middle third clavicle fracture 800

Case Report: Middle Third Clavicle Fracture

Introduction

A 23 year old male presented to the sideline with right shoulder pain after taking a hard hit during a preseason football practice. He states he was completing a pass route, went airborne and fully extended his body to catch the pass. He landed on the tip of his shoulder, sustaining a direct blow. On the sideline, he had point tenderness and gross deformity of the mid-shaft of his clavicle. The medial component was elevated due to SCM muscle spasm and depressed laterally due to the shoulder joint and pectoralis muscle. His neurological exam was within normal limits. Radiographs were obtained which revealed a closed, mid-shaft, comminuted fracture of the right clavicle with 2 cm of shortening. The patient elected to have surgical intervention.
Anterior-posterior radiograph showing midshaft clavicular fracture. Note surgical anchors related to previous shoulder stabilization.[1]Rabe, Sarah B., and Gretchen D. Oliver. “Clavicular fracture in a collegiate football player: a case report of rapid return to play.” Journal of athletic training 46.1 (2011): 107-111.

Discussion

Mid shaft clavicle fractures are one of the most common fractures seen in both adults in children. In adults, they represent 2-5% of all fractures while in children, 10-15%.[2]Neer CS II. Fractures of the distal third of the clavicle. Clin Orthop Relat Res 1968;58:43-50. The distribution is bimodal, seen in both young males under the age of 30 and elderly patients over the age of 70. Mid-shaft or middle third represents the majority of clavicle fractures with lateral third and medial third representing only 25% and 3% respectively. Risk factors include osteoporosis, osteopenia and male gender.
The mechanism of injury typically involves falling directly onto the lateral shoulder. Other mechanisms include falling on an outstretched hand, direct trauma to the clavicle, traffic accidents and sports and recreation. Associated conditions which can be seen with clavicle fractures and must be considered includes scapular fractures, rib fractures, pneumothorax, acromioclavicular joint injuries, sternoclavicular joint injuries and the dreaded great vessel or brachial plexus injuries. The extent of these co-occurring pathologies will depend largely on the mechanism.
Illustration of the clavicle and bony landmarks.[3]Images courtesy of getbodysmart.com and teachmeanatomy.info
It is worth briefly reviewing the anatomy of the clavicle. Laterally, the clavicle articulates with the acromion as it wraps anteriorly off the scapula, forming the acromioclavicular joint. Medially, it articulates with the sternum, forming the sternoclavicular joint. Muscle attachments include deltoid, trapezius, pectoralis major, sternocleidomastoid, subclavius and sternohyoid. The function of the clavicle is to help attach the upper limb to the trunk as part of the shoulder girdle. It also protects the neurovascular structures of the upper limb. Finally, it can transmit force from the upper limb to the axial skeleton.
Clinical appearance of an acutely fractured clavicle, showing extensive ecchymosis. The proximal fragment can be palpated just under the skin (arrow). b A patient with tenting of the skin and ulceration from the underlying proximal fragment. NOTE: this is not our case report patient.[4]Image courtesy of musculoskeletalkey.com
Physical exam of a mid shaft clavicle fracture is typically easy as there is a preceding trauma and often a visible deformity. Patients will complain of anterior shoulder pain, swelling, bruising. Their pain is isolated over the fracture site unless there is polytrauma. The arm is often held in adduction and internal rotation. The most important component of examining a clavicle fracture is considering neurovascular injuries. Thus it is incumbent to perform a very thoughtful neurological and vascular exam of the upper extremity.
Normal Zanca view radiograph of the clavicle and AC joint.[5]Case courtesy of Henry Knipe, Radiopaedia.org, rID: 68155
For middle third clavicle fractures, radiographs are sufficient. The so-called Zanca view provides a 15 degree cephalic tilt which can help better evaluate the clavicle on dedicated clavicle views. CT is useful to better characterize the degree of injury, evaluate for articular extension, and neurovascular injuries. Note that radiographs are not sufficient to exclude medial third clavicle fractures. Finally, ultrasound can be used and is highly sensitive and specific for clavicle fractures.[6]Hassankhani A, Amoukhteh M, Jannatdoust P, Valizadeh P, Gholamrezanezhad A. A systematic review and meta-analysis on the diagnostic utility of ultrasound for clavicle fractures. Skeletal Radiol. 2024 … Continue reading
The Edinburgh classification for clavicle fractures.[7]Ulucay, C., et al. “Treatment of clavicle fractures in athletes and young active patients.” J Trauma Treat 4.240 (2015): 2167-1222.
There are several classification systems that have been proposed and are utilized. Famously, the Allman classification breaks them down simply into lateral third, middle third and medial third. The Neer classification describes lateral third clavicle fractures and is prognostic for complications like delayed union or non-union. The Edinburgh classification expands upon the Allman classification and is useful for prognosticating middle third fractures.
Nonoperative management is indicated in the majority of most middle third clavicle fractures. Studies support higher patient satisfaction scores with nonoperative treatment.[8]Eskola A, Vainionpaa S, Myllynen P, Patiala H, Rokkanen P. Outcome of clavicular fracture in 89 patients. Arch Orthop Trauma Surg 1986; 105:337-8. Nonoperative treatment is specifically indicated in fractures that are not displaced, with <2 cm of shortening, <1 cm displacement and no neurovascular injuries. Historically, a figure of 8 brace was used however a shoulder sling is considered standard of care and is better tolerated. Early range of motion and physical therapy should be initiated under supervision.
Surgical indications include patient preference depending on occupation (as is the case in our patient who is an elite athlete and also had 2 cm shortening), skin tenting, open, neurovascular compromise, polytrauma and floating shoulder. Pediatric considerations are generally similar and not controversial given the rapid bone healing and remodeling capabilities.
Return to play typically occurs around week 6 to 8. General return to play guidelines include full range of motion, normal strength of ipsilateral shoulder and no pain with forceful palpation of the fracture site. For surgically managed patients, some experts recommend removing hardware before returning to play. Noncontact sports may return sooner than contact/ collision sports.

