FRACTURE CLAVICLE

SIGN & SYMPTOMS:
  • Pain, particularly with upper extremity movement or on front part of upper chest
  • Swelling
  • Often, after the swelling has subsided, the fracture can be felt through the skin.
  • Sharp pain when any movement is made
  • Referred pain: dull to extreme ache in and around clavicle area, including surrounding muscles
  • Possible nausea, dizziness, and/or spotty vision due to extreme pain
  • Fracture of clavicle is commonest at Junction of medial 2/3rdand lateral 1/3rd
MECHANISM OF INJURY:

The location of the clavicle
  • The most common type of fracture occurs when a person falls horizontally on the shoulder or with an outstretched hand.
  • A direct hit to the collarbone can also cause a break. 
  • In most cases, the direct hit occurs from the lateral side towards the medial side of the bone.
  • The muscles involved in clavicle fractures include the deltoid, trapezius, subclavius, sternocleidomastoid, sternohyoid, and pectoralis major muscles.
  • The ligaments involved include the conoid ligament and trapezoid ligament.
  • Incidents that may lead to a clavicle fracture include automobile accidents, biking accidents (especially common in mountain biking), horizontal falls on the shoulder joint, or contact sports such as football, rugby, hurling, or wrestling.
TREATMENT:
  • Medication can be prescribed to ease the pain and tetanus vaccination for any skin breaks.
  • Antibiotics may be used if the bone breaks through the skin. 
  • Often, they are treated without surgery. In severe cases, surgery may be done.
NONOPERATIVE:
  • The arm must be supported by use of a splint or sling to keep the joint stable and decrease the risk of further damage. 
  • Usually, a figure-of-eight splint that wraps the shoulders to keep them forced back is used and the arm is placed in a clavicle strap for comfort.
  • Current practice is generally to provide a sling, and pain relief, and to allow the bone to heal itself, monitoring progress with X-rays every week or few weeks. 
  • Surgery is employed in 5–10% of cases. However, a recent study supports primary plate fixation of completely displaced midshaft clavicular fractures in active adult patients. If the fracture is at the lateral end, the risk of nonunion is greater than if the fracture is of the shaft.
 SURGICAL:

  • X-ray of the above comminuted fracture treated with an intramedullary fixation device
  • Surgery is considered when one or more of the following conditions presents.
  1. Comminution with separation (multiple piece)
  2. Significant foreshortening of the clavicle (indicated by shoulder forward)
  3. Skin penetration (open fracture)
  4. Clearly associated nervous and vascular trauma (brachial plexus or supraclavicular nerves)
  • Nonunion after several months (3–6 months, typically)
  1. Distal third fractures (high risk of nonunion)
  2. A discontinuity in the bone shape often results from a clavicular fracture, visible through the skin, if not treated with surgery. 
  • Surgical procedures often call for open reduction internal [plate] fixation where an anatomically shaped titanium or steel plate is affixed along the superior aspect of the bone by several screws.
  • In some cases, the plate may be removed after healing, but this is very rarely required (based on nerve interaction or tissue aggravation), and typically considered an elective procedure.
  • In a surgically indicated patients now surgery of choice is elastic TEN intramedullary Nailing. 
  • These devices are implanted within the clavicle's canal to support the bone from the inside. 
  • Typical surgical complications are infection, neurological symptoms distal the incision (sometimes to the extremity), and nonunion.
Exam Question
  • Most common Complication is Malunion of Fracture of clavicle
  • In treating a fractured clavicle in a 14 month old child, the best procedure is Figure - of - eight bandage
  • Fracture of clavicle is commonest at Junction of medial 2/3rdand lateral 1/3rd
  • Clavicle fracture result from a violent force
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