Case history
Case history #1
A 20-year-old male ice hockey player presents to the urgent care clinic with acute right shoulder pain after being pushed into the boards during an ice hockey game 2 hours earlier. He was unable to continue playing due to the pain, but could remain on the bench and watch the rest of the game. During that time, his trainer applied ice to the injured area and a sling. The patient reports pain localized to the mid part of his collarbone, which gets worse with attempted range of motion at the shoulder or when he tries to lift something with his right arm. He also reports a sensation of grating at the painful area during range of motion of the shoulder. He has taken high-dose ibuprofen approximately 1 hour ago but still reports his pain is about 8 on a 0-10 scale. His vital signs are stable. Physical exam reveals moderate soft tissue swelling at and around the mid-right clavicle, and point tenderness at this location along with bony crepitus. A palpable bony step-off is noted at this location. No skin tenting or wound is present. Range of motion is moderately globally limited at the right shoulder due to pain but rotator cuff strength testing is intact. The glenohumeral, sternoclavicular, and acromioclavicular joints are nontender and stable. The scapula, ribcage, and spine are nontender. He is neurovascularly intact, his lungs are clear, and his cardiovascular exam is unremarkable.
Case history #2
A 75-year-old woman was walking to the restroom during the night and sustained a ground-level fall onto her outstretched right arm and felt a painful snap at her right clavicle. She had severe pain at the clavicle and difficulty moving the right arm, so her husband drove her to the emergency department at the local hospital. Physical exam is notable for a tender step-off at the mid clavicle. X-rays in the emergency department reveal a minimally displaced fracture of the mid-third of the right clavicle. The patient is treated with analgesics and ice. She is discharged with a sling and advised to follow up with her orthopedist in 3-5 days.
Other presentations
Although midshaft clavicle fracture is the most common type of clavicle fracture, lateral and medial clavicle fractures do occur, with lateral fractures being much more common (12% to 26%) than medial fractures (2% to 6%).[5] Pain and tenderness are usually localized to the area of the fracture. There does not appear to be a significantly different mechanism for these injuries compared with midshaft fractures. Consider stress fractures of the clavicle (as well as of the upper ribs) in overhead athletes (e.g., baseball pitchers) with signs and symptoms of a clavicle fracture but no history of acute trauma. Suspect pathologic or insufficiency fractures in patients with underlying osteoporosis, malignancy, and/or no known explanation for the fracture.
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