A 16-year-old boy was playing soccer and fell on his outstretched hand. He felt a crunch sound and intense pain in his left shoulder area. He then presented to the ER with complaints of pain in his left shoulder and hand. On exam he was holding his left arm with his right hand. There was a bruise around the clavicle area and a palpable gap was felt in the middle of the clavicle. Auscultation revealed a loud bruit just beneath the clavicle. X-ray revealed that the middle of the clavicle was fractured and displaced. The next step in his management is:
A. CT chest for pneumothorax
B. Nerve conduction studies
C. Angiogram
D. Open reduction of clavicle
E. Closed reduction with figure of eight brace
Explanation:
This boy presents with a fracture of his clavicle and had both left shoulder and hand pain. A bruit is heard and one has to rule out arterial injury with a clavicle fracture. Clavicle fractures, which are displaced, can injure the subclavian artery. On examination, one may find diminished radial pulse but an angiogram is necessary to rule out an injury to the vessel.
Choice A: The patient already has a chest x-ray and one can always look for a pneumothorax. Pneumothorax can occur with a clavicle fracture and easily identified with a chest x-ray.
Choice B: Clavicle injuries are also notorious for injuring the brachial plexus. Usually the patient will complain of pain in his arm, hand and shoulder. Brachial plexus injury can be ruled out with nerve conduction studies.
Choice D: Distal third clavicle injuries are usually unstable and may require open reduction and internal fixation. Cosmetically the results are not good but the results are acceptable.
Choice E: The treatment of clavicle injuries depends on where the clavicle is fractured. Proximal and middle third clavicle injuries can be treated with closed reduction with figure of eight brace or sling for one-to-two weeks. Early range of motion and strengthening are recommended.
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