizado al mundo físico, implica al mismo tiempo, el menosprecio por el conocimiento empírico y del propio cuerpo. De esta forma, Sócrates se preocupa por el hombre y la sociedad. Según él, la areté, es decir la virtud, consiste en obtener conocimiento a partir de la propia alma, por lo tanto el saber es virtud. Sócrates no pretende transmitir contenidos, sino establecer un método para pensar y poder diferenciar entre verdad y falsedad. Explica que el verdadero conocimiento se encuentra en el interior del alma humana, presentes como ideas innatas las cuales aparecen inseparables de la razón. Estas ideas son verdaderas, porque son universales, es decir que todos las tenemos, y necesarias, ya que no admiten crítica al ajustarse a la racionalidad. Para él, el conocimiento consiste en deshacerse de las ideas adquiridas y convencionales que impone la sociedad para encontrar en el alma, las verdaderas ideas, es decir, pensar por uno mismo. Para conseguir esto, Sócrates crea un método que se lleva a cabo mediante el diálogo.

Purpose To investigate the association between distal clavicular osteolysis and subchondral fractures of the distal clavicle at MRI. Materials and methods This study was approved by the hospital human research committee, which waived the need for informed consent. Three radiologists retrospectively analyzed 36 shoulder MR examinations in 36 patients with imaging findings of distal clavicular osteolysis. The presence of a subchondral fracture of the distal clavicle, abnormalities of the acromioclavicular joint, rotator cuff tears and labral tears were assessed by MRI. These cases were then compared with 36 age-matched controls. Results At MRI, 31 of 36 patients (86%) had a subchondral line within the distal clavicular edema, consistent with a subchondral fracture. Of the 36 patients, 32 (89%) had fluid in the acromioclavicular joint, while 27 of 36 patients (75%) had cysts or erosions in the distal clavicle. There were 13 patients (36%) with associated labral tears, while eight patients (22%) had partial-thickness rotator cuff tears. In the control group one of 36 (3%) had a subchondral line (P<0.05), while ten of 36 (28%) had rotator cuff tears and 13 of 36 (36%) had labral tears. These latter two were not statistically significant between the groups.

Osteitis condensans of the clavicle is a benign, often painful disorder of unknown etiology manifested by bony sclerosis of the clavicular head with an uninvolved sternoclavicular joint. The case presented demonstrates the characteristic scintigraphic findings of osteitis condensans of the clavicle. A review of the published pathologically proven cases reveals this disorder to have distinctive clinical and radiological features that allow differentiation from infection, neoplasia, and arthritides in most instances. The frequent observation, as in this case, of devitalized bone and marrow fibrosis with remodeling of cancellous bone suggests that osteonecrosis may play an important role in the pathogenesis of this disorder.

The pediatric musculoskeletal system differs greatly from that of an adult. Although these differences diminish with age, they present unique injury patterns and challenges in the diagnosis and treatment of pediatric orthopedic problems. Pediatric bone is highly cellular and porous, and it contains a large amount of collagen and cartilage compared with adult bone. The larger amount of collagen leads to a reduction of tensile strength and prevents the propagation of fractures, whereas the abundance of cartilage improves resilience but makes radiologic evaluation difficult [1]. The tensile strength of pediatric bone is less than that of the ligaments, so children are more likely to have bone injuries with mechanisms that would cause only ligamentous injuries in adults. The periosteum of pediatric bone is comparatively more metabolically active than the adult periosteum, leading to rapid and large callus formation, rapid union of fractures, and a higher potential for remodeling. The periosteum is also thicker and stronger in children. This difference is responsible for some of the unique fracture patterns seen in children [1,2]. The most obvious difference between the pediatric and the adult skeleton is the presence of growth plates. The physis is a transition zone between the metaphysis and epiphysis. This is a highly metabolic and rapidly changing area of bone. The germinal area of the physis rests on the epiphysis, and cartilage cells grow toward the metaphysis, forming columns of cells. These columns degenerate, undergo hypertrophy, and then calcify at the metaphysis. The growth and change that occur at a growth plate facilitate remodeling of fractures and

