Download Clavicle Fracture

CLAVICLE FRACTURE
Fragment from the “The Book of Wounds”, Edwin Smith Papyrus, Egyptian c. 1,600 BC.
“…if thou examinest a man having a break in his collar-bone and thou shouldst find his collarbone short and separated from its fellow….. thou shouldst place him prostrate on his back, with
something folded between his two shoulder-blades; thou shouldst spread out with his two
shoulders in order to stretch apart his collar-bone until that break falls into its place, thou
shouldst make for him two splints of linen, and thou shouldst apply one of them both on the
inside of his upper arm, thou shouldst bind it with yarn, and treat it afterward with honey every
day, until he recovers…”
“Case 33 from The Book of Wounds”, Edwin Smith Papyrus, c. 1,600 BC.
The Edwin Smith papyrus is thought to represent the world’s earliest known medical document,
written in Egypt around the 17th Century BCE, however it is thought to be based on far older
material, possibly as ancient as 3000 BCE. It is a textbook on trauma surgery. It describes points
of anatomy, examination, diagnosis, treatment, and prognosis of many traumatic injuries. Above
is an extract describing the treatment of a fractured clavicle. Over 5000 years later in the 21st
century the set out of the Egyptian “guidelines” still appears logical and well structured. We still
provide our patients with “splints of linen”, though the routine use of honey is no longer
recommended.
CLAVICLE FRACTURE
Introduction
Fracture of the clavicle is a very common presentation to the Emergency Department.
Clavicle fractures are also common in children and these will often be of the greenstick type in
younger children.
Most cases are uncomplicated and conservative management will be all that is required.
Anatomy
Functions of the clavicle:
●
The clavicle acts as a strut for the upper limb and provides the only bony connection
between upper limb and the thorax.
●
It helps protects major underlying subclavian vessels, the apex of the lung, and the
brachial plexus.
See also appendix 1 below.
Mechanism
In general terms:
Mid-third:
●
A fall on the outstretched hand can result in mid-third fractures.
Distal third:
●
A direct blow to the outer end of the clavicle (such as a fall onto the point of the shoulder
during sporting activities or a striking injury) can be associated with distal third injuries
as well as acromioclavicular joint injuries.
Medial third:
●
Fractures of the medial third are usually the result of direct trauma to the anterior chest
(such as in a motor vehicle accident), and can be associated with neurovascular,
pulmonary or rarely cardiac injuries.
Classification
Class A:
Approximately 80% of clavicle fractures involve the middle third.
●
Class B:
These can be shortened / comminuted / angulated.
About 15% involve will involve the distal (lateral) third.
●
Class C:
Around and lateral to coracoclavicular ligaments
About 5% involve the proximal (medial) third.
●
These can be bony injury alone or associated with a sternoclavicular
dislocation (or a physeal sleeve separation in children).
Complications
Significant complications are uncommon with clavicle injuries.
Complications can include:
●
Long term some deformity may be present due to bony callus formation but this will very
rarely affect the normal functionality of the upper limb.
●
The clavicle helps protects the major underlying subclavian vessels, the apex of the lung,
and the brachial plexus.
Displaced clavicle fractures can therefore potentially injure these structures, however
serious complications are rare.
Injuries of the medial third with posterior Sternoclavicular dislocation, (see also
separate guidelines for Sternoclavicular dislocation) in particular may cause these
complications.
●
Gross displacement of a bony fragment may produce a sharp tenting of the overlying
skin with subsequent risk is ischaemic necrosis.
●
As for any fracture the injury may be compound.
●
There may be non-union or delayed union (defined on x-ray at three months) but this is
uncommon in clavicular injuries.
A lump from callous formation usually develops at the fracture site, and this may be
visible and palpable for at least one year. The lump will decrease as remodelling occurs
and this is more complete in younger patients
Clinical Features
Symptoms
●
Pain at the site of fracture.
●
In young children and neonates non-use of an arm may be the only indication of the
fracture.
Signs
●
Tenderness at the point of fracture.
●
Some degree of deformity is usually apparent.
The proximal end may become elevated due to the pull of the sternomastoid muscle. The
shoulder may lose the prop like effect of the clavicle and so sag downwards and
forwards.
