Clavicle fracture

ICD-10 code

S42.0 Clavicle fracture.

Epidemiology of the clavicle fracture

Fracture of the clavicle is from 3 to 16% of the integrity of all bones of the skeleton. More often a fracture of the clavicle is found in young people.

[1], [2], [3], [4], [5]

What causes a clavicle fracture?

The injury mechanism is predominantly indirect: falling on the retracted arm, elbow or shoulder joint, compression of the shoulder girdle. But a direct injury mechanism is also possible - a blow to the clavicle area with an object or in the fall.

Clavicle anatomy

The clavicle is the only bone that connects the upper limb to the torso. This is a tubular bone, which has an S-shape, due to which in some northern areas of the country, its old Russian name is met with until now. The absolute length of the clavicle of an adult is 12.2-16.0 cm. The average length relative to height for men is 8.8%, for women - 8.3%. The clavicle consists of the body (middle part) and two ends: acromion and sternum. The ends are somewhat thickened and form articulations with the spatula and sternum.

The nature of the movements is determined by the shape of the joints and the direction of the muscles. Acromioclavicular joint belongs to amphiarthrosis and is distinguished by low mobility. The joint has a dense fibrous capsule, the acromioclavicular ligament is woven into it. Another, more durable ligament that holds the articulation of the clavicle with the acromion, the coraco-clavicular, consists of two ligaments (trapezoidal and conical).

The sternoclavicular joint is spherical in shape. Its fibrous capsule is strengthened by the anterior and posterior sternoclavicular ligaments. In addition, there are the costoclavicular and interclavicular ligaments, which protect articulating bones from separation. Five muscles are attached to the clavicle.

• In the area of the sternal end: from the upper outer edge is the sternocleidomastoid muscle of the neck, from the lower anterior - the clavicular part of the pectoralis major muscle.
• In the region of the acromion end: a trapezoid muscle is attached to the anterior surface, and a deltoid muscle is attached to the anteroposterior edge.
• The fifth muscle, the subclavian, passes along the back surface of the clavicle in its middle part. It should be remembered that under this muscle are located the subclavian artery, vein and nerves of the brachial plexus. Somewhat more medially, at the level of the sternoclavicular joint, on the right are the shoulder-head trunk and the common carotid artery, on the left - the subclavian artery, on both sides - the vagus nerve.

From a physiological point of view, the clavicle is a kind of springy strut between the sternum and the shoulder joint, which does not allow it to take a more medial position. The emphasis for the shoulder and mobility in the joints of the clavicle contribute to a significant amount of movement of the shoulder and shoulder girdle. An important role in the biomechanics of these movements is played by muscles attached to the clavicle. In addition, the clavicle serves as protection of the neurovascular bundle.

[6], [7], [8]

Symptoms of a clavicle fracture

The symptoms of a clavicle fracture are a sharp pain at the fracture site, the patient assumes a characteristic forced position, supports the arm on the side of the injury.

[9]

Complications of clavicle fracture

Fracture of the clavicle is complicated by include injury of the neurovascular bundle and compression of the nerve plexus.

[10], [11], [12]

Diagnosis of a clavicle fracture

[13], [14]

Anamnesis

In history - the corresponding injury.

[15]

Examination and Physical Examination

Diagnosis of a clavicle fracture is not difficult, since the bone is located under the skin and is accessible to the study (however, here the doctor is not immune from errors).

The type of patient is characteristic: the head is turned and tilted in the direction of damage, the upper arm is lowered and shifted anteriorly, and the medial edge of the scapula and its lower angle depart from the rib cage as a result of the absence of a "strut", which served as the clavicle. The shoulder is lowered, pressed against the body and rotated inside. The subclavial fossa is smoothed. Usually, in the area of the clavicle, swelling is visible due to an erect central fragment.

Palpation reveals a discontinuity of the bone, it is possible (but not desirable!) To determine the pathological mobility and crepitus.

Fracture of the clavicle is often accompanied by displacement of fragments, especially if the line of fracture goes obliquely and passes through the middle of the bone. Due to the violation of the physiological balance of the muscles, the fragments are shifted and animate the typical position. The central fragment under the action of the sternocleidomastoid muscle is shifted upward and posteriorly, and the peripheral - downwards, anteriorly and medially. The reason for the dislocation of the distal fragment is the disappearance of the support between the shoulder joint and the sternum. The deltoid muscle and the own weight of the limb shift the peripheral fragment downwards. The traction of the large and small pectoral muscles rotate the shoulder in the middle, bring the limb closer to the body and not only increase the displacement downwards, but also shift the fragment in the middle. Fragments pass one by one, the clavicle shortens. Medial displacement of the peripheral fragment is aggravated by contraction of the subclavian muscle.

[16]

Laboratory and instrumental diagnosis of clavicle fracture

X-rays of the clavicle are usually performed only in a direct anteroposterior projection, very rarely (for comminuted fractures, in order to clarify the location of the intermediate fragment) - in the axial projection.

[17],

Clavicle fracture treatment

[18], [19], [20]

Non-drug and drug treatment of a clavicle fracture

The most often conservative treatment of a clavicle fracture consists in simultaneous reposition of fragments with their subsequent fixation in the correct position for the period necessary for fusion.

Local anesthesia. 10-20 ml of a 1% solution of procaine is injected into the fracture area, and after 5-7 minutes they begin to manipulate. The purpose of the reposition is to bring the peripheral fragment to the central one by lifting the shoulder girdle and leading it outwards and backwards. There are several ways to match the clavicle fragments.

