1. CLAVICULAR FRACTURES…. DANGEROUS??? Kristin Ratnayake, MD Pediatric Emergency Medicine Fellow October 3, 2013

2. Case 16y/o female who presents with left shoulder and neck pain secondary to a motor vehicle accident

3. Patient History PMH: Pregnancy with NSVD 1 year ago PSH: Denies Family Hx: Denies Social Hx: Lives with mom, stepdad and son

4. ROS +chest pain (left anterior) +numbness left arm and shoulder +arthralgias Otherwise negative

5. PE BP 104/55 | Pulse 85 | Temp 99.1 °F (37.3 °C) (Oral) | Resp 18 | Wt 97.523 kg (215 lb) | SpO2 99% HEENT: normal Neck: Normal range of motion. Tenderness to palpation over left lateral neck. No point tenderness over cervical spine. Cardiovascular: Normal Pulmonary/Chest: Normal. Abdominal: Normal. Musculoskeletal: She exhibits tenderness. Tenderness to palpation over left clavicle. No deformity or swelling noted. Pain of left shoulder with movement of left arm. Extension of left arm limited by pain. Neurological: She is alert. No cranial nerve deficit. She exhibits normal muscle tone. Coordination normal. Numbness over lateral aspect of left upper arm and shoulder. Normal grip strength bilaterally. Skin: Normal.

6. MDM 16y/o female with left shoulder pain secondary to trauma from MVA: - CXR and left shoulder xray - tylenol for pain

8. What to do? Sling? Figure 8? Ortho? Trauma consult?

9. Trauma consulted Clavicle xrays (surprisingly not all that helpful) Other bony xrays (shoulder, knee, tib-fib, ankle- all negative) CT head, neck, chest, abdomen and pelvis - Neck and Chest with IV contrast

10. Was that appropriate management? Let’s review clavicle fractures!

11. Clavicle Fractures Common injuries Middle 1/3 most frequently fractured Mechanism

12. Important Examination Points Skin Neurovascular status

13. Subclavian Injuries Katras et al., Vasc Surg, 7 patients with blunt trauma to subclavian artery 4 with clavicle fracture, all MVA victims Only 1 with brachial plexus injury Kendall et al., J Trauma, death from subclavian artery injury from clavicle fracture

14. Treatment Traditionally clavicle fracture managed non-operatively Distal third

15. Sternoclavicular Dislocation Routine radiographs are often difficult to interpret and may falsely appear normal Serendipity view

16. Sternoclavicular Dislocation Three types of injury - First Degree – most common – strain of ligaments - Second Degree – anterior or posterior subluxation from manubrium - Third Degree – complete disruption with subsequent dislocation

17. Complications Significant morbidity and mortality with posterior dislocations Injury to lung, trachea, esophagus, vasculature, nerve

18. Treatment Supportive care and immobilization for strain type injury Closed reduction of anterior and posterior dislocations ORIF if unable to reduce, recurrent or unstable