David A. Cairns, and David J. Ross
Department of Orthopaedic Surgery, Stirling Royal Infirmary, Livilands, Stirling, FK8 2AU, UK
Midshaft clavicle fractures account for approximately 70% of all adult clavicle fractures. They commonly occur as a result of a fall on to an outstretched hand during sporting activity. Complications of these common injuries include malunion, non-union and occasionally neurovascular injury.[4.] Serious complications are extremely rare. We report the case of a patient presenting with a potentially life threatening complication of a midshaft clavicle fracture.
A 37-year-old right hand dominant man attended our department after a fall from his mountain bike. He complained of pain only in the left shoulder and a midshaft clavicle fracture with minimal displacement was confirmed on the initial radiograph (Fig. 1). A collar and cuff were provided for immobilisation and a review appointment organised for the next fracture clinic.
Figure 1. Clavicle fracture at presentation.
On return to the clinic 1 week later he complained of shortness of breath on exertion and was noted to have a pronounced deformity of the clavicle. A chest radiograph confirmed an apical pneumothorax with inferior displacement of the distal fracture segment (Fig. 2). Review of the original radiograph taken 1 week earlier showed no evidence of pneumothorax.
Figure 2. Clavicle fracture after 1 week with apical pneumothorax.
The patient was admitted to hospital for a short period of observation and as his symptoms settled was discharged home 1 day later without the need for an intercostal drain. He was subsequently reviewed in the clinic for serial chest radiographs which after 3 weeks showed complete resolution of the pneumothorax. 16 weeks post-injury he remained symptom free with a clinically and radiologically united fracture.
Pneumothorax complicating a clavicle fracture has previously only been reported in the literature four times.[1., 2., 3. and 5.] In each of these cases the Pneumothorax was apparent at initial presentation and required insertion of an intercostal drain. Our patient was initially asymptomatic with no evidence of rib fracture, and we assume that the pneumothorax developed secondary to inferior displacement of the distal fracture segment into pleura. Midshaft clavicle fractures must not be regarded as trivial injuries. The patient and all radiographs must be thoroughly examined both initially and at early outpatient follow up. A formal chest radiograph should always be requested if a pneumothorax is suspected, particularly when significant displacement of the fracture fragments has occurred.
Injury Extra. Volume 35. 7-8. July-August 2004, Pages 61-63