Makindo Medical Notes.com

There is no long-term benefit to surgical management over a conservative approach

About

• Common injury often in children and young adults
• Also seen in the elderly with osteoporosis and falls

Aetiology

• Fall onto an outstretched upper limb or hand
• Direct blow to the clavicle or indirect through the shoulder joint.

Allman Classification

• Type I: Middle third of the clavicle. Commonest. The middle is weakest. usually stable despite deformity.
• Type II: Lateral third of the clavicle. If displaced, these types are often unstable
• Type III: Medial third: Uncommon but may be seen with severe trauma and may be associated with mediastinal or other injuries as well as pneumothorax, or haemothorax

Clinical

• Localised pain over the shoulder and upper arm
• Swelling over clavicle and shoulder and front of the chest
• Sharp pain when any movement is made
• Possible nausea, dizziness, and/or spotty vision due to extreme pain

Investigations

• X-ray of the clavicle to determine the fracture type and extent of the injury.
• CT or MRI may be used if in doubt
• Assess clinically: If Posterior displacement CT chest
• Ultrasound may be equally accurate in children

Complications

• Non-union is a major complication of clavicle fractures. Usually lateral clavicular fractures
• Infection, Haemorrhage
• Medial fractures may have Posterior displacement - mediastinal injury and Nerve injury and should be referred to ortho

Management

• Analgesia and tetanus if skin breaks. Open fractures may need surgery. Medial fractures may need exclusion of other injuries with CT chest.
• Generally a broad arm sling is applied and generally kept on until the patient regains pain-free movement of the shoulder.
• Conservative: 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. Provide a sling, and pain relief, and to allow the bone to heal itself, monitoring progress with X-rays every week or few weeks. Resulting bony prominence may take months/years to remodel
• Surgery is employed in 5 to 10% of cases. If the fracture is at the lateral end, the risk of nonunion is greater than if the fracture is of the shaft. A comminuted fracture may need to be treated with an intramedullary fixation device. Surgery if there is a skin break or any neurovascular involvement or distal third fractures (high risk of nonunion)

References