Demographics: Bimodal distribution (children/young adults via sports; elderly via low-energy falls).
Mechanism of Injury (MOI):
Direct lateral blow to the shoulder (most common).
FOOSH (fall on outstretched hand).
Anatomic Distribution:
Middle third (midshaft): ~75–80% (most common site of fracture).
Distal (lateral) third: ~15%.
Proximal (medial) third: ~5% (associated with high-energy intrathoracic trauma).
Clinical Features
History:
Acute localized pain, swelling, and deformity following trauma.
Patient classically presents supporting the injured arm with the contralateral hand to minimize shoulder girdle movement.
Physical Examination (PE):
Visible/palpable step-off deformity and focal bony crepitus.
Skin tenting or blanching (indicates impending open fracture; surgical urgency).
Ecchymosis and local soft-tissue edema.
Mandatory checks:
Neurovascular (NV) status: Palpate radial/brachial pulses; test motor/sensory function of radial, median, and ulnar nerves to r/o brachial plexus or subclavian vessel compression.
Auscultation: Breath sounds (r/o pneumothorax) and subclavian bruit.
Diagnosis
Initial & Confirmatory:
Plain Radiograph (XR): Anteroposterior (AP) view of the clavicle + 20–45° cephalic tilt (apical lordotic view) to assess displacement and shortening.
Key Imaging for Complicated Cases:
CT scan: Indicated for medial-third/sternoclavicular joint involvement, complex comminuted fractures, or pre-op planning.
CT Angiography (CTA): Indicated immediately if diminished pulses, expanding hematoma, subclavian bruit, or signs of distal ischemia. c
Upright Chest XR (CXR): Indicated if dyspnea, tachypnea, or chest pain to evaluate for pneumothorax or hemothorax.
Differential Diagnostics
Acromioclavicular (AC) Joint Separation:
Diff: Point tenderness directly over the AC joint, intact clavicular shaft on XR, positive cross-body adduction test.
Sternoclavicular (SC) Joint Dislocation:
Diff: Tenderness/swelling localized over the sternal notch; posterior dislocation may present with dysphagia, dyspnea, or hoarseness (requires CT).
Proximal Humerus Fracture:
Diff: Tenderness over greater tuberosity/surgical neck of humerus, arm held in adduction; XR confirms humeral fracture.
Scapular Fracture:
Diff: Requires very high-energy blunt trauma; tenderness localized over the posterior chest wall/scapula.
Management
Conservative (First-line for uncomplicated fractures):
Indication: Minimally displaced or non-displaced fractures without NV deficits.
Intervention: Simple arm sling (equally effective to figure-of-eight bandage with fewer skin/compression complications) + analgesia (NSAIDs/acetaminophen).
Rehabilitation: Early gentle pendulum exercises at 1–2 weeks, active range of motion (ROM) at 4–6 weeks.
Surgical Intervention (ORIF - Open Reduction Internal Fixation):