Clavicle injuries
From Medical-Wiki
While clavicular injuries are painful, they are rarely considered life-threatening. However, the first sports-related injury for which there is a report is that of William III who died following an equestrian accident that lead to a false aneurysm of the subclavian artery. Clavicular injuries can indeed be serious. [1]
These injuries are common. They are also usually easy to notice because of the clavicle’s subcutaneous position. It is also true that healing of a fracture will often take place regardless of treatment. However, there are a number of possible complications that dictate attention to detail.
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Anatomy of the clavicle
The bone is relatively slender and acts as a strut between the torso and the upper limb. It is attached to the sternum at the sternoclavicular (SC) joint. It is attached to the acromion of the scapula at the acromioclavicular (AC) joint. The clavicle is joined at these joints and to the coracoid process via very strong ligaments. The bone is at its weakest at the junction of its middle and distal thirds—making this junction the most common site of fracture.
Running behind the clavicle is a neurovascular bundle. Damage to these structures is another factor that must be considered when treating injuries.
Types of clavicle fracture
Fractures of the clavicle may be caused by direct or indirect trauma. Indirect trauma causes the greatest number of fractures. Typically, a patient will fall onto the lateral shoulder. The force from the fall is transmitted across the clavicle, causing the fracture.
Direct trauma can come from a blow or a fall that impinges directly on the body of the clavicle. Football, hockey, wrestling, soccer, roller skating, skiing, bicycling, or horseback riding are all associated with clavicular injuries. [2]
Clavicle fractures may be broken down into three classes.
Group 1 Fractures - fractures of the middle third
Those occurring in the middle one third of the clavicle (Group 1) are the most common. They account for 80 percent of clavicle fractures and are treated conservatively. At one time, these fractures were treated with a figure-of-eight bandage. However, this attempt at fixation borders on being torturous and does not improve functional or cosmetic results. Consequently conservative management consists of just an arm sling for comfort, even if significant displacement is present. Ice, analgesics, elbow range-of-motion exercises when pain permits, and, upon healing, range-of-motion and strengthening exercises constitute the remainder of a treatment regimen.
Group 2 Fractures - fractures of the lateral third
Nondisplaced fractures in the lateral one third of the clavicle (group 2) are also typically treated conservatively. Group 2 fractures that extend to the articular surface, even if nondisplaced, often lead to osteoarthritis of the acromioclavicular (AC) joint. Displaced group 2 fractures are unstable and have a high rate of nonunion. Thus, they should be referred to an orthopod for a consideration of surgery. Surgical treatment has a high success rate.
Group 3 Fractures - fractures of the medial third
Displaced fractures of the medial one third of the clavicle (group 3) require orthopedic referral, as do sternoclidal dislocations. The most common side effects of these injuries are intrathoracic or neurovascular sequelae. These are circumstances that require emergency surgery. Nondisplaced group 3 fractures without associated injuries can be treated conservatively with a sling for comfort.
Acromioclavicular joint injuries
The acromioclavicular (AC) joint is also a common site of injury in athletes and active persons. The most common event causing these injuries involves a direct blow to the acromion while the humerus in an adducted position. The resultant forces push the acromion medially and inferiorly. Another common injury is via indirect trauma through a fall onto an outstretched arm or elbow.
The ligaments that can be “sprained” (stretched) are the acromioclavicular, coracoclavicular, and deltotrapezial fascia. In addition to sprains, the ligaments can be disrupted, detached, or separated. Of these, the first to be damaged is the AC ligament. Then, if enough force is applied, the coracoclavicular ligaments will be torn, and finally, the deltotrapezial fascia injured or detached.
If all support is disrupted or detached, the distal clavicle is freed to rise superiorly. When this happens, there may be an associated fracture of the coracoid process or the lateral one third of the clavicle. This is a circumstance that needs immediate orthopedic evaluation.
When a patient with an AC injury presents, there should first be an assessment neurovascular status. Then, the patient should be assessed for appropriate radiographs. The contralateral side should also be imaged for comparison. While old standards utilized weighted radiographs, their use is now being questioned.
If a patient presents with tenderness over the AC joint, no visible deformity of the distal clavicle, and a positive cross-arm test—sharp pain at the AC joint if the patient holds the arm out straight and brings it across the chest, normal radiographs will probably suffice. (Type 1 injury)
With type II injuries, the distal clavicle may be slightly more prominent on inspection. The patient will also have pain at the distal end of the clavicle. This pain is from the sprained coracoclavicular ligament. X-rays in this case may be normal but may also show slight widening of the AC joint.
Treatment of type I and II injuries consists of symptomatic relief with use of a sling for one to three weeks, ice, and nonsteroidal anti-inflammatory drugs (NSAIDs). Range-of-motion and general strengthening exercises should begin when pain allows. Usually, patients return to their prior activities although there may be mild complaints of clicking and pain with push-ups.
A patient who presents with an obvious prominence of the distal clavicle and has an x-ray that shows an obvious separation of the AC joint and an increase of the coracoclavicular distance of 25 to 100 percent compared with the normal side has a type III injury.
Types IV to VI have grossly abnormal radiographs.
Type IV, V and VI require immediate referral and usually require surgical repair. The treatment of type III injuries is variable, but it is judicious to refer them for orthopedic evaluation. [3]
