Abstract
Objective: To outline conservative chiropractic treatment and rehabilitation of a midshaft clavicle fracture in a male snowboarder.
Background: While attempting to "shred" into a turn, the athlete landed on the outer tip of his shoulder. A sideline evaluation diagnosis of clavicle fracture was determined secondary to reported crepitus and mechanism of injury. Post-injury radiographs revealed a midshaft clavicle fracture. Past medical history included a prior fracture to the same clavicle two years earlier.
Diagnosis: Closed, nondisplaced midshaft clavicle fracture.
Treatment: Surgical referral and nonsurgical options were discussed. Conservative chiropractic management was offered. More aggressive treatment procedures and rehabilitation protocols for clavicle fractures have evolved in recent years. With the sport's medicine advancements, athletes are able to return to play much more quickly without compromising their health and safety.1
Background Discussion
Snowboarding 101: Snowboarding is as an alpine sport that combines skills of downhill skiing and surfing. Two stances are typically practiced while snowboarding: Traditionally, snowboarders use their left foot as the forward foot and face the right side of their board, called regular-footed. An alternative stance is right foot forward or "goofy footed." For example, if a rider takes a traditional stance with the left foot forward, they will be more likely to injure the right upper extremity.2 Generally, the opposite edge of where the snowboarder's weight is concentrated will cause a fall in the opposite preferred direction of stance. Icy conditions often lead to the mechanism of injury.
Fractures of the Clavicle: Clavicular fractures represent 2.6 percent to 5 percent of all fractures, with middle-third fractures accounting for 69 percent to 82 percent of such fractures. The junction of the outer and middle third is the thinnest part of the bone, and the only area not protected by or reinforced with muscle and ligamentous attachments. These anatomic features make it prone to fracture, particularly from a fall on the point of the shoulder, which results in an axial load to the clavicle.
Optimal treatment of nondisplaced or minimally displaced midshaft fracture is with a sling or "figure-of-8" dressing; the nonunion rate is very low.3 Most middle-third fractures occur medial to the coracoclavicular ligament, at the junction of the middle and outer thirds of the clavicle. The proximal fragment is typically displaced upward because of the pull of the sternocleidomastoid muscle. The usual mechanism of injury involves a direct force applied to the lateral aspect of the shoulder as a result of a fall, sporting injury or motor-vehicle accident.
Anatomically, the acromioclavicular and coracoclavicular ligaments attach the clavicle to the scapula laterally. The sternoclavicular and costoclavicular ligaments anchor the clavicle medially. The sternocleidomastoid and the subclavius muscles also have points of attachment to the clavicle.
While the overwhelming majority of clavicle fractures are benign, associated life-threatening intrathoracic injuries are possible. This is true because the clavicle also protects the adjacent brachial plexus, lung and blood vessels. Complications vary based on location of fracture. The diligent chiropractor will consistently re-evaluate the athlete following the initial injury and diagnosis.
Office Examination
Shoulder pain on upper extremity movement was reported. The affected extremity was held close to the body, adducted against the chest wall, supported by the other extremity. Inferior and anterior displacement of the shoulder was observed secondary to loss of support. There was site tenderness, crepitus and edema. No ecchymosis was observed. (It should be noted that the patient had extensive forearm and upper body musculature development.)
The chest was examined and no decreased breath sounds were detected on auscultation that could indicate a possible pneumothorax. There were no decreased pulses or evidence of decreased perfusion on vascular examination suggestive of vascular compromise. The patient was without diminished sensation or weakness on distal neurovascular examination, suggesting an absence of any neurologic compromise. Routine clavicle radiography was obtained and a fracture was demonstrated on an anteroposterior (AP) view.
On-the-Field Examination
Identify and treat associated life-threatening injuries first and foremost. Initiate ATLS (call 911 for advanced trauma life support rescuers to stabilize the athlete). Perform a careful secondary survey. Apply a cold pack to the injury. Immobilize the upper extremity with a sling.
Management Options
Some orthopedists recommend an immobilization technique for midclavicular fractures; this is the clavicle (figure-of-eight) splint. The splint is applied after closed reduction of the fracture, which is accomplished by the patient pulling the shoulders up and back. Such reductions are difficult to maintain and may be associated with increased discomfort at the fracture site. The advantage of the figure-of-eight harness is that it gives patients the ability to use both hands. Unilateral strapping and taping may be utilized.
Healing may occur as rapidly as in 4-6 weeks. Immobilization should remain until repeat radiographs show callus formation and healing across the fracture site. Vigorous competitive play should be avoided until the bone healing is solid. If displacement of the fracture is detected, then operative treatment of displaced midshaft clavicle fractures may result in improved functional outcome and a lower rate of malunion and nonunion compared with nonoperative management.4
A good rule of thumb to follow with regard to medical referral is as follows: Midclavicular fractures that have more than 2 cm of initial shortening benefit from early orthopedic referral because these have been associated with a higher incidence of nonunion. Displaced medial-third fractures require orthopedic referral for reduction. Open fractures necessitate immediate consultation. Medial clavicle fractures may be associated with intrathoracic injuries.
Chiropractic providers can manage uncomplicated clavicle fractures. Complications have been associated with injuries to the neurovascular bundle and the pleural lung dome, requiring the athlete be rechecked systematically for any change in condition. Brachial plexus compression resulting from hypertrophic callus formation may occur (may cause peripheral neuropathy) and thus requires monitoring.
Early motion with passive shoulder range-of-motion exercises is strongly urged to reduce the risk of adhesive capsulitis. Fracture management includes ice, analgesics and a sling for support. This level of care is not outside the scope or education of a chiropractic primary care provider.
References
- Rabe SB, Oliver GD. Clavicular fracture in a collegiate football player: a case report of rapid return to play. J Athl Train, 2011 Jan-Feb;46(1):107-11.
- Hyde TE, Gengenbach MS. Conservative Management of Sports Injuries. Jones & Bartlett, 2007:977.
- Jeray KJ. Acute midshaft clavicular fracture. Am Acad Orthop Surg, 2007 Apr;15(4):239-48.
- McKey MD. Clavicle fractures in 2010: sling/swathe or open reduction and internal fixation? Orthop Clin North Am, 2010 Apr;41(2):225-31.
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