Typical deformity of a right clavicle fracture. Here there is significant upward
displacement of the medial end with some tenting of the overlying skin.
●
Bruising/swelling
●
Crepitus is a good sign that a fracture has occurred.
●
Assess the neurovascular status of the arm:
The subclavian artery runs closely apposed to the clavicle in the middle third, although in
practice it is rarely injured in this region.
●
Ensure there is no associated injuries such as pneumothorax.
Investigations
Plain radiography:
●
Plain A-P radiography is sufficient to make the diagnosis in most cases.
●
Specific clavicular views should be requested rather than simply shoulder views, to
ensure that the whole of the clavicle is visualized.
●
15 degrees cephalic tilt x-ray of the clavicle will show the fracture in two planes and
better define displacement.
●
A dedicated shoulder view should also be done and scapula views if injury to this bone is
also suspected.
●
Look carefully for any associated scapular fractures which may indicate of loss of
integrity of the bony articulation of the upper limb and clavicle.
●
A CXR should be included if there is any doubt about the possibility of an associated
pneumothorax.
Left x-ray shows the typical upward pull of the sternomastoid muscle on the medial segment of
the clavicle in a type A injury. The right hand panel shows a comminuted injury with a sharp
displacement liable to cause tenting of the overlying skin and possible compromise to the
vascular supply of the skin.
CT Scan:
A CT scan may be required for medial third injuries with suspected sternoclavicular dislocation.
This will be to confirm the nature of injury as well as to assess any significant complications
such as tracheal impingement, and/or associated injuries.
Management
1.
2.
Analgesia:
●
IV opioid is often required for the initial period of injury, however simple oral
analgesia will usually suffice soon after this.
●
Pain from the fracture and some restriction of movement are to be expected for 2 3 weeks on average and will require regular oral analgesia.
Conservative management:
●
The great majority of uncomplicated middle third fractures will have excellent
functional and cosmetic outcomes with conservative management.
Immobilization:
●
A broad arm sling should be used.
Note that a number of clavicular “figure of 8” bracing techniques are described
however these are difficult to correctly apply, require constant review and are not
any more effective than a simple broad arm sling and are not recommended.
●
Contact sports and similar activities should be avoided for approximately six
weeks post removal of the sling.
Fractures that involve the medial and lateral thirds, represent more complex injuries and
may require orthopaedic intervention.
3.
Surgical fixation:
Indications for possible surgical fixation (ORIF) include:
●
Severely comminuted or significantly shortened middle third (> 2 cm if over 12
years of age) fractures
●
Gross displacement of a fragment which produces a sharp tenting of the skin with
subsequent risk is ischaemic necrosis of the overlying skin
●
Displaced medial or lateral third fractures
●
Injuries associated with sternoclavicular dislocation
●
Where there is neurovascular compromise
●
Compound or pathological injuries.
Elective intervention may be considered for:
●
Injuries in elite athletes (where urgent intervention is not required) may be
considered.
●
Cosmetic reasons.
Disposition
For uncomplicated middle third fractures:
●
Most uncomplicated cases can be referred to the patient’s GP for follow-up.
●
Children < 11 years old with undisplaced fractures do not usually require follow-up by a
GP or fracture clinic. Repeat x-rays are usually not required.
●
For children ≥ 11 years old or those with displaced fractures, follow up should occur
with a GP or in fracture clinic in one week. Radiographs are usually not required.
Mobilisation out of the sling commences at 2-3 weeks depending on pain control.
Fractures involving the lateral third or medial thirds should have check x-rays at 1 week.
●
Physiotherapy may be useful in selected patients.
Gleno-humeral stiffness may occur in the elderly with prolonged periods of
immobilization.
Appendix 1
Anatomy of the clavicle:
Posterior
Anterior
Superior view of the left clavicle, (left side is medial aspect and right is lateral), Gray’s Anatomy
1918.
Anterior
Posterior
Inferior view of the left clavicle, (left side is medial aspect and right is lateral), Gray’s Anatomy
1918.
References
1.
McRae Ronald, Practical Fracture Treatment, 3rd ed 1996, p. 100-02.
2.
RCH Paediatric Fracture Guidelines.
Dr J. Hayes.
Dr Peter Papadopoulos.
Reviewed July 2013