CASE REPORT:

FRACTURE MIDDLE CLAVICLE

PRESENTED BY
SUPARI CANDI
C111 10 333
Advisor :
dr. M . Arief Faisal
dr. Handoko
Supervisor:
dr. Henry Yurianto, M.Phil, Ph.D, SpOT

Orthopaedic and Traumatology Dept

Medical Faculty of Hasanuddin University
Makassar, 2015
 PATIENT IDENTITY

Name :Mr. O
Age :42 Years old
Sex : Male
Date of admission : June 9th 2015
Registry :715063
 HISTORY TAKING

Chief Complaint: Pain at the left shoulder

History of Illness
Happen since 3 days before admitted to the hospital
because of traffic accident.
Mechanism of trauma:
Patient was riding a motorcycle but didnt see a police
bump and fell down with her shoulder first hit the ground.
History of unconciousness (+) for around 10 minutes,
history of vomitting (+) 3 times.
 Physical Examination

Generalized Status:
Compos mentis GCS 15/ Moderate illness/ Well
nourished
Vital Sign:
Blood Preassure: 140/80 mmHg
Heart Rate: 88x/minutes
Respiratory Rate: 18x/minutes
Temperature: 36,8 C
 Localized Status:
Right Shoulder Region:
Look: Theres deformity, Swelling (+), Haematoma
(+), Excoriated skin (+)
Feel: Tenderness (+)
Move: Active and passive movement of the
Shoulder region joint are cannot be evaluated due
to pain. Active and Passive movement of the
Elbow joint within normal limits.
NVD: Sensibility is good, pulsation of the radial
and ulnar artery is palpable, Capillary refill time <2
sec.
Clinical Picture
X-ray
 Laboratory Findings

Pemeriksaan Hasil Nilai normal

WBC 6,0 4,00-10,0
RBC 4,24 4,00-6,00
HGB 12,5 12,0-16,0
HCT 36,6 37,0-48,0
PLT 264 150-400
CT 800 4-10
BT 300 1-7

HBsAg Non Reactive Non Reactive

 RESUME

Male, 40 y.o, was admitted to the hospital with the chief complaint
pain at his left shoulder. The onset of this complaint was 3 before
admission
The mechanism of trauma: Patient was riding a motorcycle but didnt
see a speedbump, fell down with his right shoulder first hit the
ground.
From Physical examination, at left shoulder region from look there
deformity, swelling, and haematome, there is a excoriated wound.
From Feel, theres tenderness, and neurovascular distal are within
normal limits.
The R.O.M of shoulder joint are cannot be evaluated due to pain
From radiologic finding, theres fracture at one third middle left
clavicle.
 Diagnose

Closed fracture middle left clavicle

 Management

Analgesic
Apply arm sling
DISCUSSION
 Introduction

Solomon L, et all. Apleys System of Orthopaedics and Fractures. Ninth Edition. London :
Hodder Arnold. 2010; p.687, 772-5.
 Epidemiology

Clavicle fractures account for approximately 4% of all

fractures and 35% to 43% of shoulder girdle injuries
Middle third fractures account for 80% of all clavicle
fractures,whereas fractures of the lateral and medial
third of the clavicle account for 15% and 5%,
respectively.

Finkemeier, CG. Fracture and Dislocation of the Shoulder Girdle and Humerus. In: Chapman M, Szabo RM, Marder R, Vince
KG, et al. Ed. Chapmans Orthopedic Surgery Third Edition. New York: Lippincott Williams & Wilkins.2001. P432-80
Egol KA, Koval KJ, Zuckerman JD. Clavicle Fracture. In Handbook of Fracture. Philadelphia:Wolters Kluwer. 2010. P143-9
Anatomy
Netter, F. Atlas of Human Anatomy 6th edition
 Mechanism of Trauma

Outstreched

Egol KA, Koval KJ, Zuckerman JD. Clavicle Fracture. In Handbook of Fracture.
Philadelphia:Wolters Kluwer. 2010. P143-9
 CLINICAL FINDINGS

Patients usually present with splinting of the

affected extremity,with the arm adducted across the
chest and supported by the contralateral hand to
unload the injured shoulder.
The proximal fracture end is usually prominent and
may tent the skin. Assessment of skin integrity is
essential to rule out open fracture.
 Radiologic

Standard anteroposterior radiographs

An apical oblique view
Computed Tomography
 CLASSIFICATION (ALLMAN)

Group l: fracture of the middle third (80%). This is the most

common fracture in both children and adults; proximal and distal
segments are secured by ligamentous and muscular attachments.
Group ll: fracture of the distal third (I5%). This is subclassified
according to the location of the coracoclavicular ligaments
relative to the fracture
Group lll: fracture of the proximal third(5%). Minimal
displacement results if the costoclavicular ligaments remain
intact. It may represent epiphyseal injury in children and
teenagers.

