Review Question - QID 106156

The patient has sustained a right mid-shaft clavicular fracture that is minimally displaced. A thorough neurovascular examination must be done to help rule out brachial plexus and subclavian artery injuries.

Clavicle fractures are a common fracture seen in the emergency department. Clavicle fractures are separated into medial, middle, and distal third fractures. Middle third fractures account for approximately 80% of all clavicle fractures. Associated injuries include, but are not limited to, scapula fractures, rib fractures, pneumothorax, brachial plexus injury, and subclavian vessel injury. Treatment depends on specific fracture patterns but often include simple sling immobilization and open reduction internal fixation.

Pecci et al. note that mechanisms that can result in clavicular fracture include a fall directly onto the shoulder, fall on an outstretched arm, or a direct blow to the clavicle. Diagnosis includes a thorough history and physical in addition to radiographic evaluation. Displaced midshaft fractures tend to have increased rates of non-union and subsequent sequelae including pain with and without weakness, paresthesias, and cosmetic defects.

Robinson et al. report that neurovascular injury can occur as a rare complication of acute mid-shaft clavicular fractures. Specifically, they looked at the anatomical relationships of the subclavian vessels and brachial plexus to the clavicle in cadavers. Both the brachial plexus and subclavian artery were noted to be closest to the clavicle at the middle third region of the clavicle (mean distances within 25 mm). This should be taken into consideration when evaluating a patient with a middle third clavicle fracture and when using an anterior plate for fixation of these fractures.

Figure A demonstrates a minimally-displaced right-sided mid-shaft clavicular fracture. Illustration A demonstrates the deforming forces on a midshaft clavicle fracture. Illustration B depicts the post-operative plate fixation of a mid shaft clavicle fracture.

Incorrect Answers:
Answers 1-3, 5: Although important to investigate the injury to these structures, a mid-shaft clavicle fracture specifically puts the brachial plexus and subclavian artery at risk because of their close anatomic relationship. An injury to the median nerve, radial nerve, radial artery, and brachial artery would be distal to the zone of injury involved in a clavicle fracture. Although the supraclavicular nerve may be injured during a clavicle fracture, it is of less importance because of its function to supply superficial skin sensation over the clavicle.