CASE REPORT

SEGMENTAL CLAVICLE FRACTURE

Evander Azevedo Grossi1

ABSTRACT multiple trauma. The case of a patient with a fracture of the

diaphysis and lateral extremity of the clavicle is described:
The aim here was to present an unusual case of segmen- the patient was treated surgically and an excellent result was
tal clavicle fracture associated with ipsilateral rib fracture. achieved. Similar cases in the literature are reviewed and their
Although the management is discussed.
clavicle is very superficial, undetected cases of both types
of fracture may occur, because these patients usually suffer Keywords - Clavicle; Fractures Fixation; Orthopedic Surgery

INTRODUCTION CASE REPORT

Among clavicle fractures, 69% occur in the dia- Male patient, age 41, who fell from a roof and
physis, 28% in the lateral extremity and 3% in the was treated for vomiting, left otorrhagia, cranioence-
medial portion(1). Meanwhile, segmental fractures phalic trauma, nosebleed, segmental fracture of the
are very rare, with few articles described in English left clavicle and fracture of the third left posterior
literature. Clavicle fractures usually have a very easy rib. He required treatment in an intensive care unit,
diagnosis as their anatomical position is very su- and after clinical and neurological improvement was
perficial, and their consolidation is achieved even released to the orthopedic department. He did not
without treatment in most cases. But in spite of this present neurovascular deficit in the shoulder girdle
characteristic, many complications can occur, inclu- due to the clavicle fractures, or pneumothorax due to
ding ipsilateral rib fracture(2). They occur less often the rib fracture, but evolved with left anacusis. Clini-
cally, there was gross deformity in the middle third
after direct trauma, and this has been the mechanism
of the clavicle (Figure 1), the only site about which
described in segmental fractures in which there is
the patient complained; and, radiologically, there was
generally multiple trauma in the clavicle(3).
deviation of the lateral extremity and greater than 2
In segmental fractures, the fractured segment su- cm of the diaphyseal fracture (Figures 2A and 2B).
ffers the action of muscular forces and may evolve The fractures were classified in group I (diaphysis),
with blood supply failure, for which reason fixation and the lateral fracture in group II, as Craig type II B
should be performed early(3,4). fractures (Figure 3). Radiographs were taken in two
Allman(5), in 1967, was the first to classify frac- views in plain neutral AP and with 45° cephalic tilt
tures dividing the clavicle anatomically into three to classify and decide on the treatment.
segments. Other modifications were made, and fi- Osteosynthesis of the diaphyseal fracture was exe-
nally with more details, by Craig(6) in 1991. cuted after clinical clearance using a reconstruction
The purpose of this study is to present a rare plate molded above the clavicle and two Kirschner
fracture of the clavicle not yet published in indexed wires crossed at the distal extremity (Figure 3). The
Brazilian literature. wires were removed after seven weeks and the patient

1 – Orthopedist and Traumatologist of Fundação São Francisco Xavier/Hospital Márcio Cunha – Ipatinga, MG.
Study conducted at Fundação São Francisco Xavier/Hospital Márcio Cunha – Ipatinga, MG.
Mailing address: Av. Itália, 2.556, Bairro Cariru – 35160 115 – Ipatinga, MG. Emails: [email protected] and [email protected]
Study received for publication: 3/15/2011, accepted for publication: 6/16/2011

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This article is available online in Portuguese and English at the websites: www.rbo.org.br and www.scielo.br/rbort

© 2011 Sociedade Brasileira de Ortopedia e Traumatologia. Open access under CC BY-NC-ND license. Rev Bras Ortop. 2011;46(6):733-35
734

was referred to physiotherapy. After 14 weeks, he DISCUSSION

returned with the fractures consolidated (Figures 4A Osman et al(2) treated a similar case of fracture of
and 4B), asymptomatic, and with mobility preserved. the diaphysis and lateral third of the clavicle, which
The plate was removed after seven months due to was associated with ipsilateral rib fractures and con-
protrusion and discomfort. sequent pneumothorax. The patient underwent plate

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Rev Bras Ortop. 2011;46(6):733-35

