SAOJ Winter 2011:Orthopaedics Vol3 No4 5/9/11 11:47 AM Page 56 Page 56 / SA ORTHOPAEDIC JOURNAL Winter 2011 | Vol 10 • No 2 ARTICLE A RTICLE Bilateral clavicle fractures A case report and review of the literature HET van den Bout MBChB, LLB Senior Registrar, Department of Orthopaedics, University of Pretoria CH Snyckers MBChB,Dip.PEC(SA),MMed(Orth), FCSA(Orth) Consultant, Department of Orthopaedics, University of Pretoria Reprint requests: Dr CH Snyckers Wilgers Hospital Suite 108 Wilgers Pretoria 0041 Tel: (012) 807-5696 Fax: (012) 807-5694 Abstract Bilateral clavicle fractures are rare and are seldom reported on. Based on the literature review the incidence of bilateral clavicle fractures is 0.43% of clavicle fractures with an overall incidence of between 0.011 and 0.017%. The common mechanism of injury is one of a compressive force across both shoulder girdles and is different from that causing unilateral clavicle fractures. Bilateral clavicle fractures are usually associated with high-energy impact injuries and are commonly associated with other severe injuries. These injuries are not always evident and should be actively sought for and excluded. Bilateral clavicle fractures are not commonly mentioned as an indication for operative intervention. It is suggested that bilateral clavicle fractures should be surgically managed to limit the duration of functional disability. Furthermore the use of low profile locking plates provides the ideal fixation method allowing for an earlier functional outcome. Case report His shoulder movements on the right were more A 27-year-old male presented to our hospital on 22 October markedly decreased than on the left. He had no neu- 2010. He was involved in a motor vehicle accident after he rovascular injuries. X-rays revealed a left clavicle fracture, fell asleep behind the steering wheel and subsequently (Figure 2) rolled his vehicle. The incident occurred six days prior to which was 300% displaced, a right clavicle fracture consultation. Immediately after the accident he had pain with mild comminution and 200% displacement and a over both clavicles and his right shoulder. He was initially right scapula neck fracture, which was minimally dis- transported to a local hospital but due to a perceived delay placed. Both clavicle fractures were type 1C Allman in his definitive treatment he decided to seek treatment at fractures and type 2B1 Robinson fractures according to 1 our institution. the relevant classification systems. The right humeral On examination the patient was haemodynamically stable. head did not display any subluxation and the shoulder He had sustained a blunt injury to his left shoulder with a joint did not displace more than 5 mm. contusion and some superficial abrasions . He For mobilisation purposes and due to the displacement of (Figure 1) also presented with pain, tenderness, bruising and bony the individual fractures the patient subsequently underwent instability bilaterally over his clavicles. The clinical diagno- open reduction internal fixation (ORIF) of both clavicles. sis was made of bilateral clavicle fractures. Both surgeries were performed through the classic superior Although the patient had marked bruising and abrasions incision and the fragments were fixed with interfragmentary screws and held with anatomical locking plates . over the left shoulder, he presented with increased pain over (Figure 3) the lateral aspect of the right shoulder and was tender on The operation was uneventful and the patient was dis- palpation along the right scapular spine. charged on the second postoperative day. SAOJ Winter 2011:Orthopaedics Vol3 No4 5/9/11 11:49 AM Page 57 ARTICLE SA ORTHOPAEDIC JOURNAL Winter 2011 | Vol 10 • No 2 / Page 57 Figure 1. Clinical appearance of young male with bilateral clavicle fractures. Some tenting of the skin can be seen over the right clavicle and superficial abrasions over the left shoulder Figure 2. Pre-operative X-ray appearance of bilateral clavicle fractures. Both clavicle fractures have some comminution and are displaced. A scapula neck fracture is also visible on the right The patient was given a Barford-Jones-type arm sling for At 12 weeks postoperatively the X-rays (Figure 5) the right upper limb and a broad arm sling for the left upper revealed maintenance of initial reduction and advanced limb. He was instructed to keep his right shoulder immo- union. The patient was satisfied with the result and he was bilised for 6 weeks due to the associated scapula fracture, discharged. and to use his left hand for activities of daily living. The patient was reviewed 2 weeks, 6 weeks and 12 weeks postoperatively. On review of the patient at 6 weeks he was doing well. For mobilisation purposes and due to the He had full, pain-free range of motion of both shoulders displacement of the individual fractures the patient . The X-rays showed good alignment of the