Injury Around the Shoulder- Clavicle Fracture, Classification & Clinical Features

CLAVICLE FRACTURE
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CLAVICLE FRACTURE

Common Sites

Junction between medial 2/3 and lateral 1/3 is the vulnerable area to fracture especially with axial loading (commonest).

Fracture midshaft of the clavicle
Outer end of clavicle fracture.

Mechanism of Injury

Fall on the outer side of shoulder (common)
Fall on the outstretched hand leads to upward and backward thrust
Direct blow to the point of shoulder
Violent muscle contraction during epilepsy or stress fracture or any pathology.

Craig’s Classification

Group I: Fracture of the middle 1/3 (most clavicular fractures are group I fractures.)
Group II: Fracture of the lateral or distal 1/3.

– Type I – Minimally displaced fractures.
– Type II – Displaced fracture medial to the coracoclavicular ligament complex.

– Type III – #Fracture of the articular surface.
– Type IV – Ligaments intact to the periosteum, with displacement of the proximal fragment.
– Type V – Comminuted.

Group III: Fracture of the medial 1/3.
– Type I – Minimally displaced
– Type II – Displaced
– Type III – Intra-articular
– Type IV – Epiphyseal separation
– Type V – Comminuted.

Neer’s Classification type

Fractures of the distal clavicle (lateral one-third) 

Type I – Lateral to the coracoclavicular ligament complex, stable

Type II – Medial to the coracoclavicular ligaments, leaving the distal clavicle & the acromioclavicular joint intact but separate from the underlying  coracoclavicular ligament complex. These are associated with ↑ risk of nonunion.

Type III – Involving the articular surface of the distal portion of the clavicle.These are usually associated with major ligamentous disruption.

Clinical Features
Pain
Swelling
Tenderness (local).

Clinical Presentation

Affected arm adducted, cross the chest, supported by other hand, to avoid weight bearing over the injured side clavicle.
Sometimes due to prominent fracture end, there is rupture of the skin over it.
Crepitus may be heard.

Sometimes associated injuries like sternoclavicular dislocation, rib injuries, acromioclavicular injuries may be present.
Tachypnea may be present due to pain with inspiratory effort.

Displacement

If the fracture fragment is displaced, the inner fragment is pulled up by the sternocleidomastoid muscle and the outer fragment pulled down by gravity as well as the weight of the upper limb.

Radiological Examination

X-ray: Anteroposterior
Lateral
AP view shows caudal tilt.

Treatment

Conservative or Nonoperative

Sling immobilization for 3-4 weeks but care must be taken to avoid rubbing against the fracture site.
Figure of 8 bandage (which maintain the shoulder in backward position)
Harnesses or brace (uncommon).

Operative
Plate.

Fixation
Suturing or wiring
External devices.

Complications

Malunion – Due to displacement of fragments by pull of muscles and weight of arm, this may cause undue prominence.
If operative then scar formation occurs.
Neurovascular Injury – Sharp end of bones may rupture the nerves and vessels nearby the clavicle (like subclavian and brachial plexuses)
Sometimes due to callus formation, compression of nerves and vessels may occur.
Nonunion – Rarely occur.
Deformity – Due to malunion.
Osteoarthritis – Post-traumatic type.


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