A direct blow to the clavicle or a fall on the lateral shoulder may cause a clavicular fracture. Fractures of the clavicle occur in the middle (80%), distal (15%), and medial (5%) thirds. Patients hold the affected arm adducted and resist motion. Typically, there is swelling and tenderness over the fracture site and a visible and palpable deformity.
Imaging studies should include an anteroposterior (AP) view. Sometimes an apical lordotic view (AP view 45 degrees cephalad) helps visualize the clavicle without rib interference. A distal third fracture with articular involvement may require cone views or a lateral view. Likewise, at times a medial third fracture is seen with cone and lateral views. A computed tomography (CT) scan helps visualize articular fractures.
Complications may include subclavian vascular injuries and nerve root avulsion or contusion. Middle third fractures may develop malunion, excessive callus formation, and nonunion. Displaced distal third fractures with torn coracoclavicular ligaments may lead to delayed union. It may require years for a large callus to remodel. Articular surface involvement in either the medial or distal third can lead to degenerative arthritis.
Treatment includes ice, analgesics, sling immobilization, and physical therapy. Initial radiographs may show early callus formation. At 2-week follow-up, radiographs should be obtained to evaluate for displacement and angulation. Significant callus typically forms between 4 and 6 weeks, along with disappearance of the fracture line. If the fracture is not clinically healed, repeat radiographs at 6-8 weeks are indicated. 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.
Displaced fractures, open fractures, nonunion, and persistent pain 6-8 weeks post-fracture are indications for referral.
Eiff MP: Management of clavicle fractures. Am Fam Physician 1997; 55:121.
Colle Fractures (Distal Radius Fracture)
A fall-on-outstretched-hand (FOOSH) injury can lead to a Colle fracture. Patients typically present with pain, swelling, and tenderness at the distal forearm. On examination a "dinner fork" deformity (dorsal displacement of the distal fragment and volar angulation of the distal intact radius with radial shortening) may be identified.
Imaging studies consist of AP and lateral radiographs (Figure 38-1). Concomitant fracture of the ulnar styloid process may be present. With immobilization, the fracture becomes stable in 6-8 weeks.
Distal radius fracture. (Courtesy ...