Rehabilitation of a conservatively managed clavicular fracture
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
ISSN NO. 2320–7418 DOI: 10.22270/jmpas.V10I4.1245
Case report
Rehabilitation of a conservatively managed clavicular fracture
Komal Mandhane, Om C Wadhokar*, Neha Chitale, Pratik Phansopkar, Sakshi P Arora
Ravi Nair Physiotherapy College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
ABSTRACT
The collarbone, or wishbone, is a thin, S-shaped bone about 6 inches (15 cm) long and serves as a support between the shoulder blade and
the sternum (sternum). Clavicle fracture so occur as a result of injury or trauma. The most common site of fracture is the junction between the two
curvatures of the bone, which is the weakest point. The displacement post fracture is most common in clavicular fracture because the attachment of
the muscle sternocleidomastoid pulls the Sternal head upwards and the pectoral muscle pulls the distal clavicle downwards. After a distal clavicle
fracture, radiographic nonunion has been identified in 10% to 44% of patients. Most of clavicular fractures are managed non-surgically by physical
therapy which consists of a rehabilitation program without hampering the fracture healing, the rehabilitation consists of pain reduction, improving
strength and range of motion of the shoulder, Scapular and neck muscles and postural correction exercises in addition to a brace to support the upper
limb as the clavicle is the bone connecting the Axilla to the shoulder girdle. And the patient is started with medical management which usually
consist of analgesics. 62 year old male patient with left clavicle fracture was diagnosed on x-ray after a hit from a bullock cart. Following this
incident the patient underwent a prompt series of physical rehabilitation which included strengthening exercises, thoracic expansion exercises,
breathing exercises. The case report suggests that a physiotherapy treatment procedure led to the improvement of functional goals progressively
and significantly.
Keywords: Clavicle Fracture, Physiotherapy Rehabilitation, Strength Training
Received - 12/06/2021, Reviewed - 08/07/2021, Revised/ Accepted- 25/07/2021
Correspondence: Pratik Phansopkar* drpratik77@gmail.com
Associate Professor & HOD, Department of Musculoskeletal Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe
Institute of Medical Sciences, Wardha, Maharashtra, India.
INTRODUCTION
malunion [1]. Clavicular fracture represented 2.6% of all fractures and
The collarbone, or wishbone, is a thin, S-shaped bone
44% of those associated with shoulder girdle, the prevalence of
about 6 inches (15 cm) long and serves as a support between the
clavicular fracture reduces as the age advances [2] . The evaluation
shoulder blade and the sternum (sternum). It is one of the most
is started by history, physical examination, and the findings are
common fractures seen in adults and in children. The mid shaft
confirmed by a radiology report, for identifying the type and location
fracture is one of clavicle is the common which may be due to fall on
of fracture. The clavicular fracture are classified by Allman into
Out stretched hand or direct blow on the bone, the mid shaft clavicle
group I (mid shaft), II (lateral), III (medial). Based on this
fracture is usually managed non-surgically but they have high risk of
classification and the type of fracture the management is planned [3].
The usual treatment for clavicular fracture consist of sling or a figure
Journal of medical pharmaceutical and allied sciences, Volume 10 - Issue 4, 1245, July - August 2021, Page – 3175-3178 3175
ISSN NO. 2320–7418 DOI: 10.22270/jmpas.V10I4.1245
of 8 dressing used for several weeks [4] . The risk factors for non- 160/100 mmHg. Chest compression was negative. After consultation
union include initial fracture displacement, comminution, shortening of an orthopedist, X-ray was done and it revealed fracture of the mid-
and older age [5] . Despite the high frequency of the occurrence of the shaft of left clavicle (fig 1). Patient was advised for a nonsurgical
fracture, the choice of proper treatment is still a challenge for the treatment and was forwarded to the physiotherapy department for the
orthopedic surgeon. In most cases, the direct blow occurs from the healing and union of the broken bone. The patient was also given a
lateral side toward the medial side of the bone [6]. The most common figure of eight bandage or sling for the reduction in movements of
site for a fracture is the intersection between two curves of the bone the shoulder during both day and night time.
[7], which is the weakest point. This results in the sternocleidomastoid Figure 1: left mid shaft clavicular fracture
muscle excellently raising the medial aspect, which may lead to a
perforation of the covered skin.
The complications of clavicle fracture include
radiographic and symptomatic malunion and shoulder deformity,
non-union and infections in the bone. Radiographic nonunion after
distal clavicle fracture has been reported in 10% to 44% of patients.
An outstretched arm or direct trauma to the shoulder are the
pathophysiology mechanisms of injury. Pathophysiology: The
middle third section of the clavicle is where 75-80% of all clavicle
fractures occur.
