Diapositiva 1

Closed fracture middle right claviclePRESENTED BY : Nur Raisah UlfahC111 09 382ADVISOR : dr. M. Arief Faisal dr. Padlan

SUPERVISOR :dr. Zulfan Oktasatria Siregar, Sp.OTIDENTITYName:H.S.C.Age:56 years old / MaleAdmission:March 16th, 2015 at 17.59Registration:71 60 32Status:JKDAUTOANAMNESISChief Complain : Pain at right shoulderSuffered since 12 hours before admitted to Wahidin General Hospital due to motor vehicle accident.Patient was riding motorcycle, then hit a cow in front of him and fell down to the right side. The exact mechanism of injury was unclear.History of loss of conciousness (-), vomiting (-).Prior treatment at Bulukumba Hospital.Patient is tailor and right handed .PRIMARY SURVEYA:ClearB:RR 18 x/min, spontaneous, thoracoabdominal typeC:BP 130/80 mmHg, HR 78 x/min strong, regularD:GCS 15 (E4M6V5), pupil isochoric, diameter 3 mm/3mm, light reflex +/+E:T: 36,8 oCSECONDARY SURVEYRight Shoulder RegionLook:Deformity (+), Swelling (+), Hematome (+), Wound (-)Feel:Tenderness (+)NVD : Sensibility is good, pulsation of radial artery is palpable, CRT < 2Move

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Active and passive motions of shoulder joint can not be evaluated due to painCLINICAL FINDINGS

RADIOLOGY FINDINGS

LABORATORY FINDINGSItemResultNormal RangeWBC9,64,00-10,0RBC4,34,00-6,00HGB13,112,0-16,0HCT3937,0-48,0PLT201150-400CT7004-10BT2301-7HBsAgNon ReactiveNon ReactiveDIAGNOSISClosed Fracture Middle Right ClavicleMANAGEMENTIVFDAnalgesicApply arm sling at right upper extremityConservative Treatment10

DiscussionINTRODUCTIONSolomon L, et all. Apleys System of Orthopaedics and Fractures. Ninth Edition. London : Hodder Arnold. 2010; p.687, 772-5.

EpidemiologyClavicle fractures account for approximately 4% of all fractures and 35% to 43% of shoulder girdle injuriesMiddle third fractures account for 80% of all clavicle fractures, whereas fractures of the lateral and medial third of the clavicle account for 15% and 5%, respectively.Finkemeier, CG. Fracture and Dislocation of the Shoulder Girdle and Humerus. In: Chapman M, Szabo RM, Marder R, Vince KG, et al. Ed. Chapmans Orthopedic Surgery Third Edition. New York: Lippincott Williams & Wilkins.2001. P432-80Egol KA, Koval KJ, Zuckerman JD. Clavicle Fracture. In Handbook of Fracture. Philadelphia:Wolters Kluwer. 2010. P143-9

Anatomy

Netter, F. Atlas of Human Anatomy 6th edition18

Mechanism of TraumaEgol KA, Koval KJ, Zuckerman JD. Clavicle Fracture. In Handbook of Fracture. Philadelphia:Wolters Kluwer. 2010. P143-919CLINICAL FINDINGSPatients usually present with splinting of the affected extremity, the arm adducted across the chest and supported by the contralateral hand to unload the injured shoulder.The proximal fracture end is usually prominent and may tent the skin. Assessment of skin integrity is essential to rule out open fracture.Up to 9% of patients with clavicle fractures have additional fractures,most commonly rib fractures.Most brachial plexus injuries are associated with proximal third clavicle fractures (traction injury).

20CLASSIFICATION (ALLMAN)Group l: fracture of the middle third (80%). This is the most common fracture in both children and adults; proximal and distal segments are secured by ligamentous and muscular attachments.

Group ll: fracture of the distal third (I5%). This is subclassified according to the location of the coracoclavicular ligaments relative to the fracture

Group lll: fracture of the proximal third(5%). Minimal displacement results if the costoclavicular ligaments remain intact. It may represent epiphyseal injury in children and teenagers.Finkemeier, CG. Fracture and Dislocation of the Shoulder Girdle and Humerus. In: Chapman M, Szabo RM, Marder R, Vince KG, et al. Ed. Chapmans Orthopedic Surgery Third Edition. New York: Lippincott Williams & Wilkins.2001. P432-80Egol KA, Koval KJ, Zuckerman JD. Clavicle Fracture. In Handbook of Fracture. Philadelphia:Wolters Kluwer. 2010. P143-9Subtype Group IIType l: Minimal displacement: interligamentous fracture between the conoid and trapezoid or between the coracoclavicular and AC ligaments; ligaments still intact Type ll: Displaced secondary to a fracture medial to the coracoclavicular ligaments: higher incidence of nonunionllA: Conoid and trapezoid attached to the distal segmentllB: Conoid torn, trapezoid attached to the distal segment Type lll: Fracture of the articular surface of the AC joint with no ligamentous injury: may be confused with first-degree AC joint separation Finkemeier, CG. Fracture and Dislocation of the Shoulder Girdle and Humerus. In: Chapman M, Szabo RM, Marder R, Vince KG, et al. Ed. Chapmans Orthopedic Surgery Third Edition. New York: Lippincott Williams & Wilkins.2001. P432-80Egol KA, Koval KJ, Zuckerman JD. Clavicle Fracture. In Handbook of Fracture. Philadelphia:Wolters Kluwer. 2010. P143-9

