Fractures of the upper limb are very common injuries in all age groups. In adults, between the ages of 15-49 years, these injuries are more common in males and are usually due to high-energy mechanisms such as road traffic accidents. Between the ages of 65 and 89 years there is a considerable increase in the incidence of fractures, particularly in females. These are associated with osteoporosis and may follow minor trauma such as a fall from a standing height. Many of these injuries are relatively minor, for example clavicle fractures, which usually require no more than symptomatic treatment. Some injuries,
such as displaced forearm fractures, require internal fixation but the final result is usually good. Some of the injuries, however, particularly complex frac­tures of the proximal humerus, often result in poor results despite aggressive management including primary joint replace­ment.

Anatomy of the clavicle
The clavicle is the bone that connects the trunk of the body to the arm, and it is located directly above the first rib where it is very important part because neurovascular bundle lying behind it. There is a clavicle on each side of the front, upper part of the chest. The clavicle consists of a medial end, shaft, and a lateral end. The medial end connects with the manubrium of the sternum and gives attachments to the fibrous capsule of the sternoclavicular joint, articular disc, and interclavicular ligament. The lateral end connects at the acromion of the scapula which is referred to as the acromioclavicular joint. The clavicle forms a slight S-shaped curve where it curves from the sternal end laterally and anteriorly for near half its length, then forming a posterior curve to the acromion

Types causes and mechanism of injury of fractures clavicle

 Fractures of the clavicle are very common, accounting for 5-10% of all fractures. Males are more commonly affected than females (2.5:1) and, in males, the most common age group is the under 20 years. The fracture is usually due to sporting injuries or road traffic accidents. In females the elderly are commonly affected, often following a simple fall. The fracture may be caused by direct trauma or indirectly such as a fall on the outstretched hand. In the majority of cases fractures are closed injuries.

Most fractures occur in the midshaft of the bone and are often associated with overlap of the fragments. Fractures of the lateral end of the clavicle may result in superior displacement of bone if the coracoclavicular ligaments are involved. Fractures of the medial end of the clavicle are uncommon.
fractures clavicle are often seen in patients with multiple injuries and should be specifically looked for in this situations because they can be easily missed swelling and tenderness are usually found at the fracture site and pain is associated with shoulder motion associated neurovascular injuries can occur but uncommon

Distal-third clavicle fractures
are less common and require more care. They are classified into three types based on the location of the fracture relative to the coracoclavicular ligaments. Type I fractures occur between the coracoclavicular and coracoacromial ligaments. As long as the coracoclavicular ligaments are not disrupted, this type of distal clavicle fracture is stable and is treated with a sling similar to middle-third clavicle fractures. Type II fractures occur medial to the coracoclavicular ligaments. The muscle attachments to the medial fragment pull it superiorly, while the weight of the shoulder girdle and arm pull the distal fragment inferiorly. The amount of displacement may lead to a nonunion. but the management of this type of clavicle fracture is controversial. Those who recommend nonoperative treatment believe that initial operative treatment does not always result in a satisfactory outcome. and even if a nonunion develops, it is usually not symptomatic or can be treated. those who advocate operative treatment believe the management of the symp­tomatic nonunion is so difficult that it is better to treat all of the fractures initially with an anatomic reduction and internal fixation.

Type III fractures involve the articular surface of the acromioclav­icular joint. They are managed non operatively as long as there is not gross displacement. If the patient develops subsequent symp­tomatic acromioclavicular degenerative disease and pain, resection of the distal clavicle treatment

In the vast majority of cases clavicle fractures are treated conser­vatively by arm support with the limb rested in a broad arm sling Mobilisation can be commenced as comfort allows, with a return to full activities within 3-6 weeks. Attempts at reduction, includ­ing bracing back the shoulders with a figure-of-eight bandage, are rarely necessary.medical analgesic to relieve pain as  acetaminophen . Malunion is common but is not usually a func­tional problem. Non-union may occur in up to 5% of fractures and is more common after high-energy mechanisms such as road traf­fic accidents. 

Surgical treatment
Open reduction and plate fixation are occasionally required and may be indicated for open fractures associated neurovascular injuries or fractures of the lateral end of the clavicle with signifi­cant displacement of the fragments. Internal fixation and bone grafting are indicated for symptomatic non-unions.

prognosis of fractures clavicle

 It is depend on many factors such as Healing time varies based on age, health, complexity and location of the break as well as the bone displacement. For adults, a minimum of 2-6 weeks of sling immobilization is normally employed to allow initial bone and soft tissue healing, teenagers require slightly less, children can often achieve the same level in two weeks. During this period, patients may remove the sling to practice passive pendulum Range of Motion (ROM) exercises to reduce atrophy in the elbow and shoulder, but they are minimized to 15-20 degrees off vertical. Depending on the severity of fracture, a person can begin to use the arm if comfortable with movement and no pain results. The final goal is to be able to have full range of motion with no pain; therefore, if any pain exists, it is best to allow for more recovery time. Depending on severity of the fracture, athletes involved in contact sports may need a longer period of rest to heal to avoid re-fracturing bone. A person should be able to return unrestricted to any sports or work by 3 months after the injury


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