A partial skeleton from Hadar, Ethiopia (A.L. 438-1) attributed to Australopithecus afarensis is comprised of part of the mandible, a frontal bone fragment, a complete left ulna, two second metacarpals, one third metacarpal, plus parts of the clavicle, humerus, radius, and right ulna. It is one of only a few early hominin specimens to preserve both cranial and postcranial elements. It also includes the first complete ulna from a large A. afarensis individual, and the first associated metacarpal and forelimb remains. This specimen, dated to approximately 3 Ma, is among the geologically youngest A. afarensis fossils and is also one of the largest individuals known. Its ulnar to mandibular proportions are similar to those of the geologically older and much smaller A.L. 288-1, suggesting that body size increased without disproportional enlargement of the mandible. Overall, however, analysis of this large specimen and of the diminutive A.L. 288-1 demonstrates that the functional morphology of the A. afarensis upper limb was similar at all body sizes; there is no evidence to support the hypothesis that more than one hominin species is present at Hadar. Morphologically, all apparent apomorphic traits of the elbow, forearm, wrist, and hand of A.L. 438-1 are shared uniquely with humans. Compared to humans, A.L. 438-1 does have a more curved ulna, although A.L. 288-1 does not, and it appears to have had slightly less well-developed manipulatory capabilities of its hands, although still more derived than in apes. We conclude that selection for effective arboreality in the upper limb of Australopithecus afarensis was weaker than in non-hominins, and that manipulative ability was of greater selective advantage than in extant great apes.

The middle third of the clavicle is commonly involved in any injury and account for 5-10% of all fractures in adults. Although non-unions are rare, their treatment has not been well deWned yet. This report describes the arterial supply of the clavicle to clarify the pathological mechanism and the surgical procedure of non-unions. This study was based on delineation of the thoraco-acromial and suprascapular arteries with colored latex on 17 specimens (ten cadavers). Observations were made after macroscopic dissection and maceration. The main blood supply to the middle third of the clavicle was the periosteal. This supply came from the two branches of the thoraco-acromial trunk that penetrated the pectoralis major muscle and the deltoid muscle. In 13 cases, these two periosteal branches were anastomosed between these two muscle attachments. Periosteal vascularization was always seen on the superior surface and the anterior border of the bone, but never on the inferior surface or the posterior border. The suprascapular artery contributed to supply the middle third of the clavicle by several periosteal branches and also by an independent branch. This branch was born proximally near the internal, middle thirds union and passed along the posterior face of the subclavius muscle and pierced the bone through the nutria foramina located near the external, middle thirds union. Nevertheless, intraosseous arteries were noted only in four cases. In these cases, they were never more than 2cm long. Our results showed that the periosteal blood supply located between the muscles insertions and the arterial supply from the suprascapular artery could be twice compromised in case of important displacement or severe fracture. If treatments of clavicular fractures or non-unions cannot preserve the periosteal blood supply, bone grafting should be indicated.

We report a procedure for the virtual reconstruction of incomplete human bones applicable to skeletal remains from archaeological excavations or to reconstructive and prosthetic surgery. To test the procedure, we reconstructed a fragmented left clavicle on the basis of the contralateral clavicle. The procedure involved 3-D laser scanner acquisition of the left clavicle (complete but broken into two parts), the same manually reconstructed bone, and the intact right clavicle, which was mirror-imaged and used as a reference for the reconstruction of the whole left clavicle. in Wiley InterScience (www.interscience.wiley.com).

Ossified gastralia, clavicles and sternal ribs are known in a variety of reptilians, including dinosaurs. In sauropods, however, the identity of these bones is controversial. The peculiar shapes of these bones complicate their identification, which led to various differing interpretations in the past. Here we describe different elements from the chest region of diplodocids, found near Shell, Wyoming, USA. Five morphotypes are easily distinguishable: (A) elongated, relatively stout, curved elements with a spatulate and a bifurcate end resemble much the previously reported sauropod clavicles, but might actually represent interclavicles; (B) short, L-shaped elements, mostly preserved as a symmetrical pair, probably are the real clavicles, as indicated by new findings in diplodocids; (C) slender, rod-like bones with rugose ends are highly similar to elements identified as sauropod sternal ribs; (D) curved bones with wide, probably medial ends constitute the fourth morphotype, herein interpreted as gastralia; and (E) irregularly shaped elements, often with extended rugosities, are included into the fifth morphotype, tentatively identified as sternal ribs and/or intercostal elements. To our knowledge, the bones previously interpreted as sauropod clavicles were always found as single bones, which sheds doubt on the validity of their identification. Various lines of evidence presented herein suggest they might actually be interclavicleswhich are single elements. This would be the first definitive evidence of interclavicles in dinosauromorphs. Previously supposed interclavicles in the early sauropodomorph Massospondylus or the theropods Oviraptor and Velociraptor were later reinterpreted as clavicles or furculae. Independent from their identification, the existence of the reported bones has both phylogenetic and functional significance. Their presence in non-neosauropod Eusauropoda and Flagellicaudata and probable absence in rebbachisaurs and Titanosauriformes shows a clear character polarity. This implicates that the ossification of these bones can be considered plesiomorphic for Sauropoda. The proposed presence of interclavicles in sauropods may give further support to a recent study, which finds a homology of the avian furcula with the interclavicle to be equally parsimonious to the traditional theory that furcula were formed by the fusion of the clavicles. Functional implications are the stabilizing of the chest region, which coincides with the development of elongated cervical and caudal vertebral columns or the use of the tail as defensive weapon. The loss of ossified chest bones coincides with more widely spaced limbs, and the evolution of a widegauge locomotor style.