Tipe I: pergeseran minimal. Fraktur antara ligamen conoid dan trapezoid atau diantara coracoclaviculer dengan ligamen acromioclavicular. Ligamen tetap intak. (gambar 6A)Tipe II. Pergeseran sekunder medial dari ligamen coracoclaviculer. Insidens dari nonunion tinggi.IIA. Conoid dan trapezoid masih terhubung pada segmen distal (Gambar 7A)IIB: Conoid ruptur, trapezoid masih terhubung dengan segmen distal (gambar 7B)Tipe III. Fraktur pada permukaan sendi dari acromioclavicular dan tidak ada kerusakan ligamen. Dapat sulit dibedakan dengan terputusnya ligamen acromioclavicular. (gambar 6B)Tipe IV. Ligamen tetap terhubung pada periosteum, (anak-anak) dengan pergeseran dari fragmen proximalTipe V . Fraktur Cominutif, ligamen tidak terhubung pada fragmen proximal maupun distal, namun pada fragmen ketiga.

22Subtype Group IIIType l: Minimal displacementType ll: DisplacedType lll: IntraarticularType lV: Epiphyseal separationType V: Comminuted

TREATMENT (OPERATIVE)Indication for Operative treatment:Open FractureFracture that threaten the overlying skin (rare)Fracture that widely displaced (>2cm)Fracture associated in neurovascular compromiseFracture in multiply injured patientsIpsilateral upper extremity injuries needing early mobilizationLower Extremity injuries requiring crutch walkingFracture in patients with neuromuscular diseaseSymptomatic bump at union site, hyperthrophic callusFinkemeier, CG. Fracture and Dislocation of the Shoulder Girdle and Humerus. In: Chapman M, Szabo RM, Marder R, Vince KG, et al. Ed. Chapmans Orthopedic Surgery Third Edition. New York: Lippincott Williams & Wilkins.2001. P432-80Egol KA, Koval KJ, Zuckerman JD. Clavicle Fracture. In Handbook of Fracture. Philadelphia:Wolters Kluwer. 2010. P143-9Indication of surgical treatment:

Fracture SpecificDisplacement >2 cmShortening >2 cmIncreasing comminution (>3 fragments)Segmental fracturesOpen fracturesImpending open fractures with soft tissue compromiseObvious clinical deformity (usually associated with items 1 and 2)Scapular malposition and winging on initial examination

TREATMENT Non operatif Most minimally displaced clavicle fractures can be successfully treated non operatively with some form of immobilization.In general, immobilization is used for 4 to 6 weeks.ConservativeOperative

Immobilization (Mitella/ arm sling)

Open Reduction Internal fixation-plate fixation-intramedullary fixation

MANAGEMENTSolomon. L. et al. Injurys of the Knee and Leg in Apleys System of Orthopaedics and Fractures 9th Edition. UK: Arnold. 2010.COMPLICATIONEarly:Neurovascular CompromisePneumothoraxLate:MalunionNonunionPosttraumatic arthritisCole A, Pavlou P, Warwick, D. Injuries of the Shoulder, Upper arm, and Elbow In:Solomon L, Wawick D, Nayagam, S Ed.Apleys System of Orthopaedic and Fractures. London:Hodder Arnold. 2010. 733-66.Neurovascular compromise: This is uncommon and can result from either the initial injury or secondary to compression of adjacentstructures by callus andor residual deformity. Subclavian vessels are at risk with superior plating.Malunion: This may cause a bony prominence and may be associated with poorer DASH scores at one year.Nonunion: The incidence of nonunion following clavicle fractures ranges from 0.1% to I3.0Vo, with 85% of all nonunions occurring inthe middle third. tr Factors implicated in the development of nonunions of the clavicle include (l) severify of initial trauma (open wound), (2) ex-tent of displacement of fracture fragments, (3) soft tissue interposition, (4) refracture, (5) inadequate period of immobihzation, and (6) primary open reduction and internal fixation.Posttraumatic arthritis: This may occur after intraarticular injuries to the sternoclavicular or AC joint.28