Fracture Clavicle

SIGN & 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 surrounding muscles
• Possible nausea, dizziness, and/or spotty vision due to extreme pain
• Fracture of clavicle is commonest at Junction of medial 2/3rdand lateral 1/3rd

MECHANISM OF INJURY:

• The most common type of fracture occurs when a person falls horizontally on the shoulder or with an outstretched hand.
• A direct hit to the collarbone can also cause a break. 
• In most cases, the direct hit occurs from the lateral side towards the medial side of the bone.
• The muscles involved in clavicle fractures include the deltoid, trapezius, subclavius, sternocleidomastoid, sternohyoid, and pectoralis major muscles.
• The ligaments involved include the conoid ligament and trapezoid ligament.
• Incidents that may lead to a clavicle fracture include automobile accidents, biking accidents (especially common in mountain biking), horizontal falls on the shoulder joint, or contact sports such as football, rugby, hurling, or wrestling.

TREATMENT:

• Medication can be prescribed to ease the pain and tetanus vaccination for any skin breaks.
•  Antibiotics may be used if the bone breaks through the skin. 
• Often, they are treated without surgery. In severe cases, surgery may be done.

NONOPERATIVE:

• The arm must be supported by 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 or few weeks. 
• Surgery is employed in 5–10% of cases. However, a recent study supports primary plate fixation of completely displaced midshaft clavicular fractures in active adult patients.
• If the fracture is at the lateral end, the risk of nonunion is greater than if the fracture is of the shaft.

SURGICAL:

• Surgery is considered when one or more of the following conditions presents.
• Comminution with separation (multiple piece)
• Significant foreshortening of the clavicle (indicated by shoulder forward)
• Skin penetration (open fracture)
• Clearly associated nervous and vascular trauma (brachial plexus or supraclavicular nerves)
• Nonunion after several months (3–6 months, typically)
• Distal third fractures (high risk of nonunion)
• A discontinuity in the bone shape often results from a clavicular fracture, visible through the skin, if not treated with surgery. 
• Surgical procedures often call for open reduction internal [plate] fixation where an anatomically shaped titanium or steel plate is affixed along the superior aspect of the bone by several screws.
•  In some cases, the plate may be removed after healing, but this is very rarely required (based on nerve interaction or tissue aggravation), and typically considered an elective procedure.
•  In a surgically indicated patients now surgery of choice is elastic TEN intramedullary Nailing. 
• These devices are implanted within the clavicle’s canal to support the bone from the inside. 
• Typical surgical complications are infection, neurological symptoms distal the incision (sometimes to the extremity), and nonunion.