Medial clavicle fracture

>Trauma Surgery >Medial clavicle fractureAuthor: J. Sprakel, MD - Latest update: 10-10-2014
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Cause

  • - Direct blow to the shoulder or indirect by fall on an outstretched arm
  • - Incidence of clavicle fractures is 2,6%-10% of all fractures 1,2
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Clinical presentation

  • - Deformity of clavicle (diffence between right and left)
  • - Abnormal movability of two bones relative to each other, sometimes with crepitations
  • - Pain
  • - Assess whether the skin is endangered
Associated injuries (rare):
  • - Ribfracture
  • - Nerve injury, brachial plexus (radial, median or ulnar nerve palsy)
  • - Vascular injury of the subclavian artery and vein, running under the collarbone
  • - Pneumo-/hematothorax
  • - Given the close relationship between the medial clavicle and large vessels, there is an increased chance of vascular complications.
  • - Examination of pulsations of the arm and carotid arteries is therefore important.
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Imaging

  • Radiographs: standard X-rays
  • - X-shoulder AP view (X-clavicle)

  • Additional/optional X-rays:
  • - 45° cephalic tilt (Serendipity view)
  • - 45° caudal tilt (Garth view / apical oblique)
  •  
  • Fracture is often difficult to portray in a conventional X-rays
  • If necessary, CT-scan for suspected dislocation
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Classification

Classification of Robinson 1

Type 1: Medial 1/5th of clavicle
Incidence 5-8%, medial of a vertical line drawn from the center of the first rib
Type 2: Middle 3/5th of clavicle
Incidence 80-85%
Type 3: Lateral 1/5th of clavicle
Incidence 10-15%, laterally from a vertical line drawn from the basis of the coracoid process, normally marked by tubercle conoideum, subclassfication according to Neer
Subdivision:
Group A Undisplaced
Group B Displaced, more than shaft width of dislocation
Groep 1 Extra-articular
Groep 2 Intra-articular


Type 1: Medial claviclefracture
Type 1A1 - Medial, extra-articular, undisplaced
Type 1A2 - Medial, intra-articular, undisplaced
Type 1B1 - Medial, extra-articular, displaced
Type 1B2 - Medial, intra-articular, displaced
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Nonoperative treatment

Indication:
  • - Almost all medial claviclefractures


Treatment:
  • - Functional
  • - Sling immobilization for a maximum of 3 weeks
  • - 1th week rest
  • - 2th week gentle ROM exercises in the sling untill 90 -90 degrees
  • - 3th week practice in the sling guided by the pain without restrictions, possibly without sling
  • - 4th week removal of sling


Follow-up:
  • Outpatient follow‐up
    After 2 weeks After 6 weeks After 3 months After 6 months (optional)
    - Control with X-ray
    - Control of function
    - Practice instructions
    - Control of function
    - Physiotherapy (optional)
    - Control with X-ray in case of persistent complaints
    - Optional outpatient visit in case of persistent complaints
    - Control of function
    - Control with X-ray in cased of persistent complaints
    -


Time to recovery:
  • - The duration of the bone healing is 6-12 weeks.
  • - The functional recovery is 3-6 months.


Referral for physiotherapy:
  • - Refer patients to a physiotherapist if the range of motion is insufficient, despite good practice guidance, or if the patient doesnt understand the instructions.
  • - Mention in the referral to the physiotherapist which exercises (loaded / unloaded) can be preformed.
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Operative treatment

Indication:
  • - Open fractures
  • - Subclavian artery or vein injury
  • - Symptomatic nonunion
  • - Posteriorly displaced fractures with compression of mediastinal vessels


Treatment:
  • - Open Reduction Internal Fixation (plate and screw fixation)
  • - Consider referral to expert tertiary center
  • - Given the rarity of surgical treatment of this injury it is not described


Follow-up:
  • Outpatient follow‐up
    After 2 weeks After 6 weeks After 3 months After 6 months (optional)
    - Removal of stitches
    - Practice instructions
    - Control with X-ray
    - Control of function
    - Fysiotherapie op indicatie
    - Control with X-ray
    - Functiecontrole
    - Physiotherapy (optional)
    - Define policy concerning removal of osteosynthesis
    - Optional outpatient visit in case of persistent complaintsn
    - Control with X-ray


Time to recovery:
  • - The duration of the bone healing is 6-12 weeks.
  • - The functional recovery is 3-6 months.


Referral for physiotherapy:
  • - Refer patients to a physiotherapist if the range of motion is insufficient, despite good practice guidance, or if the patient doesnt understand the instructions.
  • - Mention in the referral to the physiotherapist which exercises (loaded / unloaded) can be preformed.
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Complications

  • Nonoperative treatment:
  • - Nonunion
  • - Vascular/nerve injuries
  • - Skin perforation
  • - Pneumothorax
  • Operative treatment:
  • - Surgical site infection
  • - Bleeding
  • - Burst out of osteosynthesis
  • - Nerve injury (rami of the nn. supraclacivulares)
  • - Pain and/or functionlo en/of loss of function despite successful osteosynthesis
  • - Pneumothorax
  • - Vascular injury of the large vessels in the mediastinum
  • - Migration of osteosynthesis material to the mediastinum
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References

  • 1. Robinson CM (1998) Fractures of the clavicle in the adult. Epidemiology and classification. J Bone Joint Surg Br 80(3):476–484
  • 2. Postacchini F, Gumina S, De Santis P, Albo F (2002) Epidemiology of clavicle fractures. J Shoulder Elbow Surg 11(5):452–456