The thinnest portion of the bone is the junction of the outer
and middle thirds, which is the only region not covered or
strengthened by muscle and ligamentous attachments. As a result, it
is vulnerable to fracture, especially in the hands. Conditions that are
related: Related injuries are uncommon, but they may involve a Clinical findings
On observation: Patient was in supine position with both upper
scapular fracture on the ipsilateral side. Dissociation of the scapula
extremities by the side, elbow extended and lower limb externally
and thorax is common. It should be considered when fracture
rotated with knee extended and ankle plantar flexed. Patient was
fragments are substantially displaced or expanded. Fractured ribs can
wearing figure of 8 slings. Swelling on the mid shaft of clavicle.
sometimes also be associated with clavicle fracture. Pneumothorax,
On palpation: grade 3 Tenderness was present over the clavicle
a blood damage to the brain, injury to the head that is closed are other
region.
common conditions that occur after clavicle fracture. Typically,
Tightness: Bilateral mild pectoral tightness as his shoulder was not
patients with clavicle fractures have well-localized pain over the
touching the bed in supine lying.
fracture site. Usually, the affected extremity is kept close to the body.
Range of Motion: left shoulder all Ranges was painful and limited all
When an injury occurs, patients can hear a snapping or cracking
other joint range was full and functional (Table 1).
sound. This case report describes fracture of left clavicle in a 62 year
Table 1: Pre Rehab Range of Motion
old male patient who underwent physical rehabilitation at AVBRH
Joint Movement Left Right
Sawangi (M), Wardha, India. Shoulder Flexion 0-40 0-160
Case Presentation Extension 0-15 0-20
A 62 year old male got hit by a bullock cart on the left Abduction 0-30 0-170
clavicle while working in the farm on January 5, 2021. He was
MMT
brought to the casualty by his relative on bike with complaints of pain Bilateral lower limb strength 5/5.
and swelling on left shoulder. The blood pressure was found to be Right upper limb strength 5/5.
Journal of medical pharmaceutical and allied sciences, Volume 10 - Issue 4, 1245, July - August 2021, Page – 3175-3178 3176ISSN NO. 2320–7418 DOI: 10.22270/jmpas.V10I4.1245
Table 2: Pre Rehab Manual Muscle testing for left Upper limb DISCUSSION
A study was done on long term outcome of initially
Joint Muscle Left
conservatively treated midshaft clavicle fracture. The study showed
Shoulder Flexors 2
Extensors 2 that the patient with >= 100% require operative management because
Abduction 3 of failure of invasive treatment [8]. A Randomized controlled trail was
Elbow Flexors 4 done to compare open reduction and plate fixation versus non operative
Extensors 4
treatment for displaced midshaft clavicular fracture. The results reveal
Wrist Flexors 5
Extensors 5
that open reduction with internal fixation is expensive and associated
with implant related complications, which are absent in non-operative
Table 3: Timeline
Date of trauma 4/1/21 treatment. They conclude that non operative treatment is more feasible
Diagnosed with fracture 5/1/21
choice for treating midshaft clavicular fracture [9]. Michael Catapano
Referred to physical Therapy 6/1/21
performed a systematic analysis on haling, pain, and function after a
Management
Patient education: Education regarding the fracture and midshaft clavicular fracture, which revealed that no studies explicitly
importance of exercise was given to the patient and relative, donning investigate the impact of immobilization and functional recovery on
and doffing of the sling was taught to the patient. No effort will be clinical results in midshaft clavicular fractures [10].
made to minimize the fracture by the orthopedic, who will use a figure- A study was done to find out the effect of plating for
of-eight bandage. The figure-of-eight bandage will be worn for four midshaft clavicular fracture and its impact on quality of life and
weeks, with participants returning every week to check and change the functional outcome. They conclude that operative treatment played a
immobilizations. As a result, the dominant arm will be able to move significant positive role in midshaft clavicular fracture assessed using
[11].
about and basic tasks will be permitted (writing, flexing the shoulder functional outcomes for quality of life A study was done by
and other activities). Non-operative management: Sling Karibasappa A G and Srinath S.R to find out the effectiveness of
immobilization with gentle ROM exercises at 2-4 weeks and surgical versus conservative treatment for managing displaced
strengthening at 6-10 weeks. midshaft clavicular fracture, they concluded that the group which
Pain management: This is done by using hot fermentation for 10 received open reduction internal fixation with osteosynthesis showed
minutes, twice a day. Further management is in Table 4. ROM good results as compared to the other group which received non-
Comparison Pre and post rehab in Table 5. Strength Comparison pre surgical treatment. We find out that conservative treatment along with
and post treatment is in table 6. physical therapy rehabilitation such as statics exercises, pendular
Table 4: Physiotherapy Management exercise, wand exercises were useful in improving the Range of
Intervention Dosage Rationale
Statics Shoulder 10 reps 5 sec hold To maintain contractility
Motion of the joint. Pain was managed by application of cold
of the muscle. fermentation directly over the surgical site, and posture correction
Strengthening Exercises All ROM Exercises with To prevent muscle
for Other limbs(8). half kg weight 10 wasting. exercise were taught such as scapular sets to prevent shoulder
repetition for each
movement.
