Clavicle Fracture with a Grade III

Acromioclavicular Joint Separation

Ameer Shihadeh

Abstract
Introduction: The clavicle and the acromioclavicular joint respectively are
amongst the most common injuries that occur in athletics. There are
different approaches to treat each condition. Severity, and grade of the
injuries allows physicians to indicate the proper techniques to treat the
injuries individually. Age of the patient also plays into effect, for there is a
difference on how an adult versus an adolescent may recover. Based on the
literature present, there are few occurrences in which both the clavicle and
the acromioclavicular joint is injured at the same time from the same
mechanism of injury.
Case Presentation: The subject is a 17 year old 56, 155lbs male football
quarterback who had complaints of shoulder pressure following a direct
impact. The subject is of good health prior to the injury.
Conclusion: The vulnerability of the shoulder to be injured in sports and
other activities are increased because of the applied pressure the shoulder is
subjected to. Failure of the shoulder structure can occur by methods like a
clavicle break or AC joint separation. Proper rehabilitation procedures is a
must to achieve adequate results for anatomical.
Key Words: clavicle, fracture, acromioclavicular joint separation,
adolescents.

the same time from the same

T
he clavicle and the
acromioclavicular joint
respectively are amongst the
most common injuries that occur in
athletics. There are different
approaches to treat each condition.
Severity and grade of the injuries
allow physicians to indicate the
proper techniques to treat the
injuries individually. Age of the
patient also plays into effect, for
there is a difference on how an
adult versus an adolescent may
recover. Based on the literature
present, there are few occurrences
in which both the clavicle and the
acromioclavicular joint is injured at
mechanism of injury.
This case study will focus on
the acute management, treatment
methods, and grades of a midshaft
clavicle fracture
and an acromioclavicular joint
separation. Also the difference
between how clavicle
fractures are treated between
adults and adolescents would be
briefly explained.
Background
 A clavicle fracture are
amongst the most common injuries
that occur in athletics amid
adolescents. The typical
mechanism of injury that causes
the clavicle to fracture is falling
onto an outstretched hand, or a
direct trauma over the bone.
Fracture to the clavicle in younger
children can result in a greenstick
fracture. Signs and symptoms that
can indicate a suspected clavicle
fracture could be, point tenderness
over the injured area,
inflammation, and possible
deformity. Another indication that
the clavicle may be injured is if the
patient is supporting the arm of the
injured side with their arm of the
non-injured side. The on site
management for a clavicle fracture
would be to immediately
immobilize the structure with a
sling. Referral to receive x-rays is
necessary to indicate the severity
of the fracture.
Clavicle deformity applies
irregular stress on the shoulder
leading to changes of the angle of
the glenoid.1 Also, complications
from midshaft and shaft clavicle
fractures may lead to symptomatic
malunion, which can leave adult
patients with long-term functional
deficiency1. Adults benefit from
operative treatment when the
clavicle is fractured.
Unlike adults, adolescents
have up to 98 percent excellent
functional outcome from non-
operative treatment on a fractured
clavicle, any incidence where a
non-union occurs is only 1-3
percent2. If the fracture is stable,
the bone unites readily, whereas if
there was any complications to the
fracture, operative treatment may
be deemed necessary2. Although,
there has been studies that
suggested that operative treatment
in adolescents may be optimal to
reduce the risk of shortening of the
clavicle1. Greater than 20mm of
shortening can be predisposed to
nonunion in adults, but because of
growing in adolescents that still
may occur, there is a wide
spectrum of relative shortening at
the fractured site1.
Along with the clavicle
fracture the subject in this case
study has sustained, the subject
had also sustained a separation of
his acromioclavicular (AC) joint. AC
joint separation is a common injury
like a fractured clavicle, although it
is rare that both structures are
compromised at the same time. AC
joint separation injuries accounts
for approximately 50 percent in
athletes playing contact sports and
12 percent in all populations3. The
mechanism of injury that separates
the joint is due to a direct impact to
the acromion process while the
shoulder is in an adducted
position3. The structure that is
responsible for the stability of the
joint is the capsule complex,
coracoclavicular ligaments, and the
AC ligaments. The joint separates
when the joint complex fails,
surrendering the coracoclavicular
ligaments responsible for the
capsules stability3. Acute
management for an AC joint
separation would be ice,
compression and immobilizing the
injury with a sling. There are six
grades that indicate the severity of
the injury, grades 1-3 do not
require surgical intervention
however grades 4-6 do4. Each
grade is categorized by what
structures has been torn, and how
far the joint has separated. Referral
is necessary to indicate the
severity of the injury.
Clavicle fractures and AC
joint separations are common
injuries to have sustained
individually, although combined are
very uncommon, and there are
very little reports in literature that
explains the specifications on how
to manage to injury5 6. Depending
on the injury, each structure is
managed based off how severe the
condition is, some structures may
be treated conservatively, or
invasive methods may have to be
utilized.
Case presentation
September 16th, 2016 a 17
year old male high school
quarterback sustained a shoulder
injury. The subject was hit from his
right side by a lineman described
to be more than six feet of height
and nearly 300 pounds. The subject
himself was 56, 155 lbs. The
lineman landed on the subjects
right side after the initial contact
creating a direct trauma between
the ground and the lateral aspect
of the deltoid of the opposite side.
The subject was able to stay in the
game for two more plays, then
came to the athletic trainer (AT)
and presented him with complaints
of pressure on the shoulder. The AT
tested the subjects range of
motion (ROM) actively, which was
within normal limits (WNL).
Although, when resistance was
applied to the ROM, the subject
was unable to flex or abduct the
shoulder to 90 degrees. The AT
instantly ruled the subject out from
the rest of the game as a result of
not being able to protect himself
during play.
Once the subject was ruled
out of play, the AT asked the
subject to remove his equipment to
be further evaluated. Upon
evaluation, point tenderness and
inflammation and a slight
protrusion was noted over the mid
shaft of the clavicle. The team
doctor intervened and suggested
that the subject would be x-rayed
to rule out a fracture to the
clavicle. There was no swelling,
discoloration or deformity noted to
the surrounding musculature or
boney prominences of the injured
area.
The subject was placed in a
sling to immobilize the shoulder to
reduce the risk of displacing a
possible clavicle fracture and was
iced on site of the incident. The
subjects parents were of
attendance and were notified of
the injury.
The subject has a family
history of diabetes and heart
disease. The subject did not have
any surgeries in the last 10 years
that would influence or elicit any
complications to the injury
sustained. The subject is of good
general health and poses no other
health issues besides the ones
mentioned above.
Results

