Injury, 7, 101-106 101

Fractures of the clavicle

M. Sankarankutty Trauma and Orthopaedic Department, Bridgend General Hospital

B. W. Turner General Practitioner, Bridgend

Summary Three hundred and forty-two patients with fractures of the clavicle attended the Fracture Clinic at Bridgend General Hospital between 1957 and 1972. The history of injury was recorded in the notes at the first visit but in only 215 cases was the exact meehan- ism of the injury clearly stated. Of these, 91 per cent were caused by a fall or a blow on the point of the shoulder.

All patients were treated symptomatically. A tri- angular sling was applied to support the weight of the arm and early use of the limb was encouraged. One hundred unselected patients were followed up, the longest period being 15 years and the shortest, 1 year. None had any loss of function or muscle power at the shoulder. Only 15 per cent were left with any noteworthy deformity at the site of fracture.

THE clavicle is the most frequently broken bone in the body (Browne, 1966). It is generally assumed that the commonest cause is a fall on the outstretched hand (Watson-Jones, 1955; Apley, 1968; De Palma, 1970; Adams, 1972). Fowler (1962), however, pointed out that the injury nearly always followed a fall or a blow on the point of the shoulder. A blow on the bone is a rare cause.

The fragments cannot be reduced or im- mobilized by traditional methods using clavicle rings, figure-of-eight bandages or plaster yokes (Nicoll, 1954). Indeed, such attempts not only cause discomfort but carry a risk of neurovascular compression (Nicoll, 1954; Fowler, 1962, 1968). In a complete fracture of the shaft of the bone, the outer fragment is displaced downwards and backwards in relation to the inner fragment. The above-mentioned methods of treatment tend to aggravate this deformity by depressing and retracting the outer fragment (Fig. 1). Patients with fractures of the clavicle attending Bridgend General Hospital have been treated

symptomatically. Only a triangular sling was applied to support the weight of the limb, with no restriction in the use of the limb.

We have not been able to find any review of the long-term results of fractures of the clavicle treated by any one method. A study was made to establish the cause of the fractures and the results of symptomatic treatment.

MECHANISM OF INJURY From 1957 to 1972, 342 patients with fractures of the clavicle came under the care of the Fracture Clinic of the Bridgend General Hospital. Of these, 127 patients were excluded from the study because the exact mode of injury was not determined. This was either due to their youth, the lack of an eye-witness, momentary concussion of the victim or the speed with which the incident occurred.

Table 1. Main causes of injury in 342 cases

Road traffic accident 69 20.0% Rugby football 43 12.6% Fall from horse 8 2.4%

The main causes of injury are shown in Table I. Of the 215 patients for whom a detailed history was available, 196 (91 per cent) had fallen on the point of the shoulder or sustained a blow on the

Tab/e //. Mechanism of injury in 215 cases

Fall or blow on the point of the shoulder 196 91% Direct injury over the bone 17 8% Fall on the outstretched hand 2 1%

102 Injury: the British Journal of Accident Surgery Vol. ~/NO. 2

point of the shoulder; 17 (8 per cent) had had a blow directly over the clavicle; and 2 (1 per cent) had fallen on the outstretched hand (T&e If).

A fall on the point of the shoulder transmits the body’s weight along the clavicle (Figs. 2 and 3). This may be seen when jockeys fall fi rom

Fig. 1. A, Radiograph of a patient with fractured clavicle with figure-of-eight bandage, but not tightened. B, After tightening figure-of-eight bandage, showing increase in deformity. The position of the X-ray tube and that of patient remained unchanged. C, Same patient with figure-of-eight bandage tightened.

Fig. 2. Fall on the point of the shoulder-the commonest mode of injury fracturing the clavicle.

their mounts and are photographed at the moment of impact with the ground.

TREATMENT Every patient was treated by applying a triangular sling to support the weight of the limb (Fig. 4) in order to relieve pain. They were encouraged to use the hand from the beginning, to remove the sling and move the shoulder as soon as they wished. In most cases the sling was soon dis- carded, and a few patients never wore the sling at all.

ASSESSMENT One hundred unselected patients treated in this manner were reviewed. All 342 patients were requested to attend for follow-up. The majority were schoolchildren at the time of the accident and had left school and moved away. Some did not think it was necessary to attend because they had no symptoms.

Sankarankutty and Turner: Fractures of the Clavicle

Fig. 3. Diagrammatic representation of the trans- mission of the impact of the body-weight along the clavicle.

103

follow-up. Residual clinical deformity as shown by bony prominence was graded thus: Grade 0, no deformity; Grade 1, slight deformity (often unnoticed by the patient); Grade 2, moderate deformity; and Grade 3, severe deformity. Representative examples are shown in Fig. 5.

RESULTS There was no case of non-union. No patient had any significant loss of muscle power or movement at the shoulder. None had any discomfort. Hence the final analysis was confined to the clinical deformity. Of 100 patients reviewed, 68 belonged to Grade 0 and 17 to Grade 1. Thus 85 per cent had little or no deformity. Table III shows an analysis of all patients accord- ing to age. Union without permanent deformity

Fig. 4. A, Improperly applied sling with the affected shoulder drooping. B, Properly applied sling with shoulders level.

