proximal end clavicle fracture from a parachute jumping injury

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Orthopaedics & Traumatology: Surgery & Research (2012) 98, 238—241 Available online at www.sciencedirect.com CASE REPORT Proximal end clavicle fracture from a parachute jumping injury A. Bourghli a,, A. Fabre b a Orthopedic Surgery Department, Pellegrin Hospital, place Amélie-Rabat-Léon, 33000 Bordeaux, France b Orthopedic Surgery Department, Richelieu Clinic, 22, rue Montlouis, 17103 Saintes, France Accepted: 16 September 2011 KEYWORDS Medial end; Clavicle fracture; Parachutist Summary Fractures of the medial end of the clavicle are the least common type of clavicle fracture. We report a 29-year-old military parachutist who presented with medial end clavicle fracture after a bad landing. He was first treated non-operatively in a tertiary center and was then referred to our center by his general practitioner. Surgery was indicated since the fracture was displaced and the patient needed anatomical reconstruction to promote rapid bone healing and a prompt return to work. The medial fragment being comminuted, K-wires were used for internal fixation instead of a plate. The two K-wires were bent 180 to avoid risk of migration and were removed 3 months after surgery when the patient had begun to perform all activities without pain. Aggressive treatment is recommended for medial end clavicle fracture in case of displacement and facilitates rapid functional recovery, notably in patients with considerable clavicular demand. © 2012 Elsevier Masson SAS. All rights reserved. Introduction Medial end clavicle fracture is rare, at no more than 10% of clavicle fractures as a whole, according to published series [1—5]. It is usually caused by high-energy trauma such as a motorcycle crash, but can also be secondary to a fall, aggression or firearm wound [3—5]. We report a case of medial end clavicle fracture sustained by a parachutist on landing. Corresponding author. Tel.: +33 5 56 79 56 79. E-mail address: [email protected] (A. Bourghli). Case report A 29-year-old military parachutist, right-handed, with no particular medical history, experienced sudden right shoul- der pain on landing after a normal training jump. At first, he took this to be a simple pain following a bad landing; how- ever, it progressively worsened and became severe under right upper limb motion. He was admitted to the near- est hospital, where clinical examination found intense pain on palpation of the clavicle. X-ray found a displaced right medial end fracture with a distal fragment lowered with respect to the proximal fragment, without contact between the two extremities (Figs. 1 and 2). Conservative manage- ment was decided on and the patient was discharged with a sling and swathe. The patient experienced great difficulty 1877-0568/$ see front matter © 2012 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.otsr.2011.09.021

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Page 1: Proximal end clavicle fracture from a parachute jumping injury

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rthopaedics & Traumatology: Surgery & Research (2012) 98, 238—241

Available online at

www.sciencedirect.com

ASE REPORT

roximal end clavicle fracture from a parachuteumping injury

. Bourghli a,∗, A. Fabreb

Orthopedic Surgery Department, Pellegrin Hospital, place Amélie-Rabat-Léon, 33000 Bordeaux, FranceOrthopedic Surgery Department, Richelieu Clinic, 22, rue Montlouis, 17103 Saintes, France

Accepted: 16 September 2011

KEYWORDSMedial end;Clavicle fracture;Parachutist

Summary Fractures of the medial end of the clavicle are the least common type of claviclefracture. We report a 29-year-old military parachutist who presented with medial end claviclefracture after a bad landing. He was first treated non-operatively in a tertiary center and wasthen referred to our center by his general practitioner. Surgery was indicated since the fracturewas displaced and the patient needed anatomical reconstruction to promote rapid bone healingand a prompt return to work. The medial fragment being comminuted, K-wires were used forinternal fixation instead of a plate. The two K-wires were bent 180◦ to avoid risk of migration

and were removed 3 months after surgery when the patient had begun to perform all activitieswithout pain. Aggressive treatment is recommended for medial end clavicle fracture in case ofdisplacement and facilitates rapid functional recovery, notably in patients with considerableclavicular demand.© 2012 Elsevier Masson SAS. All rights reserved.

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edial end clavicle fracture is rare, at no more than 10% oflavicle fractures as a whole, according to published series1—5]. It is usually caused by high-energy trauma such as

motorcycle crash, but can also be secondary to a fall,ggression or firearm wound [3—5].

We report a case of medial end clavicle fracture sustainedy a parachutist on landing.

