clavicular fractures…. dangerous???

CLAVICULAR FRACTURES….DANGEROUS???Kristin Ratnayake, MDPediatric Emergency Medicine FellowOctober 3, 2013

Case• 16y/o female who presents with left shoulder and neck

pain secondary to a motor vehicle accident

Patient History• PMH: Pregnancy with NSVD 1 year ago• PSH: Denies• Family Hx: Denies• Social Hx: Lives with mom, stepdad and son

ROS• +chest pain (left anterior)• +numbness left arm and shoulder• +arthralgias • Otherwise negative

PE• BP 104/55 | Pulse 85 | Temp 99.1 °F (37.3 °C) (Oral) | Resp 18 | Wt 97.523 kg

(215 lb) | SpO2 99%

• HEENT: normal• Neck: Normal range of motion. Tenderness to palpation over left lateral neck. No

point tenderness over cervical spine. • Cardiovascular: Normal• Pulmonary/Chest: Normal. • Abdominal: Normal.

Musculoskeletal: She exhibits tenderness. Tenderness to palpation over left clavicle. No deformity or swelling noted. Pain of left shoulder with movement of left arm. Extension of left arm limited by pain. Neurological: She is alert. No cranial nerve deficit. She exhibits normal muscle tone. Coordination normal. Numbness over lateral aspect of left upper arm and shoulder. Normal grip strength bilaterally.

• Skin: Normal.

MDM• 16y/o female with left shoulder pain secondary to trauma

from MVA: • - CXR and left shoulder xray • - tylenol for pain

What to do?• Sling?• Figure 8?• Ortho?• Trauma consult?

Trauma consulted• Clavicle xrays (surprisingly not all that helpful)• Other bony xrays (shoulder, knee, tib-fib, ankle- all

negative)• CT head, neck, chest, abdomen and pelvis

- Neck and Chest with IV contrast

Was that appropriate management?• Let’s review clavicle fractures!

Clavicle Fractures• Common injuries• Middle 1/3 most frequently fractured• Mechanism

Important Examination Points• Skin• Neurovascular status

Subclavian Injuries• Katras et al., Vasc Surg, 7 patients with blunt trauma to

subclavian artery• 4 with clavicle fracture, all MVA victims• Only 1 with brachial plexus injury

• Kendall et al., J Trauma, death from subclavian artery injury from clavicle fracture

Treatment• Traditionally clavicle fracture managed non-operatively• Distal third

Sternoclavicular Dislocation• Routine radiographs are often difficult to interpret and may

falsely appear normal• Serendipity view

Sternoclavicular Dislocation• Three types of injury

- First Degree – most common – strain of ligaments- Second Degree – anterior or posterior subluxation from manubrium - Third Degree – complete disruption with subsequent dislocation

Complications• Significant morbidity and mortality with posterior

dislocations• Injury to lung, trachea, esophagus, vasculature, nerve

Treatment• Supportive care and immobilization for strain type injury• Closed reduction of anterior and posterior dislocations• ORIF if unable to reduce, recurrent or unstable