RADIOLOGY REVIEW 1.5 ANCC Contact Distal Clavicle Fracture Hours

Patrick Graham

Introduction buttock, and ankle pain. She noted mild swelling of the shoulder and the ankle. There was a bruise of the buttock Accounting for approximately 2.5%–3% of all fractures, and shoulder in the following days. Over the next couple clavicle fractures are most commonly associated with a of weeks, her buttock and ankle symptoms steadily re- direct trauma to the shoulder ( Banerjee, Waterman, solved but the shoulder discomfort lingered on. Padalecki, & Robertson, 2011; Hatch, Clugston, & Taffe, She described continued tenderness about the distal 2017 ; Postacchini, Gumina, De Santis, & Albo, 2002). In clavicle with painful elevation of the arm. She was una- the vast majority of cases, the mechanism of injury is ble to sleep on her left side and could not tolerate the related to a fall ( Banerjee et al., 2011 ; Hatch et al., 2017 ; pressure of purse or briefcase strap draping across the Wheeless, 2015 ). Consistent with that mechanism, the shoulder. There was minimal improvement with use of incidence of clavicle fractures peaks during adoles- ibuprofen and so had basically been positioning for cence, males slightly more common than females, and comfort. She denied distal symptoms. again in the elderly (Hatch et al., 2017; Postacchini ∼ On examination was an alert, affect-appropriate fe- et al., 2002). The majority ( 70%) of clavicle fractures male in no apparent distress. She postured with the left are associated with the middle third of the bone, fol- ∼ arm held tight to her body. There was no gross deform- lowed by distal clavicle fractures ( 25%–28%), and ity, swelling, discoloration, or skin tenting. Focal ten- rarely the proximal aspect (2%–3%) ( Hatch et al., 2017 ; derness about the distal clavicle was accompanied by a Postacchini et al., 2002 ; Wheeless, 2015 ). Conservative slight step-off just proximal to the acromioclavicular management is typically suffi cient as long as there is not joint. Passive range of motion was grossly equal, al- signifi cant comminution, angulation, displacement, or though with noted discomfort. Pain limited her active skin tenting ( Banerjee et al., 2011 ; Hatch et al., 2017 ; range of motion and manual muscle testing of the Wheeless, 2015 ). The most common clinical fi nding is shoulder but did display a negative drop arm. There was tenderness overlying the clavicle and associated painful no pain with elbow, wrist, or digit range of motion. shoulder range of motion. Compartments were soft and compressible, and she was Fracture healing is divided into three stages: infl am- found to be distally neurovascularly intact. mation, repair, and remodeling. During the infl ammation Imaging obtained at the time of examination in- stage, a hematoma forms and an array of macrophages, cluded anteroposterior, Grashey, and Y-views of the left neutrophils, and platelets release cytokines. Fibroblasts shoulder and were evident for a minimally displaced and mesenchymal cells migrate to the area, forming gran- fracture of the distal clavicle (see Figure 1). There was ulation tissue about the fracture site. There is associated subtle calcifi cation about the fracture margins consist- proliferation of osteoblasts and fi broblasts. During repair, ent with early healing with overall alignment main- primary callus forms and endochondral ossifi cation con- tained. With this, the patient was instructed on contin- verts soft callus to hard callus via expression of Type II ued activity modifi cation, immobilization with use of a collagen, followed by Type I collagen. The amount of cal- sling, rest and icing, and appropriate use of over-the- lus is directly related to the extent of immobilization. The counter medications. remodeling phase begins during repair and continues on She returned for a 3-week follow-up, noting signifi - for months after clinical healing. This involves a complex cant improvement in pain and resolution of bony tender- set of pathways that ultimately organize osteoblastic and ness. Repeat radiographs showed continued healing osteoclastic activities to form new bone. Several patient with progressive bridging callus formation (see Figure 2). factors, including smoking/nicotine use, poor nutritional At this point, she was progressed to range-of-motion status, and comorbid medical conditions such as diabetes exercises including pendulums and wall crawls, as well mellitus, vascular disease, or HIV infection, can nega- as a dedicated rotator cuff stretching and strengthening tively impact bone healing (Aiyer, 2018).

Patrick Graham, RN, MSN, ANP-BC, Advanced Practice Provider and Case Presentation Advanced Practice Nurse, Northwestern Medical Faculty Foundation, A 54-year-old, right-hand-dominant woman presented Chicago, IL . with 3 weeks of left shoulder pain after sustaining a fall. The author and planners have disclosed no confl icts of interest related She slipped down about three steps and landed over onto to this educational activity, fi nancial or otherwise. her left side. At the time, she noted left acute shoulder, DOI: 10.1097/NOR.0000000000000457

© 2018 by National Association of Orthopaedic Nurses Orthopaedic Nursing • May/June 2018 • Volume 37 • Number 3 199 Copyright © 2018 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited. F IGURE 1. Initial visit—anteroposterior, Grashey, and Y-views of the left shoulder. Ellipse denotes a minimally distal clavicle fracture. Note incongruence of cortices and lucency. There is early bridging callus formation . program to be started as tolerated. Over the next few 3-month follow-up, noting no continued issues. weeks, she noted complete restoration of shoulder mo- Imaging at that time demonstrated consolidation of tion. She called with an update and was heading on a fracture fragments, evident for complete healing of the vacation with her family. She then presented for a distal clavicle fracture (see Figure 3).