∗ Corresponding author. Tel.: +33 5 56 79 56 79.E-mail address: [email protected] (A. Bourghli).

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877-0568/$ – see front matter © 2012 Elsevier Masson SAS. All rights reoi:10.1016/j.otsr.2011.09.021

ase report

29-year-old military parachutist, right-handed, with noarticular medical history, experienced sudden right shoul-er pain on landing after a normal training jump. At first, heook this to be a simple pain following a bad landing; how-ver, it progressively worsened and became severe underight upper limb motion. He was admitted to the near-st hospital, where clinical examination found intense painn palpation of the clavicle. X-ray found a displaced rightedial end fracture with a distal fragment lowered with

espect to the proximal fragment, without contact betweenhe two extremities (Figs. 1 and 2). Conservative manage-ent was decided on and the patient was discharged with

sling and swathe. The patient experienced great difficulty

served.

Page 2: Proximal end clavicle fracture from a parachute jumping injury

Proximal end clavicle fracture from a parachute jumping injury 239

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Min the literature. The etiology found in the present casehas seldom been mentioned. The most frequent lesions fol-lowing parachute jumps are to the ankle [6]; few studies

Figure 1 Anteroposterior (AP) radiograph showing the medialend right clavicle fracture.

during the week following the trauma and was referred byhis departmental physician for a second opinion. CT fractureanalysis (Figs. 3a and 3b) confirmed considerable displace-ment and found a comminuted medial fragment. Given thepresenting complaint and type of fracture, open surgery wasindicated for reduction and osteosynthesis, and was per-formed at day 10 post-trauma. The patient was positionedin dorsal decubitus with a support between the two scapu-lae, and the upper limb included in the operative field.The horizontal incision along the clavicle was in this caseextended toward to the medial end. The platysma musclewas sectioned perpendicular to its fibers. The periostealincision was performed just above the pectoralis majorinsertions, with a subperiosteal approach avoiding unnec-essary periosteal stripping. The comminuted aspect of themedial fragment was confirmed peroperatively; osteosyn-thesis therefore used not a plate but two 20 mm K-wiresrunning from the distal fragment and then crossed andcurved back 180◦ to avoid secondary migration (Fig. 4). Post-operative sling immobilization was prescribed for 4 months,with regular follow-up. Consolidation was achieved by the3rd month, with complete clinical recovery of right shoul-der function. The osteosynthesis material was subsequentlyremoved (Fig. 5). The patient was able to return to work as

a professional parachutist by the 8th month and was com-pletely asymptomatic.

Figure 2 AP radiograph enlargement showing the great dis-placement at the fracture site with no contact between fractureends.

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igure 3 a and b: computed tomography (CT) scan showinghe comminuted aspect of the medial fragment with an articularracture line at the sternoclavicular joint.

iscussion

edial end clavicle fracture is rare and little referred to

igure 4 AP radiograph showing the two crossed K-wires bent80◦ to avoid risk of migration.

igure 5 Radiograph of the clavicle fracture after hardwareemoval.

Page 3: Proximal end clavicle fracture from a parachute jumping injury

240 A. Bourghli, A. Fabre

Table 1 Epidemiological data in the literature for medial end clavicle fractures.

Claviclefracture (n)

Medial endfracture (%)

Mean age(years)

Mostfrequentmechanism

Treatment Non-union (%)

Nordqvist (1994)[1]

2035 3 59 [34—70] RA Conservative100% Not specified

Nowak (2005) [2] 222 2 31 [15—67] Not specified Conservative100% 7Postacchini (2002)

[3]535 2 56 [36—76] RA (47%) Not specified Not specified

Robinson (2004)[9]

868 2.8 30 [19—47] Body-height fall (30%) Conservative100% 8

Throckmorton(2007) [5]

614 9.3 46 [19—88] RA (53%) Conservative 93% Not specified

Lowe (2008) [12] 5 100 43 [25—52] RA (80%) Surgical 100% 0

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ave reported the incidence of clavicle fracture in theseases. In 1948, Ciccone and Richman [7] reported a seriesf 3000 fractures and major soft-tissue lesions followingarachute jumps, including 35 clavicle fractures —– about 1%f all lesions, confirming the rarity of this fracture in thisontext. More recently, Bricknell and Craig [8] published aeview of the literature on military parachuting lesions, withlavicular fracture rates ranging from 0.1 to 1.2% accordingo the series. None of the reports detailed the types of clav-cular fracture. Medial end fracture is even rarer than theates mentioned in the various reports concerning parachuteump lesions.

