Clavicle: An S shaped subcutaneous bone, attached to the sternum and acromion process. It acts a link between axial and appendicular skeleton. Has sternocleidomastoid and pectoralis major originating from its surfaces. It is in close proximity to the brachial plexus, major vessels and the apical lung.
How it happens: fall on the shoulder 87% or from fall on an outstretched hand 6%, direct blow to it in 7%
Types:
1/3 middle: 80%
1/3 distal: it has 3 types (15%)
Type I: minimally displaced: between ligaments
Type II: minimally displaced; between ligaments
Type III: fracture through AC joint. Ligaments intact
1/3 proximal (5%)
Where: Junction of middle and outer third of the clavicle is the commonest site.
Second commonest site is the outer third of the clavicle.
This fracture is usually displaced. The outer fragment displaces medially and downwards because of the gravity and pull by the pectoralis major muscle attached to it.
The inner fragment displaces upwards because of the pull by the sternocleidomastoid muscle attached to it.
Clinical Manifestation
Pain
Swelling and ecchymosis
Tenderness and crepitation on palpation
Restricted movement due to pain
Acute Fracture
Inspection
Arm held close to the body and supported at the elbow to prevent movement
Deformity
Swelling over the fractured area
Sometimes, a sharp end may threaten to burst the skin (skin tenting), there is a wide gap and comminution (middle third fracture).
Palpation
Step/ gap/ irregularity
Stress test: abnormal mobility with acute pain
Measurement: shortening
Uniting fracture
Old trauma
Inspection: bony swelling
Palpation: Globular bony swelling and warmth at the fracture site
Stress test: Stress pain and stress mobility
Measurement: shortening, if maluniting
Non union
Old trauma
Inspection: deformity
Palpation: step/ gap/ irregularity
Stress test: abnormal mobility with little pain
Measurement: shortening
Mal union
Old trauma
Inspection: deformity/ hump
Palpation: deformity/ irregularity/ angulation
Stress test: no abnormal mobility/ no pain
Measurement: shortening
What to actively look for?- Haemothorax
- Brachial plexus and ulnar nerve injury
- Pneumothorax
- Rib fracture
- Scapular fracture
- Sternoclavicular joint injury
Radial pulsation/ cap refill
Motor/ sensory
Rib palpation/ springing
Palpate scapula and shoulder movement
Auscultate chest
Diagnosis:
Do Xray AP and 25-30 degree cephalad angle clavicle projection
Treatment
A&E Management
Goal: immobilisation by
Cuff and collar sling
Triangular sling
Arm bag
- They usually unite readily even if displaced, hence reduction of the fragment is not essential
A triangular sling is sufficient in cases with minimum displacement. Active shoulder exercises should be started as soon as the initial severe pain subsides, usually 10-14 days after the injury. A figure of 8 bandage may be applied to a young adult with a displaced fracture
It serves the purpose of immobilisation, and gives pain relief
Open reduction and internal fixation is required either when the fracture is associated with neurovascular deficit, or in some severely displaced fracures, where it may be more of a cosmetic concern. In such cases, the fracture is fixed internally with a plate or a nail.
Complications
Early complications
- The fractured fragment may injure the subclavian vessels or brachial plexus
Late complications
- Shoulder stiffness is a common complication, especially in elderly patients.
It can be prevented by shoulder mobilisation as soon as the patient becomes pain free.
- Malunion and non union (the latter being very rare) often cause no functional disability and need no treatment. Rarely, for a painful non union of the clavicle, open reduction and internal fixation with bone grafting may be necessary
Causes of non union
Lack of cortical apposition
Comminution
Female gender
Advancing age
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