Ortho Dx: Shoulder Pain Following a Tractor Accident

Slideshow

  • Figure 1. Anteroposterior radiograph of the left clavicle.

  • Figure 2. Radiograph of the left clavicle following fixation with a Steinman pin.

A 79-year-old man presents with pain in his left shoulder after he fell 2 days ago. He lost his balance while stepping off of his tractor and landed directly on the left shoulder. Physical examination reveals ecchymosis and pain to palpation over the lateral clavicle. Anteroposterior radiograph of the left clavicle (Figure) shows a distal clavicle fracture with significant displacement.

Clavicle fractures generally are sustained following impact directly on the shoulder with the majority occurring in the middle third segment of the bone.1,2 Lateral clavicle fractures are more common in older patients with osteoporosis.2 Identifying lateral clavicle fractures is critical...

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Clavicle fractures generally are sustained following impact directly on the shoulder with the majority occurring in the middle third segment of the bone.1,2 Lateral clavicle fractures are more common in older patients with osteoporosis.2 Identifying lateral clavicle fractures is critical as these fractures are usually more unstable than midshaft fractures.

The coracoclavicular (CC) ligaments (trapezoid and conaid ligaments) are the primary stabilizers of the clavicle against superior migration. Fracture location in relation to the CC ligaments helps predict stability and guides treatment.1,2

The patient in this case appears to have sustained a fracture just medial to the CC ligaments as evidenced by the superior migration of the clavicle. This fracture pattern is the most unstable type of lateral clavicle fracture and is prone to nonunion.1

Unstable fractures should be treated surgically. There are several techniques available including transacromial wire fixation, open reduction and internal fixation with locking plates, intramedullary fixation, percutaneous pin fixation, tension band wiring, and excision of the lateral clavicle fragment.1-3

This patient was treated with a closed reduction and percutaneous fixation with a Steinman pin (Figure 2).  

Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor in chief of the Journal of Orthopedics for Physician Assistants.

References

1. Ahn L, Sheth U. Midshaft clavicle fractures. OrthoBullets. Updated October 28, 2020. Accessed November 12, 2020.

2. Sambandam B, Gupta R, Kumar S, Maini L. Fracture of distal end clavicle: a review. J Clin Orthop Trauma. 2014;5(2):65-73.

3. Image quiz: lateral clavicle fractures. J Bone Joint Surg J Orthop Physician Assist. 2017;5(1):e2.

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