CLAVICLE FRACTURE

Defination

A clavicle fracture is a bone fracture in the clavicle, or Collarbone. It is often caused by a fall onto an outstretched upper extremity, a fall onto a shoulder, or a direct blow to clavicle. Many research projects are underway regarding the medical healing process of clavicle fractures.

Anatomy
The clavicle is the bone that connects the trunk of the body to the arm, and it is located directly above the first rib. There is a clavicle on each side of the front, upper part of the chest. The clavicle consists of a medial end, shaft, and a lateral end. The medial end connects with the manubrium of the sternum and gives attachments to the fibrous capsule ot the sternoclavicular joint, articular disc, and interclavicular ligament. The lateral end connects at the acromion of the scapula which is referred to as the acromioclavicular joint. The clavicle forms a slight S shaped curve when it curves from the sternal end laterally and anteriorly for near half its length, then forming a posterior curve to the acromion of the scapula.

Prevalence

Clavicle fractures occur 30 60 cases per 100,000 a year and are responsible for 2.6 5 % of all fractures. Fractures occur twice much in males than females. About half of all clavicle fractures occur in children under the age of 7 and is most common pediatric fracture.

Risk Factors / Prevention

Those who have a Low dietary intake of calcium and vitamin D may have a higher risk of clavicle fractures. Increasing the integrity of the bone by a sufficient amount of dietary calcium and vitamin D will help to prevent fractures in the bone. Also Sedentary individuals may be at a higher risk due to weakness in muscle stabilizers of the clavicle, Also participation in extreme sports such as mountain biking and snowboarding will increase the risk of a clavicular fracture as well.

Mechanism of Injury
Clavicle fractures are commonly known as a breaking of the collarbone, and they are usually a result of injury or trauma. The most common type of fracture occur when a person falls horizontally on the shoulder or with an outstretched hand. A direct hit to the collarbone will also cause a break. In most cases, the direct hit occur from the lateral side towards the medial side of the bone. The muscles involved in clavicle fracture includes the deltoid, trapezius, subclavius, sternocleidomastoid, sternohyoid and pectoralis major muscles. The ligament involved include the conoid ligament and trapezoid ligament. Incident that may lead to a clavicle fracture include automobile accidents, horizontal falls etc.

Signs and Symptoms

Pain, particularly with upper extremity movement or on front part of upper chest. Swelling Often, after the swelling has subsided, the fracture can be felt through the skin. Sharp pain when any movement is made. Referred pain: dull to extreme ache in and around clavicle area, including muscles. Possible nausea, dizziness, and spotty vision due to extreme pain.

Diagnosis

The basic method to check an clavicle fracture is by an X-ray of the clavicle in order to determine the fracture type and extent of injury. In most cases, X-rays will be taken of both bones for comparison purposes. In more severe cases a CAT scan or MRI will be taken. However, the standard method of diagnosis is through ultrasound imaging performed in the emergency room may be equally accurate in children.

Non Operative
The arm must be supported by a use of a splint or sling to keep the joint stable and decrease the risk of further damage. Usually, a figure of eight splint that wraps the shoulders to keep them forced back is used and the arm is placed in a clavicle strap for comfort. Current practice is generally to provide a sling, and pain relief, and to allow the bone to heal itself, monitoring progress with X-rays every week for few weeks. Surgery is employed 5 10% of cases. However, a recent study supports primary plate fixation of completely displaced mid shaft clavicular fractures in active adult patients In the fracture is at lateral end, the risk of nonunion is greater than if the fracture was of the shaft.

Surgical
The surgery is indicated when one or more of the following conditions presents. Communication with separation. Significant foreshortening of the clavicle. Skin penetration. Clearly associated nervous and vascular trauma. Non union after several months. Distal third fractures which interface with normal function of the ACJ.

A discontinuity in the bone shape often results from a clavicle fracture, visible through the skin, if not treated with surgery. Surgical procedure will often call for ORIF where an automatically shaped titanium or steel plate is fixed along the superior aspect of the bone via several screws. In some cases the plate may be removed after healing, but this is very rarely required, and typically considered as elective procedure. Alternatively, intramedullary fixation devices can be im planted to support the fracture during healing. These devices are implanted within the clavicles canal to support the bone from the inside. Typical surgical complications are infection, neurological symptoms distal the incision and non-union.

Bone healing
Bone healing or fracture healing is a proliferative physiological process in which the body facilitates the repair of bone fracture. Generally bone fracture treatment consists of a doctor reducing dislocated bones back into place via relocation with or without anaesthetic, stabilizing their position, and then waiting for the bones natural healing process to occur.

