Fracture Clavicle

Subperiosteal new bone formation Clavicle fractures Long bone shaft fractures Linear skull fractures... 

Injuries of the medial end of the clavicle account for under 1% of clavicle fractures in children. They can occur if there is compression to the shoulder during contact sports such as ruby. Rather than the sternoclavicular dislocation seen in adults, which they mimic, these are Salter-Harris type I or II fractures (Denham andDiNGLEv 1967). They are poorly seen on radiographs and CT or MR imaging are indicated, especially if (with posterior displacement) there is evidence of dysphagia or respiratory or vascular compromise (Fig. 17.2). If there is evidence of... 

Tonsillectomy at age 5, fractured right clavicle (sports related) FH... 

A seven-month-old child "fell over" while crawling, and now presents with a swollen leg. At age one month, the infant has multiple fractures in various states of healing (right clavicle, right humerus, right radius). At age seven months, the infant has a fracture of a bowed femur, secondary to minor trauma (see x-ray below). The bones are thin, have few trabecula, and thin cortices. A careful family history ruled out nonaccidental trauma (child abuse) as a cause of the bone fractures. The child is most likely to have a defect in ... 

The subclavian artery can be damaged by a fractured clavicle or a cervical rib, with later embolization up the vertebral arteries or even up the right common carotid artery (Prior et al. 1979). 

Fracture of a central venous catheter due to compression between the clavicle and the adjacent first rib has been reported (5). A pinched-off sign on X-ray indicates the need to remove the catheter, because of a significant risk of subsequent fracture, which has an incidence of 0.9%. Catheters lying anterior to the subclavian vein between the clavicle and the first rib are hable to be compressed and to fracture subsequently. This is a potentially life-threatening complication that can be averted by correct placing of the central venous catheter and by immediate chest radiography to search for evidence of catheter kinking or compression. 

A 67-year-old woman was provided with a totally implantable venous device in the right subclavian vein by the Seldinger technique with a peel-away sheath. The device was used for a course of chemotherapy. After about 1 month there was subcutaneous extravasation of the drug. A chest X-ray showed that the sihcone catheter had fractured below the clavicle and the distal portion of the catheter had embolized into the right atrium. The fragments were removed. 

Ramsden WH, Cohen AT, Blanshard KS. Case report central venous catheter fracture due to compression between the clavicle and first rib. Clin Radiol 1995 50(l) 59-60. 

Another venous lead implantation approach of historical interest is the jugular vein. The first method to acces the vein was nonpercutaneous, in which two incisions are required. The first skin incision, performed above the clavicle between the posterior rim of the sternocleidomastoid muscle and the anterior rim of the trapezius muscle, is necessary to reach the external jugular vein or, extended forward, the carotid sheath wherein internal jugular vein is present. A second infraclavicu-lar incision is then necessary to fashion the pocket over the pectoral muscle. Only the latter is required for the percutaneous approach, but regardless of the method used, in both cases, the lead must be tunneled to the pocket (usually over the clavicle). These techniques have been abandoned due to frequent complications related to lead failure. Outside the vein, the lead must run at an acute angle to reach the pocket, which is the reason for the recurrent lead fracture related to this venous approach. However, this is probably the better approach in case of lead extraction. 

Congenital pseudoarthrosis of the clavicle may he mistaken for a fracture. This condition is almost always right sided and rarely hilateral. It usually presents with a painless, palpable prominence in the mid-portion of the clavicle. Approximately half of all patients present in the first 2 weeks of life, the others during childhood. The differential diagnosis includes cleidocranial dysostosis or a birth injury. Radiographically there is a defect in the middle segment of the clavicle, and the ends of the bones are... 

Fig. 7.6. Overlap of the medial end of the clavicle and a vertebral transverse process simulating a fracture (arrow)...

Clavicular fractures are by far the most frequent and maybe discovered incidentally on a chest radiograph or clinically with the development of the hard lump of callus. The humerus is the commonest long bone to be fractured at birth. In Cumming s series of 23 birth related fractures the sites were clavicle, humerus and... 