protraction, scapular muscle strengthening was taught as it is important
ROM Exercises 10 Repetition of each To maintain complete for glenohumeral joint. A figure of 8 bandage was given to the patient
movement Range
Breathing Exercises Deep breathing followed To maintain lung to prevent mal-union and development of faulty posture. Figure of
by 2 sec hold and then compliance and avoid
eight bandage is the one where bandage turns cross each other like
exhalation secretion formation
Stretching Stretching for 30sec 3 To maintain ROM number 8. It provides fixation to the joint and maintain stability.
reps(9)
CONCLUSION
We conclude that non-operative treatment along with
Table 5: Pre and Post Treatment ROM Comparison
Joint Movement Pre Rehab Post Rehab physical therapy showed better results in non-operatively managed
Shoulder Flexion 0-40* 0-80* clavicular fracture. Planning and intervention resulted into improving
Extension 0-15* 0-18*
the functional goals progressively. Pain reduction, Range of Motion
Abduction 0-30* 0-45*
improvement, improving strength of shoulder musculature and
Table 6: Pre and post treatment strength comparison scapular muscles, postural correction exercise, and use od figure of 8
Joint Muscle Group Pre Post
brace ameliorated the disabilities and showed progress in the patient’s
Shoulder Flexors 2 4
Extensors 2 4 condition.
Abductors 3 4
Journal of medical pharmaceutical and allied sciences, Volume 10 - Issue 4, 1245, July - August 2021, Page – 3175-3178 3177ISSN NO. 2320–7418 DOI: 10.22270/jmpas.V10I4.1245
Informed consent
Patient was informed about the study and informed consent was taken
from the patient
Competing interests
The authors declare that they have no conflict of interest.
Authors' contributions
All Author’s contribute equally.
Acknowledgement
All author made best contribution for the concept, assessment and
evaluation, data acquisition and analysis and interpretation of the data.
REFERENCES
1. Franco P, Stefan G, Pierfrancesco DS, 2002. "Epidemiology of
clavicle fractures". J Shoulder Elbow Surg. 11(5), 452–6.
2. Toogood P, Horst P, Samagh S, Feeley BT, 2011. "Clavicle
fractures: a review of the literature and update on treatment". Phys
Sportsmed. 39(3), 142–50.
3. Shapira S, Givon U, Pritsch M, 2011. "Middle third clavicle
fractures--diagnosis, complications and treatment". Harefuah.
150(9):725–8, 750.
4. Denard PJ, Koval KJ, Cantu RV, Weinstein JN, 2005.
"Management of midshaft clavicle fractures in adults". Am J
Orthop Belle Mead NJ. 34(11), 527–36.
5. Wane M, Naqvi WM, Vaidya L, Kumar K, 2021. "Kinesiophobia
in a Patient With Postoperative Midshaft Fracture: A Case Report
of Its Impact on Rehabilitation in a 16-Year-Old Girl". Cureus. 12
(11), 19470. PMC7719470.
6. Jawade S, Naidu N, Vardharajulu GG, 2020. "Efficacy of strength
training program on muscle performance by determining 1
repetition maximum in adults". Eur J Mol Clin Med. 7(2), 1946–
54.
7. Zade R, Deshmukh M, 2019. "A Comparative Study Based On
Two Stretching Protocol for Piriformis Tightness: A Research
Protocol". J Crit Rev. 6(6), 911–4.
8. Lee GB, Kim H, Jeon I-H, Koh KH, 2021. "Long-term outcomes
of initially conservatively treated midshaft clavicle fractures".
Clin Shoulder Elb. 24(1), 9–14.
9. Robinson CM, Goudie EB, Murray IR, Jenkins PJ, Ahktar MA,
Read EO, et al., 2013. "Open Reduction and Plate Fixation Versus
Nonoperative Treatment for Displaced Midshaft Clavicular
Fractures: A Multicenter, Randomized, Controlled Trial". JBJS.
95(17), 1576–1584.
10. Catapano M, Hoppe D, Henry P, Nam D, Robinson LR,
Wasserstein D, 2019. "Healing, Pain and Function after Midshaft
Clavicular Fractures: A Systematic Review of Treatment with
Immobilization and Rehabilitation". PM&R. 11(4), 401–8.
11. van der Linde RA, Beetz I, van Helden SH, 2017. "Plating for
midshaft clavicular fractures: The impact on quality of life and
functional outcome". Injury. 48(12), 2778–83.
How to cite this article
Komal M, Om W, Neha C, Pratik P, Sakshi A, 2021.
“Rehabilitation of a Conservatively Managed Clavicular
Fracture- A Case Report”. Jour. of Med. P’ceutical &Allied.
Sci. V 10 - I 4, 1245 P-3175-3178. doi:
10.22270/jmpas.V10I4.1245
Journal of medical pharmaceutical and allied sciences, Volume 10 - Issue 4, 1245, July - August 2021, Page – 3175-3178 3178You can also read
