Questions to ask the patient:
Mechanism (story)
Pain locations
Numbness or tingling?
I like to always ask the same ROS for billing purposes and picking up on the more dangerous things chest pain, shortness of breath, nausea, vomiting, fevers, chills. Add on pertinent ROS to injuries if you can think of them (You need a documented 10 point ROS for billing, instead of taking the time to ask the whole thing you can infer some of the ROS from discussion with the patient)
Medical history: Diabetes, bleeding, clotting problems, blood thinners, stents or problems with anesthesia in the past, allergies, these are important surgical factors, baseline mental status
Surgical history: Previous shoulder injuries or surgeries? Other ortho surgeries? What is the date and who performed those ortho surgeries? Good time to ask about problems with anesthesia or bleeding.
Social history: Smoking, alcohol, drugs; all are very important factors for you to be able to identify healing problems
Dominant hand?
Occupation: Helps you to know their activity level and functional status
Uses a walking assist device? (Walker, cane, wheelchair?)
If needs surgery: DNR status, last food intake
What to look for on an Ortho exam:
Look for skin tenting
Look for cap refill of skin over tented area
Reason: no cap refill could indicate impending skin breakdown
Check sensation to light touch
Over deltoid (axillary)
Dorsal aspect of index and long fingers/radial dorsum of hand (radial)
Palmar side of index and long fingers (median)
Pinky and lateral hand (ulnar nerve)
Check motor
Isolate interphalangeal joint of thumb for flexion, this doubles as checking flexor pollicis longus (FPL) (anterior interosseous nerve (AIN))
Isolate index finger distal interphalangeal (DIP) joint for flexion with other fingers in flexed position, have patient flex DIP of index finger
To check AIN with both FDP and FPL at the same time have patient make the okay sign
Have patient cross fingers or “cut like scissors to check finger adduction (ulnar nerve)
Have patient abduct fingers against resistance (ulnar nerve)
If suspicious for tendon rupture: Check tenodesis effect (DIP and IP joint flexion with wrist extension) – Differentiates motor from tendon rupture, if fingers don’t flex with wrist extension, tendon could be ruptured
Check vascular
Check radial pulse and compare to contralateral side, finger cap refill (should be less than 2 seconds)
One of the most important things to know while on call is to be able to decide whether a clavicle can be treated nonoperatively or not.
Non-operative clavicle fractures
What is the nonoperative treatment?
Sling for comfort and non weight bearing (NWB) on the injured side
Indications
< 2cm shortening and displacement
< 1cm displacement of the superior shoulder suspensory complex
Important to know, but from our experience this isn’t commonly discussed when deciding between nonoperative vs. operative for clavicle fractures by themselves
Always important to consider floating shoulder (glenoid separated from the body either through ligament disruption at the acromioclavicular (AC) joint or clavicle fracture plus a scapula fracture (this will be discussed in a future post)
No neurovascular injury
Outcomes (These are important to talk to patients about when explaining outcomes of non operative management)
Nonunion (1-5%)
See risk factors below: Smoking is a big one
Poor cosmesis
Decreased shoulder strength and endurance
Found in healed clavicle fractures with >2cm of shortening
Superior Shoulder Suspensory Complex
Credit: Orthobullets
Non-op Complications
Nonoperative treatment
Nonunion (10-15%)
Risk factors
Fracture comminution (Z deformity)
Female gender
Advanced age
Smoker
> 2cm shortening
> 100% displacement
Treatment
If asymptomatic, no treatment necessary
If symptomatic, ORIF with plate and bone graft
Malunion
Definition
Shortening >3cm
Angulation >30degrees
Translation >1cm
Presentation
Increased fatigue with overhead activities
Thoracic outlet syndrome
Dissatisfaction with appearance
Difficulty with shoulder straps, backpacks
Treatment
Clavicle osteotomy with bone grafting, if symptomatic
The clavicle can be broken up into 3 sections: Distal third, middle third, and medial third clavicle fractures. We are going to first talk about midshaft clavicles.
Clavicle Fractures
Operative clavicle fractures
Often treated with open reduction internal fixation (ORIF), (Closed reduction intramedullary fixation is more rarely done depending on which program you are at).
Clavicle ORIF Example
Credit: Synthes Technique Guide
Indications
Absolute (Definitely needs to be fixed)
Open fractures
Displaced fracture with skin tenting
Skin tenting is when the fracture piece pushes on the skin. If the skin is blanchable, meaning you can press on the skin and you can see the color change from pale to pink visualizing that capillary refill. Then the overlying skin is likely safe from breakdown.
Subclavian artery or vein injury
Floating shoulder (Both clavicle and scapular neck fracture)
Symptomatic nonunion
Symptomatic malunion
Relative and controversial
Displaced with >2cm shortening (for midshaft clavicle fractures)
Attendings may be more likely to fix in athletes
Bilateral displaced clavicle fractures
Brachial plexus injury (66% have spontaneous return)
Closed head injury
Seizure disorder
Risk for future displacement with subsequent seizures
Polytrauma patient
Thought is to try to help the patient ambulate with consideration for using a walker and needing both upper extremities or at least one good arm
Summary of operative clavicle fracture based on type
Distal clavicle fractures (Always look at the conoid and trapezoid ligaments where the clavicle meets the coracoid)
Displaced fracture medial to the conoid and trapezoid ligaments or separation of clavicle from the the ligaments
Type IIA and IIB and Type V fractures (highlighted in red boxes below)
Type IV is non operative because it is a physeal fracture in pediatrics
Neer Classification for Distal Clavicle fractures
Credit: Orthobullets
Midshaft Clavicle fractures
Neer Classification: 100% displaced clavicle fractures
AO Classification: Type C Complex
Medial Clavicle fractures
Generally treated nonoperatively
May need CT scan for posterior dislocation of sternoclavicular joint for damage to underlying neurovascular structures (more commonly a trauma surgery/ CT surgery problem)
Contraindications for surgery (Reminder: The clavicle does not have much overlying skin so anything that will negatively affect healing should be carefully considered)
Infection
Severe skin condition (acne)
Stroke patient with little extremity usage
Operative Complications
Hardware prominence
Neurovascular injury
Nonunion
Risk factors (Things that affect blood flow or healing)
Smoking
Infection
Risk factors
Illicit drug use
Diabetes
Previous shoulder surgery
Mechanical failure
Whenever you see a plate or nail break you have to think about the bone not healing. The plate or nail can only flex with normal body weight so many times before breaking. Where if the bone heals appropriately, the plate or nail is less likely to break.
Pneumothorax
Adhesive capsulitis
References:
https://www.orthobullets.com/trauma/1011/midshaft-clavicle-fractures
https://www.orthobullets.com/trauma/12770/distal-clavicle-fractures?expandLeftMenu=true