The morning following the
injury, the subject saw an
orthopedist to be x-rayed.
The physician diagnosed the
subject to have a fracture on the
midshaft of the clavicle along with
a grade 3 acromioclavicular joint
separation. The fracture was
stable and there would be no
complications if the fracture healed
non-invasively. A grade 3 AC joint
sprain was diagnosed and resulted
in the separation of the joint, the
rupture of the AC ligament and the
coracoclavicular ligament were not
severe enough for surgery to be
performed on. A sling was to be
worn for two weeks along with
protective padding over the AC
joint to reduce the risk of injuring
the joint again. Physical therapy
was prescribed by the physician.
The subject is to remain in a sling
for two weeks. The subject was
also instructed under doctors
order that he is not allowed to
return to play for at least five
weeks but should sit out longer if
the AT deemed it necessary. No
further instructions was given to
the subject from the physician.
Discussion
Physicians would still prefer
treating clavicle fractures non-
operatively in children, even if the
fracture presents displaced
References
1. Robinson L, Gargoum R, Auer R,
Nyland J, Chan G. Sports
participation and radiographic
findings of adolescents treated
nonoperatively for displaced
segmental patterns1. Although,
physicians would operate on elite
overhand athletes. What influences
the decision to whether a physician
should operate or not depends on
the patients age, sport, and the
severity1.
Studies showed that adults
who suffered a clavicle fraction and
did not undergo operative
treatment produced decreased
ROM, strength, and endurance on
the affected side, whereas adults
who received operative treatment
showed no functional limiting1.
These findings show that
adolescents have better healing
qualities than those of adults,
hence why surgical methods are
not necessary if the fracture is not
severe or displaced.
The vulnerability of the shoulder to
be injured in sports and other
activities are more likely to occur
because of the compression the
shoulder is subjected to5.
When too much force over exceeds
the capacity that of which the
shoulder capsule can handle,
failure of the structure can occur by
either a clavicle break or AC joint
separation5. Proper rehabilitation
procedures is a must to achieve
adequate results when associated
with a clavicle fracture and to
achieve anatomical restoration of
the AC joint5.
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