UPPER EXTREMITY FRACTURES
Clavicle fractures (Figure 39-1) are relatively common, accounting for 2–5% of all fractures in adults. The typical mechanism of injury is a fall on an outstretched arm or a direct blow to the shoulder or clavicle. The patient will complain of pain involving the affected shoulder and will typically hold the arm in adduction and internal rotation, avoiding any motion. There may be swelling, discoloration, and deformity at the fracture site. Displaced fractures may cause visible tenting of the skin.
Clavicle midshaft fracture. (Reproduced with permission of Justin Montgomery, MD; University of Kentucky Radiology.)
Clavicle fractures are best seen on an AP view. An AP view with the beam directed 30°–45° cephalad is sometimes necessary to lessen rib interference. A computed tomography (CT) scan can better visualize poorly seen medial or lateral one-third fractures. Additional x-rays of the ipsilateral shoulder may be necessary to evaluate for associated injuries. All x-rays need to be carefully examined for the presence of a concomitant scapular fracture resulting in a floating shoulder.
Complications may include injuries to the subclavian blood vessels or brachial plexus. Associated pneumothorax is also a rare complication. Fractures displaced ≥100% appear to be at increased risk for nonunion. Excessive callus formation can lead to cosmetic deformity or more rarely, compromise of neurovascular structures. It may require years for a large callus to remodel. Intraarticular fractures on either the medial or lateral end can lead to degenerative arthritis.
Nonsurgical management is the treatment of choice for most clavicle fractures and involves a sling for comfort, analgesics, and avoidance of overhead activity. This includes minimally displaced midshaft fractures as well as the vast majority of lateral and medial one-third fractures. Indications for operative management include open fractures, fractures that compromise the airway or neurovascular structures, the presence of significant displacement and/or tenting of the skin, or a floating shoulder. Radiographs should be obtained at 2-week follow-up to assess for displacement and angulation. Visible callus typically forms between 4 and 6 weeks, coinciding with significant clinical improvement. Once the fracture is clinically and radiographically healed, radiographs can be discontinued. The patient may return to normal activity when the clavicle is painless, the fracture is healed on radiograph, and the shoulder has a full range of motion and near-normal strength. Noncontact sports may often be resumed at 6 weeks, but return to contact sports may require ≤4 months.
JB. Clavicle fractures. Am Fam Physician. 2008;77(1):65–70.
Van der Meijden