segmental clavicle fracture with acromioclavicular joint disruption: report of a rare case

Clavicle fractures are common, which accounts for 2.6% of all adult fractures, but the segmental clavicle fracture is an uncommon pattern, with one study showing 0.8% of clavicle fractures to be segmental. We present a rare case of segmental clavicle fracture (middle 1/3 rd and lateral end) with acromioclavicular joint (AC-joint) disruption. A lateral clavicular plate was applied fixing both fractures and K-wire for AC-joint disruption. The K-wire was removed after 6 weeks. The patient was followed up at 6 months and one year and outcome was assessed functionally by Oxford Shoulder Score (OSS) and radiologically. The patient had an excellent functional outcome with OSS of 48/48 and full range of motion without instability of AC-joint and good union radiologically. We report good outcome of segmental clavicle fracture with AC-joint disruption treated surgically and discuss relevant literature.

introduction Clavicle fractures are common which accounts for 2.6% of all fractures in adults and 10% to 15% in children [1]. They are commonest in young males often resulting from sports injury or road traffic accidents. The most common mechanism of injury is a direct force to the clavicle or a fall onto the outstretched arm [2,3]. Mid-shaft clavicular fractures are the most common, ranging from 69% and 82%, distal fractures comprise 21% to 28%, and proximal fractures occur between 2% and 3% [4]. We could not find case of segmental clavicle fracture with acromioclavicular joint (AC-joint) disruption in English-literature. It was treated with lateral clavicular plate fixing both fractures and K-wire for AC-joint disruption. Rare case reports have been published of AC-joint dislocations with ipsilateral mid-shaft clavicle fractures, including a series of four cases with a range of management and good outcomes [5][6][7][8]. We found one case report of a segmental clavicle fracture with sternoclavicular joint disruption [9].We were unable to find any cases reported in the literature with the fracture pattern in this case.

case report
A 35-year-old patient presented to emergency department with pain in right shoulder following fall from motorcycle. On examination swelling was present over right clavicle area with tenderness over middle and lateral 1/3 rd clavicle including AC-joint.
Bony discontinuity was present with palpable ACjoint deformity.
There was no open wound and no distal neuro vascular deficits. Radiograph ( Figure 1) showed unusual presentation of segmental clavicle fracture which includes middle 1/3 rd and lateral end clavicle fracture with AC-joint disruption. As it is obvious AC-joint dislocation on radiograph we didn't took opposite shoulder radiograph or same shoulder MRI. He was operated the next day after injury under general anesthesia. Open reduction and internal fixation was done with lateral clavicular plate fixing both fractures and K-wire for AC-joint disruption ( Figure 2). AC-joint was stable with single k-wire fixation. K-wire was left outside the skin and was removed after 3 weeks. Physical therapy for shoulder movement with active exercises was started. Bony union was achieved by 12 weeks (Figure 3) and the patient had pain-free full range of movements of shoulder joint (Figure 4). At 12 months after his initial surgery, the patient had an excellent outcome with an Oxford Shoulder Score of 48/48 and with a full clinical range of movement without instability of the AC-joint. He has no restrictions in his work or hobbies, even returning to motorcycle riding.

Discussion
Segmental fractures of clavicle are rare. The segmental clavicle fracture is an uncommon pattern, with one study showing 0.8% of clavicle fractures to be segmental [10]. Although the majority of clavicle fractures are managed non-operatively, specific indications exist for operative intervention [11]. Segmental long bone fractures are considered unstable injuries with the risk of nonunion and nonoperative approach being considered unacceptable [12]. The clavicle forms an important structure which connects upper limb to the axial skeleton and it is important for the normal functioning of the upper limb. Non-union of the clavicle fracture would result in considerable functional disability. With little literature regarding segmental clavicle injuries, no consensus exists about the management of these fractures with some case reports advocating a nonoperative [9,13] while others an operative approach [12,14].
Osman et al. [15] treated a similar case of fracture of the diaphysis and lateral third of the clavicle, which was associated with ipsilateral rib fractures and consequent pneumothorax. The patient underwent plate osteosynthesis with subsequent removal of the plates since one of the screws caused an impact in the coracoid process, and also due to the risk of fracture between the plates. There are no rib fractures in our case.  Miller et al. [16] presented a report of fracture of the medial and lateral extremity of the clavicle with the use of a reconstruction plate and another with locking T-plate. Our case had middle and lateral clavicle fracture treated with single plate. Karimi et al. [17] had a segmental clavicle fracture with rib fracture treated with plating. There is no rib fracture in our case.
conclusion Whenever patients present with clavicle fracture, he/she had to screen for segmental fracture. Often this type of fractures may be missed. So detailed clinical and radiological examination has to be done. Segmental fractures have to be operated to reduce the risk of non-union, pseudo-arthrosis.

Conflicts of interest
Authors declare no conflicts of interest.