The supraclavicular fasciocutaneous flap is a well-recognized flap in head and neck reconstruction. In this report, we describe for the first time a variation of this flap, the osteocutaneous supraclavicular (SOC) free flap, which was used to reconstruct a composite nasal defect. The defect arose after resection of a recurrent squamous cell carcinoma and involved dorsal nasal skin, cartilage, and the entire nasal bone. A 6 cm 3 4 cm size flap including skin, subcutaneous tissue, and a vascularized cortico-periosteal segment of the clavicle was raised based on the transverse cervical artery. The flap survived with no complications. A satisfactory aesthetic outcome was achieved following two revision procedures. We believe that the incorporation of bone to the supraclavicular flap may expand its applications in reconstruction of composite nasal and facial defects. V C 2015 Wiley Periodicals, Inc. Microsurgery 00:000-000, 2015.

The clavicle has a complex osteologic structure that makes morphological analysis extremely difficult. A three-dimensional study was conducted to examine the anatomical variations and characteristics of the bone. Sixty-eight human cadaver clavicles were dissected, CAT-scanned, and reconstructed. An automated parameterization and correspondence shape analysis system was developed. A new length, designated as centerline (CL) length, was defined and measured. This length represents the true length of the clavicle. The endpoint length was measured as the distance between two endpoints. The width and curvature were measured in the axial (AX) and frontal (FR) plane and defined along the CL. Next gender and side characteristics and variations were examined. The mean CL length was 159.0 6 11.0 mm. The mean endpoint length was 149.4 6 10.3 mm, which was statistically significantly shorter than the CL. The male clavicle was significantly longer (166.8 6 7.3 mm vs. 151.0 6 8.2 mm), wider (14.6 6 1.5 mm vs. 12.7 6 1.3 mm lateral FR plane, 25.9 6 4.1 mm vs. 23.5 6 3.0 mm lateral AX plane and 24.7 6 2.8 mm vs. 22.8 6 2.8 mm medial AX plane), and more curved (10.8 6 2.8 mm vs. 8.6 6 2.3 mm medial and 10.5 6 3.3 mm vs. 9.1 6 2.5 mm lateral) than the female one. Left clavicles were significant longer (159.8 6 10.9 mm vs. 158.0 6 11.2 mm) than right clavicles. A novel three-dimensional system was developed, used and tested in order to explore the anatomical variations and characteristics of the human clavicle. This information, together with the automated system, can be applied to future clavicle populations and to the design of fixation plates for clavicle fractures. Clin. Anat. 00:000-000,

, and comprised newborn babies. Data was collected using a proforma, completed by an orthopaedic Resident, and included the following information: age of the mother, the number of previous deliveries, history of gestational diabetes mellitus (GDM), delivery method, type of presentation in cases of vaginal delivery (VD), use of forceps or vacuum, induction with oxytocin, healthcare professional (HCP) doing the delivery (doctor or midwife), gestational age, gender, weight, length, head circumference of the newborns, and the Appearance, Pulse, Grimace, Activity, and Respiration(APGAR) score in the first and fifth minutes after delivery. 3-7,8,9

Visually seriated radiographs of the proximal femur, proximal humerus, clavicle, and calcaneus from 130 individuals from the Hamann-Todd collection were examined as indicators of skeletal age at death. The clavicle demonstrated the most consistent relationship to age in both sexes. The same radiographs were also seriated by size-normalized optical density as a means of establishing relative radiolucency. In this context, visual seriation proved superior. The four sites studied showed strong divergence in response to age. Since each was sampling bone response from the same individual, it is concluded that bone loss is highly site specific. This demonstrates the individual character of specific skeletal sites. Visual inspection of clavicular radiographs, seriated on a populational basis, provides age estimates that are comparable to anatomical age indicators and provides independent estimates of skeletal age when included in the summary age method (1985: Am. J. Phys. Anthropol. 68:1–14).