Injuries to the shoulder are reported to account for about for 8%-16% of fractures in children. Falls onto the shoulder are the usual cause of fractures of the clavicle, whilst falls onto the outstretched hand cause proximal humeral fractures. Whilst the mechanisms of injury to the shoulder in children are similar to those in adults, the fracture patterns seen differ as a consequence of the presence of the physes, with physeal separation occurring in preference to dislocation. 

Fractures of the clavicle result from falls onto the shoulder or lateral compression of the shoulder girdle. There is rarely any associated injury to the subclavian vessels, brachial plexus or pleura, unless the injury is due to a direct blow. Clavicular fractures have been (Allman 1967) classified into three types type 1, middle third type 2 distal to the coracoclavicular ligaments and type 3 medial to the sternocleidomastoid and costoclavicular ligament. 

The majority of fractures of the clavicle involve the middle third. The fracture pattern may be buckle, greenstick or displaced. Callus formation can be exuberant and, because it is subcutaneous, the prominence can be a cause of concern (Fig. 17.1). Treatment is usually symptomatic with a broad arm sling for comfort. A figure eight harness can provide additional support, especially for displaced... 

Fig. 17.1. a This child presented with an undisplaced fracture of the clavicle, b He was re-referred 12 weeks later because of concerns over the prominent callus that developed... 

Fractures of the clavicle occur in around 1.5% of deliveries and are the commonest birth injury (Lam... 

J Bone Joint Surg (Br) 45 312-319 Allman FL (1967) Fractures and ligamentous injuries of the clavicle and its articulation. J Bone Joint Surg (Am) 49 774-784... 

Fig. 4.19 Deep (A) and superficial (B) anatomic relationships of the Magney approach to subclavian vena puncture. Point M indicates the medial end of the clavicle. X defines a point on the clavicle directly above the lateral edges of the clavicular/subclavius muscle (tendon complex). Rl. Point D overlies the center of the subclavian vein as it crosses the first rib. St, the center of the sternal angle Cp, coracoid process Ax, axillary vein star, costoclavicular ligament open circle with closed circle, costoclavicular ligament open circle with closed circle inside, costoclavicular ligament sm, subclavius muscle. The arrow points to Magney s ideal point for venous entry. (Magney JE, Staplin DH, Flynn DM, et al. A new approach to percutaneous subclavian venipuncture to avoid lead fracture or central venous catheter occlusion. Pacing Clin Electrophysiol 1993 16(11) 2133-2142, with permission.)...

Inspect the entire length of the lead for lack of integrity, such as fracture, compression, or crimp. Intermittent or complete failure to capture or sense or output could be secondary to lead conductor coU fracture or loss of insulation integrity. Attempt to follow each lead along its course, assessing the conductor coil. Also, inspect for any crimping of the lead as it passes under the clavicle. 

Mead quoted the case of a sailor who had suffered from a fractured clavicle which had apparently healed normally and which broke again 4 months later when the sailor was suffering from scurvy. Six months after this, after the sailor had been on a diet of green vegetables for some time, the fracture reunited. 

As with pacemaker leads, the leads of an ICD system can fracture at the first rib and clavicle due to crush injury between the two bones, especially when inserted by a subclavian vein puncture, in my experience. 

The axillary vein can be accessed lateral to the junction of the first rib and clavicle. The cephalic vein can be accessed by a "cut-down" approach in the delto-pectoral groove. Some physicians believe both of these avenues of venous entry may be less likely to fracture due to trauma between the first rib and clavicle. 

Fractures of the sternum, scapulae, or clavicles are also possible, but generally they require a more forcefiil trauma for them to occur in adults. The clavicle is the most commonly fractured bone in children, however. 

Any joint in the upper extremity may dislocate if sufficient force is applied to it. The glenohumeral joint is especially prone to dislocating, usually in an anterior direction. A prominent end of the clavicle and loss of roundness of the shoulder may indicate a dislocation. Frequently there is an associated tear of the capsule. With any joint dislocation, radiographic imaging should be obtained to rule out an associated fracture. 

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