In most health patients, the prognosis is excellent and patients are able to return to pre-injury levels of function. The most common complications are nonunion and malunion. Nonunion risk factors include displacement, comminution, advanced age, female gender and tobacco use.[9]Evidence-Based orthopedics. (2012). Wiley-Blackwell. https://doi.org/10.1002/9781119413936 Additional chronic complications include shoulder dysfunction, residual pain, poor cosmesis and post-traumatic arthritis.

Radiograph showing plate osteosynthesis.[10]Rabe, Sarah B., and Gretchen D. Oliver. “Clavicular fracture in a collegiate football player: a case report of rapid return to play.” Journal of athletic training 46.1 (2011): 107-111.
Radiograph showing 3.5-mm interfragmentary screw.[11]Rabe, Sarah B., and Gretchen D. Oliver. “Clavicular fracture in a collegiate football player: a case report of rapid return to play.” Journal of athletic training 46.1 (2011): 107-111.

Case Conclusion

The patient underwent plate osteosynthesis. There was a large butterfly fragment which was fixed with a 3.5 mm interfragmentary screw. The rehabilitation process began immediately post surgery under the direction of the medical and athletic training staff. The patient was performing pendulum range of motion exercises, bicep curls and triceps extensions 2 days post op. He was allowed to maintain cardiovascular fitness on a stationary bicycle. By postoperative day 4, the patient had achieved 170 degrees of shoulder flexion, abduction and 20 degrees of shoulder extension, adduction. (see rehabilitation protocol image)
Rehab protocol used by the sports medicine team (click to enlarge).[12]Rabe, Sarah B., and Gretchen D. Oliver. “Clavicular fracture in a collegiate football player: a case report of rapid return to play.” Journal of athletic training 46.1 (2011): 107-111.
Weekly radiographs were taken to ensure routine healing. In week two, the patient was transitioned to an elliptical machine for cardio. Shoulder extension and adduction continued to improve. On week three, he was allowed to begin jogging and discontinue the bicycle. He began advancing to a more dynamic rehabilitation program including ball dribble, bodyblade, ergometer and team conditioning drills. Modalities that helped with muscle tightness included cryotherapy, thermotherapy and manual therapy. At week 4, the patient began push-up progressions, dynamic stabilization and advanced scapular exercises. In week 5, full range of motion and strength was achieved. At 6 weeks, a CT scan revealed adequate healing, a clavicle padding was placed and the athlete was allowed to return to full competition.

– Read more about clavicle fractures @ Wiki Sports Medicine: https://wikism.org/Clavicle_Fracture

References[+]