Physiology and process of healing

In the process of fracture healing, several phases of recovery facilitate the proliferation and protection of the areas surrounding fractures and dislocations. The length of the process depends on the extent of the injury, and usual margins of two to three weeks are given for the reparation of most upper bodily fractures; anywhere above four weeks given for lower bodily injury. The process of the entire regeneration of the bone can depend on the angle of dislocation or fracture. While the bone formation usually spans the entire duration of the healing process, in some instances, bone marrow within the fracture has healed two or fewer weeks before the final remodeling phase.

 While immobilization and surgery may facilitate healing, a fracture ultimately heals through physiological processes. The healing process is mainly determined by the periosteum (the connective tissue membrane covering the bone). The periosteum is one source of precursor cells which develop into chondroblasts and osteoblasts that are essential to the healing of bone. The bone marrow (when present), endosteum, small blood vessels, and fibroblasts are other sources of precursor cells.

Phases of fracture healing

There are three major phases of fracture healing, two of which can be further sub-divided to make a total of five phases; 1. Reactive Phase i. Fracture and inflammatory phase ii. Granulation tissue formation 2. Reparative Phase iii. Cartilage Callus formation iv. Lamellar bone deposition 3. Remodeling Phase v. Remodeling to original bone contour

Acromioclavicular joint dislocation

1. General Acromioclavicular joint dislocation or "Separation"

2.Mechanism a) Fall on an outstretched hand b) Direct trauma Top of Shoulder or Acromion with Shoulder adducted

Grading: AC joint dislocation (Rockwood Classification)

A. Incomplete dislocation (Types I to II) Type I: Simple AC joint Contusion or strain Type II: AC joint ligament rupture B. Complete dislocation (Types III to V) Type III: Rupture of coracoclavicular ligaments Type IV: Joint posteriorly displaced (uncommon) Type V: Overlying muscle penetrated (uncommon) Type VI: Clavicle displaced behind biceps (rare)

Symptoms
Tenderness and swelling over AC joint Pain on lifting arm

Signs 1. Outer clavicle elevated

2. Deformity if Grade III or higher Provocative Maneuvers eliciting pain Downward traction on arm Shoulder Crossover Maneuver Rotator Cuff Tear Clavicle Fracture (lateral third) Coracoid process Fracture

Differential Diagnosis Complications

Radiology: Clavicle XRays

Differentiate incomplete from complete AC Dislocation Weighted views are no longer indicated Diagnosis is clinical and XRay may be diagnostic with stepoff seen Old protocol used XRay taken with 10 kg weights hanging from each arm Measured coracoid process to clavicle distance Discrepancy between sides suggested AC Dislocation

Management
A. 1. 2. 3. a. B. 1. 2. 3. C. 1. 2. Symptomatic relief Immobilize with sling for 3 days based on pain See RICE-M Analgesics as needed Clavicle tip often prominent, but usually painless Active range of motion of strengthening Begin as soon as possible See Shoulder Range of Motion Exercises See Shoulder Strengthening Exercises Surgery Indications Type 4 to 6 AC Dislocation Type 3 AC Dislocation if physically active

Management: Taping Technique (consider in Wilderness)

A. 1. 2. Realignment Examiner 1 pushes down on clavicle Examiner 2 pushes up on upper arm from elbow

B. 1. a. b. 2. 3. a.

Taping technique Start Tape from just medial and superior to nipple Extend tape over Shoulder and onto mid Scapula Repeat with overlapping strips moving laterally Secure above taping with tape over ends Start tape perpendicularly to above Run over top of Shoulder from medial to lateral

Sternoclavicular Dislocation Epidemiology - Uncommon injury Mechanism

SC Dislocation results from direct fall onto Shoulder

Types of Sternoclavicular Dislocation

A. 1. a. b. B. 1. a. b. Anterior Dislocation (More common) May occasionally occur spontaneously without trauma Older adult presents with painless sternal mass Affects sternal end of clavicle Posterior Dislocation Rarely may cause pressure anterior neck Leads to Dyspnea and vascular compression Requires emergent reduction

Differential Diagnosis
A. Epiphyseal Fracture in child 1. Non-surgical management as with SC Dislocation

Symptoms and Signs

Tender, visible prominence at sternoclavicular Joint Discomfort with Shoulder Range of Motion

Radiology: Shoulder XRay

SC Joint difficult to visualize on XRay View angled upward including uninjured side helpful Sternoclavicular joint MRI may be necessary

Management: SC Anterior dislocation

A. 1. 2. 3. B. 1. 2. Reduction by traction and manipulation Reduction difficult to maintain Commonly recurs No loss of function (cosmetic only) Surgery (rarely indicated) Indicated for post-traumatic arthritis Excise medial 1 to 2 cm of clavicle

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