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Clavicle Fractures

- See: 
      - Clavicular Frx in ChildrenCongential Pseudoarthrosis of Clavicle 
      - AC joint / Sternoclavicular Joint Injury / Scapula Fracture 
- Discussion and Classification 

- Exam Findings:
    - brachial plexus 
    - ref: Injury to the brachial plexus by a fragment of bone after fracture of the clavicle

- Radiology: 
      - Serendipity View 
      - best visualized sitting up w/ AP view & view w/ beam angled 30 deg. cephalad; 
      - w/ frx of clavicle, distal fragment & arm tend to sag, while proximal fragment, held by SC joint tends
                to point upward; 
      - in any clavicular frx, carefully scutinize x-rays for presence of scapular frx, which represents
                a floating shoulder
      - references:
             - Upright versus supine radiographs of clavicle fractures: does positioning matter?

- Non Operative Treatment:
     - it is difficult to reduce and maintain the reduction of clavicle fractures;
     - despite deformity, healing usually proceeds rapidly; 
     - union usually occurs rapidly & produces prominent callus;
     - w/ midshaft fractures, there will also be some degree of malunion;
              - in these patients be attentive to medial cord nerve symptoms (more often ulnar nerve);
     - distal clavicle fractures may have a high incidence of non union but most of these are asymptomatic, and of these
              only a small number will be severe enough to require surgery;
     - references:
              - Treatment of clavicular fractures. Figure-of-eight bandage versus a simple sling.
              - Recovery following fractures of the clavicle treated conservatively.
              - Primary Nonoperative Treatment of Displaced Lateral Fractures of the Clavicle.
              - Closed treatment of displaced middle-third fractures of the clavicle gives poor results.
              - Estimating the Risk of Nonunion Following Nonoperative Treatment of a Clavicular Fracture.
              - Deficits Following Nonoperative Treatment of Displaced Midshaft Clavicular Fractures
              - Shortening of clavicle after fracture. Incidence and clinical significance, a 5-year follow-up of 85 patients.
              - Operative Versus Nonoperative Treatment of Midshaft Clavicle Fractures in Adolescents
              - Pediatric refracture rates after angulated and completely displaced clavicle shaft fractures.
              - Arteriovenous Fistula Development After Nonoperative Treatment of a Clavicular Fracture
              - Arteriovenous Fistula Development After Nonoperative Treatment of a Clavicular Fracture. A Case Report
              - Dynamic Compression of the Subclavian Artery Secondary to Clavicle Nonunion. A Report of 2 Cases

   - Operative Treatment / Intramedullary Pin Fixation

- Non Union and Malunion of the Clavicle:
    - defined as absence of radiographic healing by 4 months; 
    - non unions occur in more severe traumatic injuries;
    - occurs most often in the central third where the clavicle lacks abundant muscular coverage;
           - in mid-clavicular region, deforming forces include pectoralis major (pulls distal fragment inferiorly and medially) and
                     sternocleidmastoid (pulled superiorly);
    - note that the diagnosis of clavicular non union can sometimes be difficult (because 2 orthogonal views cannot be obtained), and
           supermposed ends of the clavicle on the AP view can give the false impression of union;
    - exam:
           - note function of brachial plexus (esp lower trunk);
           - r/o presence of thoracic outlet syndrome;
    - management:
           - intra-medullary clavicular fixation:
           - iliac crest bone grafting;
           - internal or external bone stimulator;
    - references:
           - Nonunion of the clavicle and thoracic outlet syndrome.
           - Non-union of fractures of the mid-shaft of the clavicle. Treatment with a modified Hagie intramedullary pin and autogenous bone-grafting.
           - Non-union of the clavicle. Associated complications and surgical management.
           - The operative treatment of mid-shaft clavicular non-unions.
           - Surgery for ununited clavicular fracture.
           - The treatment of nonunion fractures of midshaft of the clavicle with an intramedullary Hagie pin and autogenous bone graft
           - Midshaft Malunions of the Clavicle.
           - Short malunions of the clavicle: an anatomic and functional study
           - Brachial Plexus Palsy Secondary to Clavicular Nonunion.

- References:

Osteolysis of the distal part of the clavicle in male athletes
Condensing osteitis of the clavicle. A review of the literature and report of three cases.
Atlanto-axial rotatory fixation and fracture of the clavicle. An association and a classification