History and Physical Examination
The assessment of patients with ipsilateral fractures of the clavicle and scapular neck includes not only evaluation of the injury but also, more important, evaluation of the whole patient. An emergency physician and, often, a trauma surgeon (depending on the associated injuries) are usually the first to see these patients.
As with most scapular fractures, ipsilateral fractures of the clavicle and scapular neck have a high incidence of associated injuries, which may result in underdiagnosis as attention is drawn to more life-threatening injuries. [12, 13]
In series in which associated injuries specifically are reported, the incidence ranges from 40% to 96%. [12, 14] In one series, five of 36 patients died from their associated injuries, and four of 36 had severe head trauma that precluded shoulder rehabilitation for more than 3 months. [15]
Closed head injuries and pulmonary injuries (eg, pneumothorax, multiple rib fractures, hemothorax) each constitute approximately one third of associated injuries. Cervical spine injuries and long bone fractures each constitute another 10-20%. Other reported injuries include brachial plexus and subclavian artery injury, liver lacerations, and other forms of intra-abdominal injury secondary to blunt trauma.
Specific clinical findings in the involved upper extremity can vary with the severity of the trauma and the presence and severity of associated injuries. However, some findings are common. Pain is much greater than that observed with isolated upper-extremity fractures, not only because of the additional fracture but also because of the resulting displacement and secondary muscle spasm.
Traction neuritis of the brachial plexus also can increase the pain. The patient's limb usually hangs lower than the limb on the uninjured side. Some of this effect is attributable to the inferior displacement of the distal fracture fragments, and some is secondary to postural changes assumed by the patient to increase comfort. The scapula usually appears to be protracted as part of the postural changes. A loss of the normal concavity at the anterior aspect of the shoulder is likely to occur as the distal glenoid fragment and humeral head are displaced anteriorly.
Routine complete history and physical examination of the patient are followed by appropriate laboratory and radiographic studies (see Workup).