Finkemeier, CG. Fracture and Dislocation of the Shoulder Girdle and Humerus. In: Chapman M, Szabo RM, Marder R, Vince
KG, et al. Ed. Chapmans Orthopedic Surgery Third Edition. New York: Lippincott Williams & Wilkins.2001. P432-80
Egol KA, Koval KJ, Zuckerman JD. Clavicle Fracture. In Handbook of Fracture. Philadelphia:Wolters Kluwer. 2010. P143-9
 Subtype Group II
Type l: Minimal displacement:
interligamentous fracture between
theconoid and trapezoid or between
the coracoclavicular and AC
ligaments; ligaments still intact
Type ll: Displaced secondary to a
fracture medial to the
coracoclavicular ligaments: higher
incidence of nonunion
llA: Conoid andtrapezoid atbached
to the distal segment
llB: Conoid torn, trapezoid atlached
to the distal segment
Type lll: Fracture of the articular
surface of the AC joint with no
ligamentous injury: may be confused
with first-degree AC joint separation

Finkemeier, CG. Fracture and Dislocation of the Shoulder Girdle and Humerus. In: Chapman M, Szabo RM, Marder R, Vince
KG, et al. Ed. Chapmans Orthopedic Surgery Third Edition. New York: Lippincott Williams & Wilkins.2001. P432-80
Egol KA, Koval KJ, Zuckerman JD. Clavicle Fracture. In Handbook of Fracture. Philadelphia:Wolters Kluwer. 2010. P143-9
 Subtype Group III
Type l: Minimal displacement
Type ll: Displaced
Type lll: Intraarticular
Type lV: Epiphyseal separation
Type V: Comminuted
 TREATMENT (CONSERVATIVE)

Figure of Eight
Arm Sling
 TREATMENT (OPERATIVE)

Indication for Operative treatment:

Open Fracture
Fracture that threaten the overlying skin (rare)
Fracture that widely displaced (>2cm)
Fracture associated in neurovascular compromise
Fracture in multiply injured patients
Ipsilateral upper extremity injuries needing early mobilization
Lower Extremity injuries requiring crutch walking
Fracture in patients with neuromuscular disease
Symptomatic bump at union site, hyperthrophic callus

Finkemeier, CG. Fracture and Dislocation of the Shoulder Girdle and Humerus. In: Chapman M, Szabo RM, Marder R, Vince
KG, et al. Ed. Chapmans Orthopedic Surgery Third Edition. New York: Lippincott Williams & Wilkins.2001. P432-80
Egol KA, Koval KJ, Zuckerman JD. Clavicle Fracture. In Handbook of Fracture. Philadelphia:Wolters Kluwer. 2010. P143-9
 Operative Treatment

Plate fixation: This is placed either on the superior

or on the anteroinferior aspect of the clavicle.
lntramedullary fixation (Hagie pin, Rockwood pin):

Finkemeier, CG. Fracture and Dislocation of the Shoulder Girdle and Humerus. In: Chapman M, Szabo RM, Marder R, Vince
KG, et al. Ed. Chapmans Orthopedic Surgery Third Edition. New York: Lippincott Williams & Wilkins.2001. P432-80
Egol KA, Koval KJ, Zuckerman JD. Clavicle Fracture. In Handbook of Fracture. Philadelphia:Wolters Kluwer. 2010. P143-9
 Complication

Early:
Neurovascular Compromise
Pneumothorax
Late:
Malunion
Nonunion
Posttraumatic arthritis

Cole A, Pavlou P, Warwick, D. Injuries of the Shoulder, Upper arm, and Elbow In:Solomon L, Wawick D, Nayagam, S Ed.Apleys System of
Orthopaedic and Fractures. London:Hodder Arnold. 2010. 733-66.
THANK YOU