Presentation
Intoxicated and fell on her back, very tender over the sternoclaviclular joint and mild SOB ?pneumothorax ? sterno clavicular joint disruption.
Patient Data
Displaced bony fragments projected over the left upper zone, and irregularity of the inferior border of the left clavicle medially, appearances in keeping with displaced fracture of the inferior aspect of the medial left clavicle, likely involvement and displacement of the medial end of the left clavicle, hence likely disruption of the left sternoclavicular joint.
The left scapula appears intact.
Normal alignment of left glenohumeral and acromioclavicular joints.
Multiple old left-sided rib fractures.
Orthopedic metalwork in right proximal humerus.
No gross collapse or consolidation. No pneumothorax.
Annotated Lt frontal shoulder radiograph
Annotated left frontal shoulder radiograph highlighting the bony fragment and the medial clavicle which is the donor fracture fragment site (note that the cortex is not distinct at the left medial clavicle, and compare with the partially imaged right medial clavicle which does have a discernible cortex suggest that the right medial clavicle is intact).
Comminuted fracture of the medial end of the left clavicle. Slight widening of the sternoclavicular joint but no gross dislocation. The fracture lines involve the articular surface. Overall appearance and position of the fracture unchanged since the previous imaging.
Moderate surrounding hematoma.
Normal acromioclavicular and glenohumeral joint.
Old left-sided rib fractures. No scapular fracture.
Pulmonary emphysema.
No focal pulmonary lesion or other incidental findings.
Case Discussion
Medial clavicle fractures can be difficult to discern on plain radiography, in this case symmetry was helpful in determining that this was a medial clavicle fracture. The clinical team initially thought that this was a scapula fracture, especially given that the patient reported falling backwards, and did not report falling on to her front, however the other views obtained at the time did not demonstrate scapular injury.
Subsequent CT confirms that this is indeed a medial clavicle fracture.
Conservative management is currently being pursued, the orthopedic team feel union can be achieved with non-operative management; the fracture configuration would make operative fixation very challenging.