SEGMENTAL CLAVICLE FRACTURE
735

osteosynthesis with subsequent removal of the plates

since one of the screws caused an impact in the cora-
coid process, and also due to the risk of fracture be-
tween the plates. Our patient’s second-rib fracture did
not cause pneumopathy.
Miller et al(7) presented a report of fracture of the
medial and lateral extremity of the clavicle with the
use of a reconstruction plate and another with locking
T-plate, and Karimi et al(8) had a case similar to ours
that was also treated by the same method; both au-
thors emphasized that due to the rarity of the case,
there is no routine surgical technique described for
the treatment of this type of fracture.
Osteosynthesis of diaphyseal clavicle fractures Figure 5 – 'LJLWDOUDGLRJUDSK\VKRZLQJFRQVROLGDWLRQRIIUDFWXUHV
with locked plates is an excellent treatment option, DIWHUVHYHQPRQWKV
and some authors(2,4) have treated segmental fractures
similar to this one using this method. But in our case, shape of the clavicle prevents the same nail from fi-
such an implant is not available for use in patients of xing the two fractures with rigidity.
the public health network. Since many conventional radiographic examina-
We agree with the indication of osteosynthesis in
tions carried out to diagnose clavicle fracture have
this type of fracture due to the risk of pseudarthrosis,
good visualization in the diaphysis and to a lesser
according to Heywood and Clasper(4), who treated
segmental clavicle fracture with a superior plate and degree in the lateral extremity, we noticed, during
use of the hook plate, but the latter is seldom used in the treatment, that it was necessary to take separate
our circles. radiographs of these segments to monitor fracture
The choice of plates as diaphyseal clavicle fracture consolidation; yet with digital radiography, it was
synthesis material is more common, and their ante- possible to analyze both fractures in just one view
rior placement is more aesthetic, while the superior (Figure 5).
placement has the advantage of greater rigidity(9,10),
yet they increase the risks of neurovascular lesion CONCLUSION
and prominence of the plate, a fact that was observed
in our patient. The intramedullary method has also Segmental clavicle fractures are rare, but need a
been used in diaphyseal fractures, through threaded, good radiological examination of the whole bone in
smooth wires, locked mobile nails and cannulated more than one view for diagnosis and treatment, whe-
screws; but in the case of segmental fracture, the “S” reas surgical indication ensures a satisfactory result.

REFERENCES
1. Robinson CM. Fractures of the clavicle in the adult. Epidemiology and clas- 5. Allman FL Jr. Fractures and ligamentous injuries of the clavicle and its articula-
sification. J Bone Joint Surg Br. 1998;80(3):476-84. tion. J Bone Joint Surg Am. 1967;49(4):774-84.
2. Osman N, Sinopidis C, Gibson L Unusual segmental fracture of clavicle as- 6. Craig EV. Fractures of the clavicle. In: Rockwood CA Jr, Matsen FA 3rd, editors.
sociated with rib fractures and pneumothorax. J Orthop Surg. 2010;15(2). The shoulder. Philadelphia: Saunders; 1990. p. 367-412.
Disponível em: http://www.ispub.com/journal/the_internet_journal_of_orthope- 7. Miller D, Smith K, Mc Clelland D. Bipolar segmental clavicle fracture. Eur J
dic_surgery/volume_15_number_2_2/article/unusual-segmental-fracture-of-the- Orthop Traumatol. 2009;19:337-9.
clavicle-associated-with-rib-fractures-and-pneumothorax.html 8. Karimi A, Ettehad H, Akbar MH. Segmental fracture of the clavicle (a very rare
3. Singh B, Singh S, Saraf N, Farooque K, Sharma V. Unusual Mechanism of case in trauma surgery) Shiraz E-Medical J. 2007;8(2):90-5.
Injury with Segmental Fracture Clavicle. J Orthop Surg. 2007;6(1). Disponível 9. Iannotti MR, Crosby LA, Stafford P, Grayson G, Goulet R. Effects of plate
em: http://www.ispub.com/journal/the_internet_journal_of_orthopedic_surgery/ location and selection on the stability of midshaft clavicle osteotomies: a bio-
volume_15_number_2_2/article/unusual-segmental-fracture-of-the-clavicle- mechanical study. J Shoulder Elbow Surg. 2002;11(5):457-62.
associated-with-rib-fractures-and-pneumothorax.html
10. Celestre P, Roberston C, Mahar A, Oka R, Meunier M, Schwartz A. Biome-
4. Heywood R, Clasper J. An unusual case of segmental clavicle fracture. J R chanical evaluation of clavicle fracture plating techniques: does a locking plate
Army Med Corps. 2005;151(2):93-4. provide improved stability? J Orthop Trauma. 2008;22(4):241-7.

Rev Bras Ortop. 2011;46(6):733-35