CASE

On one of the last nights of my orthopedic rotation of intern year, I saw a 92-year-old lady who had fallen down two stairs at home. When she arrived, she complained of pain in her right hand and wrist. X-rays of her right wrist, forearm, and elbow revealed that she broke both bones in her forearm, which we quickly reduced and splinted. Initially, she did not complain of any pain elsewhere but a few hours later, a bruise started to develop over her right shoulder. Dedicated clavicle x-rays showed a non-displaced fracture of the right clavicle. The orthopedic resident shrugged. “Put her in a sling”.

I knew this was the protocol for most clavicle fractures, but I was still curious. What if it had been displaced? Would that have changed anything? How did he know it would heal properly? And after about 5000 years of orthopedic surgical history, didn’t we have anything better than a sling?

DISCUSSION

The clavicle is one of the most commonly broken bones in the human body, accounting for about 3% of all fractures despite representing only about 0.5% of the bones in the body [1]. The clavicle is a long bone, but it is uniquely curvy and fragile. Evolutionarily, this gives us an advantage: the clavicle absorbs force from a fall on an outstretched hand or shoulder, preventing us from breaking more vital bones, like our skull or our vertebrae [2].

Of course, humans have been breaking bones for all of human history, but when did we start fixing them? Ancient Egypt had specialized doctors as early as 5000 years ago, and we have archaeological evidence of orthopedic practices in mummified bodies, ancient papyrus scrolls, and wall paintings of procedures that are not so dissimilar from today’s. The wall painting here is believed to show an ancient Egyptian using the Kocher method to relocate a dislocated shoulder.

One of the oldest known medical documents is known as the Edwin Smith surgical papyrus, which is believed to date to the 30th century BC. It was translated from cursive hieroglyphic to English in 1930 by Professor J. Breasted and describes the treatment of 48 different injuries. An example of one of the cases is shown below:

The cases are numbered head-to-toe and unfortunately, the document was left abruptly unfinished, as though its author was interrupted [4]. There are no documented cases involving the pelvic area or the lower extremities, but there are a few very interesting cases pointing to the development of orthopedic surgical procedures, particularly of the clavicle and upper extremity.

Case 34 describes a sterno-clavicular dislocation, which is treated with reduction and binding with stiff linen: “If thou examinest a man having a dislocation in his two collar-bones, shouldst thou find his two shoulders turned over, (and) the head(s) of his two collar-bones turned toward his face … Thou shouldst cause (them) to fall back, so that they rest in their places. Thou shouldst bind it with stiff rolls of linen; thou shouldst treat it afterward [with] grease (and) honey every day, until he recovers.” [5]

The next case is a clavicular fracture, which is treated with reduction and splinting: “Thou shouldst place him prostrate on his back, with something folded between his two shoulder-blades; thou shouldst spread out with his two shoulders in order to stretch apart his collar-bone until that break falls into its place. Thou shouldst make for him two splints of linen, (and) thou shouldst apply one of them both on the inside of his upper arm and the other on the underside of his upper arm. Thou shouldst bind it with ymrw, (and) treat it afterward with honey every day, until he recovers” (5).

The language is a little old-fashioned, of course, and we use Ortho-Glass or plaster instead of honey now. However, for clavicle fractures, we haven’t moved far beyond that same splinting technique. We categorize clavicular fractures into three groups using the Allman classification: group I (midshaft of the bone), group II (distal third), and group III (medial/proximal third). Midshaft fractures account for approximately 75-80% of all clavicle fractures and typically occur in younger people who have been victims of trauma [6].

Midshaft clavicular fractures can be treated non-operatively or with surgical fixation depending on several factors. If the fracture is nondisplaced, conservative management is almost always preferred. The figure-of-eight bandage was once a common treatment for clavicular fractures, as shown below:

According to the AAFP, a simple sling is now preferred over the figure-of-eight, as several studies show outcomes are similar and patient comfort is much higher in a simple sling [6].

Even in displaced midshaft fractures, surgery isn’t always the answer but if the clavicle is more than 15-20 mm short, if the fracture is comminuted, extremely displaced, or if there are other factors that put the patient at risk of nonunion, surgical fixation may be appropriate [6].

For Allman group II, or distal third clavicle fractures, the coracoclavicular ligaments often mean the fracture does not tend to displace. Even when they do displace, studies show that patient outcomes in terms of function, strength, and pain are the same regardless of operative intervention [7,8]. Therefore, most distal clavicular fractures are treated conservatively, as well.

Proximal clavicular fractures are the rarest and the most dangerous. If they are nondisplaced, they too can be treated with a simple sling. If they are displaced, of course, they should be carefully evaluated for signs of neurovascular compromise, or even airway compromise, as large hematomas can press onto nearby vital structures [5]. In this case, we can refer to Case 34, the sterno-clavicular dislocation approximately 3000 years ago, and “Thou shouldst cause (them) to fall back, so that they rest in their places” [5], then bind them with a stiff roll of linen (a sling) and treat it afterwards with grease and honey (ok, maybe skip that part) until he recovers.

Author: Dr. Allison Barshay is a current second year emergency medicine resident at Brown Emergency Medicine Residency.

Faculty Reviewer: Dr. Michelle Myles is a clinician educator at Brown Emergency Medicine Residency.

REFERENCES

1. Postacchini, F., Gumina, S., De Santis, P., & Albo, F. (2002). Epidemiology of clavicle fractures. Journal of shoulder and elbow surgery, 11(5), 452–456. https://doi.org/10.1067/mse.2002.126613.

2. Adams, William. (2018). Why is it so easy to fracture your clavicle? Here’s the surprising evolutionary reason. February 27, 2018. https://www.forbes.com/sites/quora/2018/02/27/why-is-it-so-easy-to-fracture-your-clavicle-heres-the-surprising-evolutionary-reason/?sh=be36f4ff38b4.

3. Said G. Z. (2014). Orthopaedics in the dawn of civilisation, practices in ancient Egypt. International orthopaedics, 38(4), 905–909. https://doi.org/10.1007/s00264-013-2183-z.

4. Blomstedt P. (2014). Orthopedic surgery in ancient Egypt. Acta orthopaedica, 85(6), 670–676. https://doi.org/10.3109/17453674.2014.950468.

5. Breasted JH. University of Chicago Press; Chicago: 1930. The Edwin Smith Surgical Papyrus.

6. Pecci, M., Kreher, J. (2008). Clavicle Fractures. Am Fam Physician, 77(1):65-70. https://www.aafp.org/pubs/afp/issues/2008/0101/p65.html

7. Robinson CM, Cairns DA. (2004). Primary nonoperative treatment of displaced lateral fractures of the clavicle. J Bone Joint Surg Am. 2004;86-A:778-82.

8. Rokito AS, Zuckerman JD, Shaari JM, Eisenberg DP, Cuomo F, Gallagher MA. (2002-2003). A comparison of nonoperative and operative treatment of type II distal clavicle fractures. Bull Hosp Jt Dis. 2002–2003;61:32-9.