F IGURE 2. Three-week follow-up—anteroposterior and Grashey views. Ellipse again denoting fracture. Here we can appreciate blunting of fracture edges and progressive callus formation consistent with healing.

200 Orthopaedic Nursing • May/June 2018 • Volume 37 • Number 3 © 2018 by National Association of Orthopaedic Nurses Copyright © 2018 National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited. orthopaedic surgeon to discuss options for defi nitive surgical management (Banerjee et al., 2011; Hatch et al., 2017 ; Wheeless, 2015 ). There are a variety of tech- niques utilized for fi xation of clavicle fractures, with insuffi cient evidence to demonstrate superiority of any particular technique (Banerjee et al., 2011; Hatch et al., 2017 ; Wheeless, 2015).

Discussion Clavicle fractures should be in the differential for any patient presenting with shoulder pain after direct trauma or a fall, especially if there is tenderness upon palpation of the clavicle. If clinically noted, radio- graphs should then be obtained to confi rm the diagno- sis. Conservative management, being suitable for the majority of cases, should be guided by the patient’s symptoms, with progression of activities as tolerated as their symptoms allow. The advanced practice provider can provide reas- surance that radiographic healing lags behind true F IGURE 3. Three-month follow up—anteroposterior view with ellipse denoting healed distal clavicle fracture. clinical healing, a good reminder to treat the patient, not the imaging studies. One should also be cognizant of fi ndings that warrant referral to an orthopaedic sur- Management geon, including any open fracture, those with neuro- Initial management of clavicle fractures includes im- vascular compromise, severe comminution or angula- mobilization, typically with a sling or fi gure-of-eight tion, displacement, shortening, skin tenting, or a brace as symptoms allow ( Ersen, Atalar, Birisik, symptomatic nonunion or malunion as noted earlier Saglam, & Demirhan, 2015; Hatch et al., 2017). Patients (Banerjee et al., 2011; Hatch et al., 2017; Wheeless, should be instructed on positioning for comfort and 2015 ). the use of ice and medications for pain management EFERENCES (Hatch et al., 2017 ; Wheeless, 2015 ). Given the poten- R tial impedance of initial healing, some providers may Aiyer , A. (2018 ). Fracture healing. Ortho Bullets. Retrieved choose to withhold nonsteroidal anti-infl ammatory from https://www.orthobullets.com/basic-science/ 9009/fracture-healing drug use in the fi rst few weeks, especially if the patient Banerjee , R. , Waterman , B. , Padalecki , J. , & Robertson , has other comorbid conditions that negatively impact W. ( 2011 ). Management of distal clavicle fractures. bone healing. Providers should take the opportunity to Journal of the American Academy of Orthopaedic discuss and encourage smoking cessation. Surgeons , 19 ( 7 ), 392 – 401 . The patient should be seen back every 2–3 weeks Ersen , A. , Atalar , A. C. , Birisik , F. , Saglam , Y. , & Demirhan , after initial evaluation for repeat imaging and exami- M. (2015 ). Comparison of simple arm sling and fi gure nation. With resolution of pain and tenderness on ex- of eight clavicular bandage for midshaft clavicular amination, the patient may be progressed with range fractures: A randomized controlled study . The Bone of motion, gentle stretching, and exercises for rotator and Joint Journal , 97 ( 11 ), 1562 – 1565 . cuff strengthening as tolerated. Although early joint Hatch , R. L. , Clugston , J. R. , & Taffe , J. (2017 ). Clavicle fractures. UpToDate . Retrieved from https://www. mobilization is benefi cial in avoiding stiffness and uptodate.com/contents/clavicle-fractures compensatory symptoms, one should not be pro- Postacchini , F. , Gumina , S. , De Santis , P. , & Albo , F. gressed when tenderness and pain at rest are still ( 2002 ). Epidemiology of clavicle fractures. Journal of noted, as this increases the risk of developing a nonun- Shoulder and Elbow Surgery , 11 ( 5 ), 452 – 456 . ion or malunion. Those patients with a symptomatic Wheeless , C. R. ( 2015 ). Clavicle fractures . In Wheeless’ nonunion or malunion after 3 months of appropriate Textbook of Orthopaedics. Retrieved from http:// conservative management should be referred to an www.wheelessonline.com/ortho/clavicle_fractures

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© 2018 by National Association of Orthopaedic Nurses Orthopaedic Nursing • May/June 2018 • Volume 37 • Number 3 201 Copyright © 2018 National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.