subsequently underwent ORIF of both clavicles (Figure 4) fractures with early signs of union. SAOJ Winter 2011:Orthopaedics Vol3 No4 5/9/11 11:49 AM Page 58 Page 58 / SA ORTHOPAEDIC JOURNAL Winter 2011 | Vol 10 • No 2 ARTICLE Figure 3. Immediate postoperative X-ray showing good reduction and fixation with interfragmentary screws and low profile locking plates on both clavicles Figure 4a & b. Postoperative images showing full recovery of abduction and forward flexion of both arms SAOJ Winter 2011:Orthopaedics Vol3 No4 5/9/11 11:50 AM Page 59 ARTICLE SA ORTHOPAEDIC JOURNAL Winter 2011 | Vol 10 • No 2 / Page 59 Figure 5. Postoperative X-ray at twelve weeks showing advanced union and maintenance of initial reduction Literature review There are however several case reports in the literature. Clavicle fractures are common injuries. Isolated clavicle These case reports vary from bilateral non-traumatic clavi- 9 8-25 fractures have a reported incidence of 2.6%2 to 4%3 of all cle fractures, to bilateral traumatic clavicle fractures, and 29,32,40 fractures. The overall reported annual incidence ranges bilateral clavicle fracture non-unions. 18 from 29/100 0001 to 64/100 0003 with the highest inci- Marya reports on five bilateral clavicle fractures seen in dence (up to 150/100 000) found in young males.3,4 a time span of 3 months and they suspect that this injury Although clavicle fractures are often seen, bilateral clav- might be more common than previously reported. icle fractures are rare and are seldom reported on. The first few cases of bilateral clavicle fractures found are An electronic search of the English literature from 1887- documented and summarised in three articles in 8,23,24 The Lancet 2010 was completed. Inclusion criteria were articles that of July 1890. In these three articles reference is made to report on patients with bilateral clavicle fractures as well 41 cases of bilateral clavicle fractures with Gurlt having as articles that investigated bilateral clavicle non-union seen 18 of them. and epidemiological studies on clavicles. Including the two cases presented, there was a total of 29 Several series of clavicle fractures have been published males and 11 females with bilateral clavicle fractures, and 65 patients in which the gender was unknown . and the incidence of bilateral clavicle fractures is as fol- (Graph I) lows: The different age groups of patients with bilateral clavicle 3 fractures reviewed are illustrated in . In 74 cases the • Nordqvist reported no bilateral cases in 2 035 clavi- Graph II cle fractures. age is not stated. • Nowak4 had two bilateral cases in 185 patients. Regarding the mechanism of injury in unilateral clavicle • Throckmorton5 found 16 bilateral clavicle fractures fractures, it has been shown that several mechanisms can 26 in 593 patients. cause a unilateral clavicle fracture including a fall on an • Daab6 found four cases out of 1 348 clavicular frac- outstretched hand, a fall onto the shoulder, a direct blow on tures. the point of the shoulder and a direct blow on the clavicle. It • Rowe7 found a 1% incidence in 690 fractures. was previously thought that the most common cause of a • Malgaigne8 found only one case in over 2 000 cases. unilateral clavicle fracture is a fall on an outstretched hand • Robinson1 had no bilateral cases in 1 000 cases but he but subsequent studies have shown that a fall or a blow on excluded patients who had other shoulder girdle the point of the shoulder is the more common mecha- 26,27 injuries. nism, causing clavicle fractures in up to 94%. • Postacchini2 reported on two bilateral fractures in 533 Mechanisms for causing bilateral clavicle fractures patients but his study only looked at patients with iso- include a compressive force across both shoulder gir- 14,17,19,23,28 8,12,14,22 lated clavicle fractures, which means that polytrauma dles, direct trauma to both clavicles, direct patients were excluded, and most patients with bilat- trauma on one side and indirect violence in a subsequent fall 22 eral clavicle fractures have multiple injuries. on the other and two sequential episodes of direct trauma 20,21 Based on above studies, excluding those by Robinson and to the shoulder. Only one case is reported where indirect Postacchini, the incidence appears to be around 0.43% of violence (fall on outstretched arms) caused bilateral clavicle 8 clavicle fractures. fractures. SAOJ Winter 2011:Orthopaedics Vol3 No4 5/9/11 11:50 AM Page 60 Page 60 / SA ORTHOPAEDIC JOURNAL Winter 2011 | Vol 10 • No 2 ARTICLE 70 36% of patients with unilateral clavicle fracture with 14.4% having a superficial wound on the upper extremity or head, 60 1.8% having another extremity fracture, 7.2% having one or more rib fractures, 5.4% cerebral concussion and 7.2% hav- 50 ing two or more associated injuries. 40 In contrast, bilateral clavicle fractures are usually described in the setting of polytrauma.