• The first way. The patient is placed on his back on the edge of the table with a high roller set between the shoulder blades. The arm on the side of the fracture is hung from the table. After 10-15 minutes the assistant surgeon stands at the head of the patient and, grasping the patient’s armpits, shifts his shoulder girdle up and back. The surgeon, facing the patient, with one hand fixes the shoulder joint, the second adjusts and holds fragments.
• The second method is similar to the first, but it is performed in the upright position of the patient, who is seated on a low stool. The surgeon's assistant becomes behind the victim, grasps his armpits in the front and, resting his knee on the patient’s back, lifts and spreads his upper arm as much as possible. The surgeon performs the reposition directly at the fracture site.
• The third method is used in the absence of an assistant. Near put two stools. On them the patient and the surgeon sit sideways to each other. The doctor turns his forearm into the patient's armpit, while keeping his chest and elbow joint of the victim in his casting position with his chest. Then, with his forearm, he lifts the patient's upper arm and, acting as a lever, retracts it posteriorly. Free hand matches fragments.

Performing any of the described reposition methods, one should not, as advised in some textbooks, remove the victim’s shoulder, since the pectoralis major muscle is pulled, the shoulder joint is brought in, which makes it difficult to juxtapose fragments.

At the end of the manipulation, without weakening the thrust, it is necessary to fix the shoulder girdle and shoulder on the affected side in the position reached by reposition. This is best done with a plaster cast. Of the many proposed dressings, it stood the test of time and earned the recognition of the dressing proposed in 1927. MP Smirnov and V.T. Vanshteynom. When carrying out immobilization, it is necessary to put a cotton-gauze roller in the armpit.

Another device that creates a reliable fixation of fragments, is the SI bus. Kuzminsky. In case of failure in case of simultaneous reposition, this bus can be used for gradual (within 2-3 days) comparison of fragments. Correct installation of body segments and the correction of thrust by moving the belts allow the tire to be used as a repositioning device.

Previously proposed by Beler (Bohler, 1928), H.D. Rakhmanov (1949), M.K. Tikhomirov (1949), M.I. Chizhin (1940) special tires are currently practically not used and have only historical significance.

Good results with proper use gives method A.V. Titova (1950), based on the use of a certain size and shape of the "oval", placed in the patient's axillary cavity. Hand hang on the scarf. Prescribe early functional treatment.

Soft-woven dressings are unsuitable for fixing fragments of the clavicle: the 8-shaped dressing and Delbe's rings do not create a rise in the shoulder girdle, but only retract it backwards; Kosynochnaya, Deso and Velpo bandages do not fix fragments in the desired position. In addition, after 1-2 days, the bandage tours, as a rule, weaken, as a result of which the bandage ceases to perform a fixing role. However, as an exception, the listed dressings can be used in children (with subperiosteal fractures) and in elderly and senile persons.

Fracture of the clavicle is often an integral part of polytrauma, then the listed methods of treatment become unacceptable because of the forced lying position of the patient. We believe that in such situations, the Kuto method should be included in the arsenal of catastrophe medicine, which consists in the following. The patient lies on his back, closer to the edge of the bed with his arm hanging for 24 hours. Then, the arm bent at the elbow joint is placed on a low added stool for 14-21 days. Assign UHF, massage, exercise therapy for the elbow joint and fingers.

[21], [22], [23], [24]

Surgical treatment of clavicle fracture

Surgical treatment of a clavicle fracture is performed according to strict indications: damage to the neurovascular bundle, open fracture, multi-fragment fracture with the threat of damage to blood vessels and nerves, the interposition of soft tissues, the threat of perforation of the skin with a sharp fragment. If the fragments with a sharp edge stand considerably, and the skin at the site of protrusion is anemic (white), one should not wait for the appearance of an open fracture - the patient should be operated on. The operation makes it possible to make a cut in the desired projection and under aseptic conditions.

Surgical treatment of a clavicle fracture involves exposing fragments, open reposition and fixation of bone fragments in one of the ways. The most commonly used intraosseous osteosynthesis with a metal pin. The fixator can be inserted from the central fragment or retrograde, when the pin is sneaked into the peripheral fragment before going out for the acromion, and then, after matching the bone fragments, the pin is inserted into the central fragment, moving it in the opposite direction.

There are also possible external fixation methods with the help of plates, cerclages, and bone homotransplants that block the fracture line. To avoid bias, the graft is attached to the clavicle with screws or wire. Immobilization is carried out using a plaster thoracobrachial dressing.

Currently, researchers use external fixation devices, usually of their own design, for treating clavicle fractures.

Regardless of the method of treatment and the type of fixation device, immobilization should last at least 4-6 weeks. From the 3-4th day, UHF is necessary for the fracture area and exercise therapy for non-immobilized joints. On the 7th-10th day, the static contractions of the muscles of the forearm and shoulder are started. From the 18th to 21st day, electrophoresis of calcium and phosphorus drugs is prescribed to the fracture area.

After the immobilization period has expired, the plaster cast is removed and radiography is performed. If consolidation has come, proceed to rehabilitation treatment: exercise therapy for the joints of the upper limb, shoulder and shoulder massage, ozokerite and procaine electrophoresis, calcium chloride on the shoulder joint, laser therapy, hydrotherapy in the pool, etc.

[25], [26]

Approximate duration of disability

Fracture of the clavicle is accompanied by loss of working capacity for 6-8 weeks.

[27], [28], [29]