Clinical assessment was carried out by one was invariable in children of 10 and under, observer who was not involved in the treatment. even in those with marked angulation or gross The deformity at the fracture site, the range of overlap (Fig. 6). Fifty-one per cent were under shoulder movement and the muscle power were the age of 15 years and it is in this group that all noted. All the patients had radiographs at remodelling of the bone produced the best

104 Injury: the British Journal of Accident Surgery Vol. ~/NO. 2

Tab/e ///. Analysis of deformity in 100 cases of fractured clavicle

No. of patients

Age (years)

Percentage in each Grade Grade0 Grade 1 Grade 2 Grade3

37 O-l 0 100 - - - 51 O-l 5 94 6 - - 69 O-20 82.6 8.7 7.2 1.5

100 o-20+ 68 17 11 4

cosmetic results. No patient in this group had any notable deformity.

There were 16 patients with cornminuted fractures. The incidence of deformity is shown in Table IV. Comminuted fractures of the clavicle may result in severe malunion, and the 4 patients with Grade 3 deformity had com- minuted fractures. However, even in those with wide separation of the fragments, healing occurred with little or no deformity (Fig. 7).

No patient with a Grade 2 or 3 deformity was sufficiently concerned about its unsightliness to ask for it to be corrected. They had no loss of function and were able to resume their normal activities.

DlSCUSSlON

Over 200 methods of treating fractures of the clavicle have been described (Kreisinger, 1927).

Fig. 5. A, Grade 1 deformity of the left clavicle. B, Grade 2 deformity of the right clavicle. C, Grade3deformity of the right clavicle and Grade 2 deformity on the left side. (This rugger player had broken his right clavicle three times and the left one twice. He continues to play rugby and is not concerned by the deformity of his collar bones.)

Sankarankutty and Turner: Fractures of the Clavicle

A

Fig. 6. A, Angulated fracture of the clavicle in a boy of 16. B, Correction and remodelling after 34 years.

Tab/e IV. Analysis of 16 cornminuted fractures

Grade 0 5 31 .25% Grade 1 1 6.25% Grade 2 6 37.50% Grade 3 4 25.00%

Figure-of-eight bandages or similar devices are the most frequently used forms of treatment. They are uncomfortable and need repeated adjustments, which require frequent visits to the hospital or the doctor. Serial radiographs show that these methods of treatment do not reduce the fractures (Mullick, 1967). Despite the fact that such treatment was claimed to be unnecessary as long ago as 1954 by Nicoll and

Fig. 7. A, Comminuted fracture of the clavicle with wide separation in a man of 26. B, Shows sound union and remoulding in 1 year 8 months. C, The patient had no clinical deformity (Grade 0).

106 Injury: the British Journal of Accident Surgery Vol. ~/NO. 2

subsequently by Fowler (1962, 1968), they continue to be widely used (De Palma, 1970; Adams, 1972; Sharrard, 1973).

It is often argued that the treatment with these devices is useful in reassuring the patient or the parent that something is being done for the fractured bone. As someone put it, ‘ We must splint the mind .’ In view of the drawbacks of such treatment, however, and in view of our results with a simple triangular sling, this attitude is hardly justified.

APLEY A. G. (1968) A System of Orthopaedics and Fractures, 3rd ed: London, Buiterworih, p. 408.

BROWNE C. C. L. (1966) The most broken bone. The Field 228, 901. ’

FOWLER A. W. (1962) Fractures of the clavicle. J. Bone Joint Suug. 44B, 440.

FOWLER A. W. (1968) Treatment of fractured clavicle. Lancer 1, 46.

KREISINGER P. V. (1927) Sur le traitement des fractures de la clavicule. Rev. Chir. Orthop. 65, 396.

MULLICK S. (1967) Treatment of midclavicular fractures. Lancet 1, 499.

NICOLL E. A. (1954) Miners and mannequins. J. Acknowledgements Bone Joint Surg. 36B, 171.

We are grateful to Mr A. W. Fowler, FRCS, for DE PALMA A. F. (1970) The Management qf Fractures

his encouragement in preparing this paper and and Dislocations, 2nd ed., vol I. Philadelphia,

to him and Mr J. G. H. James, FRCS, for W. B. Saunders, p. 487.

access to their patients. Our thanks are due to SHARRARD W. J. W. (1973) Paediatvic Orthopaedics

the Central Press Photo Ltd, 6 & 7 Gough and Fractures. Oxford, Blackwell, p. 937.

WATSON-JONES R. (1955) Fractures and Joint Injuries, Square, Fleet St, London EC4A 3DJ for I?,,. 2. 4th ed., vol 2. Edinburgh, E. & S. Livingstone,

p. 460. REFERENCES

ADAMS J. C. (1972) Outline of Fractures, 6th ed. Edinburgh and London, Churchill Livingstone, p. 113.

Rrquesfs& wprinfr should be uddrcssrd to: Mr M. Sankarankutty, FRCS, Bridgend General Hospital, Bridgend, Glam.