Respiratory rate is one of the key vital signs yet unlike temperature, heart rate or blood pressure, there is no simple and low cost measurement device for medical use. Here we discuss the development of a respiratory sensor based upon clavicular motion and the findings of a pilot study comparing respiratory rate readings derived from clavicular and thoracic motion with an expiratory breath flow reference sensor. Simultaneously sampled data from resting volunteers (n = 8) was analysed to determine the location of individual breaths in the data set and from these, breath periods and frequency were calculated. Clavicular sensor waveforms were found to be more consistent and of greater amplitude than those from the thoracic device, demonstrating good alignment with the reference waveform. On comparing breath by breath periods a close agreement was observed with the reference, with mean clavicular respiratory rate R 2 values of 0.89 (lateral) and 0.98 (longitudinal-axis). This pilot study demonstrates the viability of clavicular respiratory sensing. The sensor is unobtrusive, unaffected by bioelectrical or electrode problems and easier to determine and more consistent than thoracic motion sensing. With relatively basic signal conditioning and processing requirements, it could provide an ideal platform for a low-cost respiratory monitor.

Malunion after mid shaft clavicle fractures has recently been recognized as a cause of pain and dysfunction of the shoulder. The mechanism that causes these complaints is however yet unclear. In this study we describe the kinematic changes that occur in the shoulder girdle due to clavicle shortening. An experimental cadaveric study was performed on five shoulders of three fresh frozen specimens. The specimens were fixed in an upright position that allowed free motion of the shoulder girdle. We measured position of the bony structures with an opto-electronic system (Northern Digital Inc., Waterloo, Ontario Canada) in rest and during in a series of motions. Measurements were done with a normal clavicle and after shortening of the clavicle by 1.2, 2.4 and 3.6 cm. The shoulders were moved manually by one of the researchers. We examined for changes in resting position and during movement that resulted from the experimental shortening of the clavicle. In the resting position, winging of t...

Based on nine patients 4 to 26 )'ears of age, we describe the cfinical characteristics of chronic recurrent multifocal osteom)'elitis. This disorder was characterized b)' an insidious onset of fever, local swelling and pain in affected bones, and radiologic findings suggesting ostcom)'elitis. The lesions were mainl), localized to the clavicles and the metaph)'ses of tubular bones. The clinical course was characterized b)" intermittent periods of exacerbation and improvement over several )ears. Six of the patients had recurrent pustulosis pahnaris and phzntaris, which closel)" parallelled the exacerbations of the bone lesions. Biopsies from the bone lesions showed nonspecific inflamnmtor)' changes with granuloc)'tic infiltration. Repeated bacterial and fimgal cultivations from blood, bone biopsies, and pusndes were negative. Immunologic investigation revealed no abnormality common to the patients. Tlwre was no indication of a genetic etiology. The pathogenesis of the disorder is unknown. Antibiotic treatment had no obviotts effect but corticosteroid therapy appeared to be of benefit in some patients. The long-term prognosis appears to be relatively good.

Purpose: The purpose of this study was to evaluate the outcome of arthroscopic distal clavicle resection by the direct superior approach for treatment of isolated osteolysis of the distal clavicle. Type of Study: Case series. Materials and Methods: Forty-one shoulders in 37 patients underwent arthroscopic resection of the distal clavicle. Thirty-three patients were male and 4 female, with an average age of 39 years. All patients complained of pain localized to the acromioclavicular joint region. Symptoms began after a traumatic event in 18 shoulders and were associated with repetitive stressful activity in 23 shoulders. Results: At an average follow-up of 6.2 years, 22 shoulders had excellent results, 16 had good results, and 3 were failures. All 3 failures occurred in patients with a traumatic etiology. Conclusions: Arthroscopic resection for osteolysis of the distal clavicle has results comparable to open excision with low morbidity. Patients with a traumatic etiology had slightly worse results compared with patients with a microtraumatic etiology.

and "humeral canal" were searched for full text articles pertaining to the evaluation of recognized approaches and techniques for brachial plexus anesthesia. The search was limited to RCTs involving human subjects and published in the English language. Seventy-six RCTs were identified.

Background: This prospective, randomized, blinded study tested the hypothesis that ultrasound guidance can shorten the onset time of axillary brachial plexus block as compared with nerve stimulation guidance when using a multiple injection technique.

The median nerve N20 component constitutes the initial response of the primary somatosensory cortex to somatosensory stimulation of the upper extremity. Knowledge of the underlying generators is important for basic understanding of the initial sequence of cortical activation.

The supraclavicular island flap has been widely used in head and neck reconstruction, providing an alternative to the traditional techniques like regional or free flaps, mainly because of its thin skin island tissue and reliable vascularity. Head and neck patients who require large reconstructions usually present poor clinical and healing conditions. An early experience using this flap for late-stage head and neck tumour treatment is reported.

Osteoma is a rare benign tumor, composed of bony tissues. It predominantly involves the skull but rarely the long bones. In this report we present a case of clavicular osteoma associated with bronchial osteomas. This association has not previously been reported. There was no evidence of Gardner's syndrome.