Management of medial end clavicle fracture is usuallyonservative, but there were several reports of pain andubjective impairment persisting long after trauma [2,5]nd of high rates of non-union [9]. Table 1 summarizes theiterature data. Clavicular surgery is rare, reputedly entail-ng a risk of neurovascular lesions. Our patient complainedf considerable discomfort due to his displaced fracture,nd the lesion mechanism was inherent to his job as aarachutist. Involvement was of the dominant side. Takingll this together, along with the risk of non-union, surgeryeemed logically indicated. Due to the severe comminutionf the medial fragment, osteosynthesis had to rely on two-wires, running from the distal toward to proximal frag-ent, crossed and, given the considerable risk of secondaryigration well established in the literature [10,11], cut andent back 180◦. In a series of five patients, Lowe et al. [12]eported results with surgical treatment of displaced medialnd clavicle fracture, stressing the importance of earlyntervention for rapid recovery of anterior function withinimal complications. One case in that series was similar to

he present, and was managed with a single screw betweenhe two fragments associated to bone suture, which was notossible in the present case as the fracture line was not suf-ciently oblique and the comminution would have impairedcrewing. Material was removed in the 3rd month, to elim-nate any further risk of wire migration. The patient was a

arachutist who intended to carry on with his job, with thettendant risks of falls or bad landings and of displacementf material by strong trauma to the body and to the claviclesn particular.

Medial end clavicular fracture is rare and generallyue to a motorcycle accident; it can also be caused byarachute landing, without associated multiple trauma. Its often overlooked due to insufficient plain X-ray, and CTxamination is essential for classifying fractures, deter-ining joint involvement, assessing fragment displacement

nd measuring the proximity of any vascular axes. In casef displacement, treatment should be surgical, comprisingeduction and osteosynthesis, particularly in professionalarachutists. K-wire stabilization may be useful in case ofomminution, but the procedure must be strictly rigorous,ending the wires back 180◦ to avoid secondary migration.he wires should be removed once clinical and radiologicalonsolidation has been achieved.

isclosure of interest

he authors declare that they have no conflicts of interestoncerning this article.

eferences

[1] Nordqvist A, Petersson C. The incidence of fractures of theclavicle. Clin Orthop Relat Res 1994;300:127—32.

[2] Nowak J, Holgersson M, Larsson S. Sequelae from clavicularfractures are common: a prospective study of 222 patients.Acta Orthop 2005;76:496—502.

[3] Postacchini F, Gumina S, De Santis P, Albo F. Epidemiol-ogy of clavicle fractures. J Shoulder Elbow Surg 2002;11:452—6.

[4] Robinson CM. Fractures of the clavicle in the adult. Epi-demiology and classification. J Bone Joint Surg Br 1998;80:476—84.

[5] Throckmorton T, Kuhn JE. Fractures of the medial end of theclavicle. J Shoulder Elbow Surg 2007;16:49—54.

[6] Ekeland A. Injuries in military parachuting: a prospective studyof 4499 jumps. Injury 1997;28:219—22.

[7] Ciccone R, Richman RM. The mechanism of injury and the distri-

bution of 3000 fractures and dislocations caused by parachutejumping. J Bone Joint Surg Am 1948;30A:77—97.

[8] Bricknell MC, Craig SC. Military parachuting injuries: a litera-ture review. Occup Med (Lond) 1999;49:17—26.

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review. Rozhl Chir 2005;84:373—5.

Proximal end clavicle fracture from a parachute jumping inj

[9] Robinson CM, Court-Brown CM, McQueen MM, Wakefield AE.Estimating the risk of non-union following non-operativetreatment of a clavicular fracture. J Bone Joint Surg Am

2004;86-A:1359—65.

[10] Leppilahti J, Jalovaara P. Migration of Kirschner wires followingfixation of the clavicle: a report of two cases. Acta OrthopScand 1999;70:517—9.

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11] Priban V, Toufar P. A spinal cord injury caused by a migratingKirschner wire following osteosynthesis of the clavicle: a case

12] Lowe AK, Duckworth DG, Bokor DJ. Operative outcome of dis-placed medial end clavicle fractures in adults. J Shoulder ElbowSurg 2008;17:751—4.