Interesting case

นพท. วิชญตุร์ ภมิูวฒัน์ ชัน้ปีที่ 6

วิทยาลยัแพทยศาสตร์พระมงกฎุเกล้า

History

• Case ผู้ ป่วยชายไทย อาย ุ27 ปี U/D old pulmonary TB

• CC : MC ล้ม 10 ชัว่โมง 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 : ผู้ ป่วยเป็นใบ้และหหูนวกแตก่ าเนิด E4V5M6 pupil 3 mm RTLBE

– E : no life-threatening wound

History

• Secondary survey– A : pyrazinamide

– M : ไมมี่ประวตัิยาเดิม ตอนนีไ้มมี่ยาท่ีใช้ประจ า

– P : old pulmonary TB รับยา รพ.โชคชยั on ยา 12/57 – 05/58

– L : NPO time 08:30 น. (2 hr)

– E : 10 hr PTA ขบัรถจกัรยานยนต์ ขบัรถล้มเอง ไมส่ลบ ไมส่วมหมวกนิรภยั ตวัด้านขวาและขาขวาลงพืน้ มีอาการปวดไหลข่วา ยกแขนไมข่ึน้เน่ืองจากปวด มีแผลถลอกตามร่างกาย ไป รพช. On arm sling ก่อนสง่ตอ่มาท่ีรพ.มหาราช

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

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

Diagnosis

• Closed fracture at middle third of right clavicle

Treatment

• Figure of eight splint

• D/C

• F/U 30/1/60 (1 week)– Advice ใส ่Figure of eight ตลอดเวลาจนถงึวนันดั

– HM• Paracetamol 500 mg oral prn q 6 hr

Mini reviewClavicle fracture

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

Anatomy

Anatomy

Anatomy

Mechanism of injury

• Fall onto shoulder 87%

– Traffic accident

– sport

• Direct injury to clavicle

– Falling object

– assault

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

Allman classification

Neer classification

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

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

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

Investigation

X-ray finding

X-ray finding

• Group I

X-ray finding

• Group II

X-ray finding

• Group III

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

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)

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

Treatment

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

Treatment

• Operative– Coracoclavicular ligament repair/reconstruct

– plate and screw fixation

• reconstruction plate

• intramedullary screw or nail fixation

• hook plate

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

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 until 4 weeks after clinical healing– Required 8 – 12 weeks before returning to contact sport

– Should remove hardware before playing