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9/14/2018 0 Comments

Clavicle Fracture


Background
  • Secondary to shoulder trauma (not as much direct clavicle trauma)
    • Tackled to ground
    • FOOSH
    • Direct impact to lateral shoulder
  • Majority of fractures involves the middle third (75-80%); Distal third (15%); Medial third (5%)
  • Distal third associated with AC joint injury and/or coracoclavicular ligament rupture
  • Medial fracture àintrathoracic injuries
 
Clinical Features
  • Swelling, deformity, tenderness, pain over anterior shoulder
  • Patient may be supporting affected arm with the contralateral arm
  • Displaced fractures
    • Medial fragment displaced posteriorly and superiorly (SCM pulls)
    • Lateral fragment displaced inferiorly and medically (Pectoralis and weight of arm pulls)
    • Open fractures usually result from medial fragment buttonholing through platysma
 
Evaluation
  • Assess distal pulses, motor, and sensation
  • XR (CXR, SXR, Dedicated clavicle films)
    • Associated injuries are rare, but can see rib fractures, PTX, neurovascular injuries
    • Additional XR view = ZANCA view (15-degree cephalic tilt)
      • Determines superior/inferior displacement
      • Have patient hold 5-10 lbs weight in affected hand
  • Consider CT for further eval and possible vascular injury
 
Classification
  • Neer, Allman, Craig, Robinson
  • AO Classification:
    • Type A, B, C (A = Simple; B = Wedge; C = Complex)
 
Management
  • Non-operative
    • Sling or figure-of-eight immobilization with early ROM exercises at 2-4 weeks; start strength training at 6-10 weeks
    • Best for minimally displaced, <2 cm shortening, no neuro deficits
    • Nonunion rate = 1-5 %
      • Most often in elderly and females
  • Operative
    • ORIF
      • Open fractures
      • Displaced fracture with skin tenting
      • Neurovascular injury
      • Risk of need for future procedures, implant removal or debridement for infection
  • Pain control
    • Chang AK, Bijur PE, Esses D, et al. Effect of a Single Dose of Oral Opioid and Nonopioid Analgesics on Acute Extremity Pain in the Emergency Department: A Randomized Clinical Trial. JAMA2017;318:1661-7
 
Disposition
  • Discharge with ortho/sports follow-up
  • Possible surgical intervention for comminuted fractures, significant displacement or >2 cm of shortening
  • Consult orthopedics in the ED if patient has an open fracture, Neurovascular compromise or skin tenting
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