This document summarizes a case report of a 27-year-old man who presented with right shoulder pain and limited range of motion after falling off his motorcycle without a helmet. Physical examination revealed tenderness and limited range of motion of the right shoulder. X-rays showed a fracture of the middle third of the right clavicle. The diagnosis was a closed fracture of the right clavicle. Treatment involved figure-of-eight splint immobilization and pain medication. The patient was advised to keep the splint on until his follow-up appointment in one week.

1. Interesting case
นพท. วิชญุตร์ ภูมิวัฒน์ ชั้นปีที่ 6
วิทยาลัยแพทยศาสตร์พระมงกุฎเกล้า

2. History
• Case ผู้ป่วยชายไทย อายุ 27 ปี U/D old pulmonary TB
• CC : MC ล้ม 10 ชั่วโมง PTA
• Primary survey
– A : patent airway, no C spine tender
– B : equal breath sound, no tachypnea
– C : vital sign stable, no external active bleed
– D : ผู้ป่วยเป็นใบ้และหูหนวกแต่กาเนิด E4V5M6 pupil 3 mm RTLBE
– E : no life-threatening wound

3. History
• Secondary survey
– A : pyrazinamide
– M : ไม่มีประวัติยาเดิม ตอนนี้ไม่มียาที่ใช้ประจา
– P : old pulmonary TB รับยา รพ.โชคชัย on ยา 12/57 – 05/58
– L : NPO time 08:30 น. (2 hr)
– E : 10 hr PTA ขับรถจักรยานยนต์ ขับรถล้มเอง ไม่สลบ ไม่สวมหมวกนิรภัย
ตัวด้านขวาและขาขวาลงพื้น มีอาการปวดไหล่ขวา ยกแขนไม่ขึ้นเนื่องจาก
ปวด มีแผลถลอกตามร่างกาย ไป รพช. On arm sling ก่อนส่งต่อมาที่รพ.
มหาราช

4. Physical examination
• Vital sign : BT 35.9 BP 127/63 PR 87 RR 20
• GA : an adult Thai man, good consciousness, deaf,
• HEENT : not pale conjunctivae, anicteric sclerea
• Heart : normal S1S2, no murmur
• Lung : equal breath sound, no adventitious sound
• Abd : soft, not tender, no palpable mass
• Ext : affected part
• Neuro : motor grade V all, sensory intact

5. Physical examination
• Affected part
– Tender at right proximal to middle clavicle area
– Stepping at right proximal to middle clavicle area
– Skin dimple seen at right proximal to middle clavicle area
– limit ROM of right shoulder due to pain
– Intact neurovascular

9. Diagnosis
• Closed fracture at middle third of right clavicle

10. Treatment
• Figure of eight splint
• D/C
• F/U 30/1/60 (1 week)
– Advice ใส่ Figure of eight ตลอดเวลาจนถึงวันนัด
– HM
• Paracetamol 500 mg oral prn q 6 hr

14. Mini review
Clavicle fracture

15. Epidemiology
• 2.6% of all fractures
• 69% in middle third
• 28% in distal third
• 2.8 – 9.3% in proximal third
• Peak incidence in children and young adults

16. Anatomy

17. Anatomy

18. Anatomy

19. Mechanism of injury
• Fall onto shoulder  87%
– Traffic accident
– sport
• Direct injury to clavicle
– Falling object
– assault

20. Classification
• Allman classification
– 3 groups based on location
• Group I : fractures of the middle third  most common
• Group II : fractures of the distal third  Neer classification
• Group III : fractures of the proximal third

21. Allman classification

22. Neer classification

23. Clinical presentation
• Group I
– Localized pain exacerbated by movement of arm
– Snap/cracking sensation
– Bone angulation/hematoma
• Group II
– Pain around AC joint
– Cross arm test positive
– Minimal deformity

24. Clinical presentation
• Group III
– Pain near sternoclavicular area
– Worsen by movement of shoulder and supine position
– Anteriorly protruding of medial clavicle
– Often associated with serious injury

25. Investigation
• Imaging
– Radiographs
• AP view of bilateral shoulders
– to measure clavicular shortening
• 45° cephalic tilt superior/inferior displacement
• 45° caudal tilt AP displacement
– CT
• may help evaluate displacement, shortening, comminution, articular
extension, and nonunion
• useful for medial physeal fractures and sternoclavicular injuries

26. Investigation

27. X-ray finding

28. X-ray finding
• Group I

29. X-ray finding
• Group II

30. X-ray finding
• Group III

31. Complication
• Malunion  most common
• Nonunion (if fail to heal after 4 – 6 mo)
• Pneumothorax
• Subclavian vessels/carotid A. compression or laceration
• Brachial plexus injury
• Post-traumatic arthritis

32. Treatment
• Non-operative
– Sling immobilization
• indications
–Non-displaced Group I (middle third)
–stable Group II fractures (Type I, III, IV)
–Non-displaced Group III (medial third)
–pediatric distal clavicle fractures (skeletally immature)

33. Treatment
• Sling immobilization
– Arm sling or figure-of-eight splint
• have no differences in healing times, healing rates, and alignment at final
follow-up
– Adjust q 7 – 10 days
– After 3-4 weeks begin gentle range of motion exercises

34. Treatment

35. Treatment
• Operative (should refer)
– open reduction internal fixation indications
• absolute
–unstable Group II fractures (Type IIA, Type IIB, Type V)
–open fracture
–displaced fracture with skin tenting
–subclavian artery or vein injury
–floating shoulder (clavicle and scapula neck fracture)
–symptomatic nonunion
–posteriorly displaced Group III fracture
–displaced Group I (middle third) with >2cm shortening

36. Treatment
• Operative
– Coracoclavicular ligament repair/reconstruct
– plate and screw fixation
• reconstruction plate
• intramedullary screw or nail fixation
• hook plate

37. Surgical complication
• hardware prominence
• superior plates  increased irritation
• neurovascular injury (3%)
– superior plates associated with increased risk of subclavian vessels penetration
– subclavian thrombosis
• nonunion (1-5%)
• infection (~4.8%)
• mechanical failure (~1.4%)
• pneumothorax
• adhesive capsulitis

38. Return to work and sport
• In general
– 6 – 8 weeks
• Distal clavicle fracture return to pre-injury level sooner
– 4 – 6 weeks
• Should avoid contact sport and strenuous activity until4 weeks
after clinical healing
– Required 8 – 12 weeks before returning to contact sport
– Should remove hardware before playing