The emergency medicine management of clavicle fractures

A systematic review and meta-analysis on the diagnostic utility of ultrasound for clavicle fractures

BACKGROUND

Ultrasound's real-time, high-resolution imaging, and accessibility at the point of care make it a valuable tool for diagnosing clavicle fractures, with growing evidence supporting its diagnostic accuracy compared to other imaging modalities.

OBJECTIVE

To assess the diagnostic utility of ultrasound in detecting clavicle fractures.

METHODS

A systematic review and meta-analysis were conducted by performing a comprehensive literature search in PubMed, Scopus, Web of Science, and Embase databases up to March 10, 2023, following established guidelines. Eligible studies that reported outcomes of interest were included, relevant data elements were extracted, and data analysis was performed using STATA software version 17.0.

RESULTS

Meta-analysis of seven included studies showed high-pooled sensitivity (0.94) and specificity (0.98) values for ultrasonography in diagnosing clavicle fractures, with low to moderate heterogeneity for sensitivity and high heterogeneity for specificity. Meta-regression and subgroup analyses revealed that pediatric studies had higher sensitivity but significantly lower specificity (P=0.01) compared to mixed or adult studies. Additional subgroup analysis in the pediatric group indicated decreased heterogeneity for specificity. Fagan plot analysis demonstrated favorable post-test probabilities for both positive and negative results across varying pre-test probabilities. Additionally, the likelihood ratio scatter matrix showed moderate to high test performance for both exclusion and confirmation purposes.

CONCLUSION

The current literature supports ultrasound as a reliable imaging modality for detecting clavicle fractures. It offers accurate diagnosis without exposing patients, especially children, to radiation.

A novel surgical method for treating fractures of the middle third of the clavicle

BACKGROUND

The clavicle is recognized as the bone most vulnerable to fractures. Moreover, approximately 80% of fractures occur in the middle third of the clavicle. Conservative treatment is associated with a higher rate of nonunion, while surgical treatment of fracture via internal fixation may have a variety of postoperative complications. Therefore, to improve patient satisfaction and reduce the complications related to internal fixation techniques, we modified the surgical approach to external fixation.

OBJECTIVE

The purpose of this study was to assess the modified intervention's prospects for clinical application.

METHODS

A total of 36 patients with middle clavicle fractures were treated with screw-rod external fixation between April 2015 and October 2019. We observed the operative time, intraoperative blood loss, length of hospital stay, and fracture healing time. The patients were followed up regularly, and the clinical efficacy of the modified intervention was evaluated. Finally, the patients' shoulder function was assessed based on the disabilities of the arm, shoulder, and hand (DASH) score.

RESULTS

For the screw-rod external fixation, the mean operative time was found to be 48.6 ± 6.8 min, the intraoperative blood loss was 30.6 ± 17.2 mL, the length of hospital stay was 4.5 ± 1.5 days, and the fracture healing time was 2.8 ± 0.4 months. Eventually, all the patients healed well, with the combined "excellent" and "good" rate of shoulder function being assessed to be as high as 94.44%. Furthermore, the DASH scores were all less than 10, with the average score being 4.65 ± 3.34.

CONCLUSIONS

The screw-rod external fixation technique offers the advantages of convenience, reliability, and good aesthetics, suggesting that it could be used as an alternative treatment method for fractures of the middle third of the clavicle.

Clavipectoral plane block performed in the emergency department for analgesia after clavicular fractures

Clavicle fractures are common injuries in the Emergency Department (ED). Adequate pain control with oral or intravenous medications is the central aspect of treatment. The ultrasound-guided clavipectoral plane block (CPB), previously described in anesthesia literature, offers complete analgesia of the clavicle with a low adverse effect profile. In this case series, we describe the first reported utilization of the CPB for analgesia for acute clavicular fractures in the ED. We performed the CPB for distal and midshaft clavicular fractures on patients who suffered from a variety of traumatic accidents including bicycle accidents, motorcycle accidents, and motor vehicle accidents. All patients experienced significant reductions in their reported pain without any reported complications. Given the need to provide patients with appropriate pain control in the ED, the CPB offers an effective, simple method for providing analgesia without known significant risks, including without the risks associated with high-dose systemic analgesia.

Pseudoaneurysm of the subclavian artery as a delayed complication of a clavicle fracture

Vascular complications are relatively rare following surgical fixation of midshaft clavicle fractures. Here, we report a case of a woman in her 30s presenting 10 years after right clavicular open reduction and internal fixation with revision 6 years prior with sudden and rapidly progressive neck swelling. Physical examination revealed a soft pulsating mass in her right supraclavicular fossa. Ultrasound and CT angiography of the head and neck showed a pseudoaneurysm of her right subclavian artery with a surrounding haematoma. She was admitted to the vascular surgery team for endovascular repair with stenting. Postoperatively, she developed arterial thrombi requiring thrombectomy (twice) and is now on lifelong anticoagulation. It is crucial to be aware of complications that can develop in patients with a history of clavicular fracture managed non-operatively or operatively even years later and highlights the importance of risk and benefit discussions and counselling.

The human clavicle's nutrient foramen's prevalence, number, location, and direction: A systematic review and meta-analysis

INTRODUCTION

The clavicle's nutrient foramen is a surrogate marker for its nutrient artery. Knowing its location may be useful for interpreting fractures and to avoid iatrogenic lesions. The aim of this review was to determine the prevalence, number, location, and direction of the nutrient foramen.

METHODS

Embase, Medline, PubMed, Scopus, and Web of Science were searched and supplemented by Google Scholar, hand-searching major anatomical journals, and the reference list of included studies (updated March 08, 2022). Titles and abstracts were screened for eligibility, and observational studies with quantitative data were included based on full text evaluation. Internal validity was assessed using the anatomical quality assessment tool. Pooled prevalence proportions were derived using a random effects DerSimonian-Laird model using the Freeman-Tukey double arcsine transformation with Miller's inverse back-transformation.

RESULTS

From 18,889 unique reports, 33 studies with 3760 clavicles and 3358 foramina were included. All studies suffered from untransparent reporting. The prevalence of the nutrient foramen was 97.75%, 95% confidence interval 94.70%-99.60%. It was mainly found as a single foramen on the middle third segment's posterior surface with acromial (lateral) obliquity. Results were stable over time, robust to sensitivity analyses, albeit limited by unexplained heterogeneity and asymmetry.

CONCLUSION

This review may aid in interpreting fractures passing through a high-risk area (mean foraminal index range 36.31-61.03%) for lesions to the nutrient artery. Practical implications are a need to update current inaccurate textbook descriptions and further advocate evidence-based anatomy to improve conduct and reporting of anatomical research.