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Isolated fractures of the clavicle are among the commonest of traumatic fractures and usually, with appropriate treatment, will heal uneventfully. The clinician must be mindful that injuries to underlying vital structures, though rare, are a potentially serious complication. We report a case of an isolated fractured shaft of the clavicle complicated by a significant pneumothorax necessitating the insertion of a chest drain. Such a complication has been noted only rarely in the literature.1
The importance of early recognition of this potential complication by proper physical examination and by close inspection of an upright film that demarcated the ipsilateral upper lung field, cannot be over emphasised.2
A 17 year old man had direct trauma by a fist to the right shoulder during an assault. He had pain in the right shoulder and on inspiration. Swelling and tenderness around the clavicle was noted. Breath sounds and percussion notes were normal on both sides. There was no evidence of direct injury of the chest wall. The patient was haemodynamically stable and neurovascaular examination was normal. Roentgenograms showed a displaced fracture of the right clavicle, the apical pneumothorax being overlooked on these films.
The patient continued to complain of pain on inspiration. A chest radiograph revealed a 30% pneumothorax on the same side as the claviclar fracture. There was no evidence of fractured ribs on initial or subsequent chest films. The pneumothorax was treated by the insertion of a chest drain under local anaesthesia. The chest drain was removed five days after the injury and the patient was discharged home with the right arm rested in a sling. Two months after the accident, the clavicular fracture had united and the chest radiograph was normal.
The clavicle is one of the most commonly fractured bones, accounting for up to 4% of all fractures. These fractures are comparatively easy to manage and typically heal with routine immobilisation. Anatomically, the apex of the lung lies behind and above the medial one third of the clavicle, with the anterior scalene muscle, brachial plexus, and subclavian vessel interferences. However, the incidence of complications associated with isolated clavicle fractures, including vascular, brachial plexus, and penumothorax, are low.3
Most clavicular fractures result from a fall on an ipsilateral shoulder. Other mechanisms of injury include direct blows and falls on an ipsilateral outstretched hand. It is interesting to note that three of five reported cases in the literatures of pneumothorax complicating clavicular fractures were caused by direct injury of low velocity.4,5
Careful history and physical examination with particular attention to the neurovascular and chest examination are vital.3 Close inspection of the radiographs for such a potential complication are mandatory in all clavicular fractures and cannot be overstated.
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