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Case 2 - Clavicular Fracture

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So this was a case of a patient who presented to the ED

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with trauma, and while we were able to identify initially the minimal right

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sided fracture with the small hematoma, there was another finding that we

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actually did not identify, and so here, it was really just the history

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of the patient coming back and saying they also had left clavicular pain.

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And so we went back to look at this image again,

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we looked at the left clavicle, there wasn't anything that we could see

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really definitively, recognizing that some of this may have been angulation

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and we might be missing something, and there was definitely tenderness there,

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we said, "Please get a dedicated clavicle, and let's see what we can

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find," since there was such a concern. And so I'll share that with

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you, really to make the point that if you're getting feedback from the

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clinical service around what's happening, there are some dedicated views

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that you can actually do. And this was really a surprising case because

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we recognize that really the dedicated views made all the difference,

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and this was not really a find that we were able to see

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or even recreate on the plain film of the chest itself,

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but with focused views and the angulation, you can actually see that there

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is a bulbous nature of the distal aspect of the clavicle,

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with a little bit of readiness around the AC joint. And initially I

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was like, "Well, this looks really quite chronic, there may have been an

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old fracture forming there." But then when they angled, made the patient

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more lordotic, you can see the break in the cortex which looks much

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more acute in the fracture fragment, it's actually sitting there. And while

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the changes in the AC joint were likely chronic, and they do look

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like they're ongoing, the distal clavicle here, the fracture, which is minimally

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displaced and has a fracture fragment here so it's really technically comminuted,

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is actually real. This is not something that you appreciated on even the

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AP view without it being angled and we couldn't see it on

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the radiograph. So again, problem solving tool, dedicated views

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can make the difference, and they're oftentimes something that you can suggest

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if you're given information that doesn't quite line up. This patient has

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really bad point tenderness in the left clavicle, but we're not seeing anything

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on the radiograph, which is a really good screening tool, the next step

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is to do some in depth investigative work, which in this case with

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a dedicated clavicle view, we were able to make the additional finding of

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an acute minimally displaced comminuted distal left clavicular fracture.

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Incidentally, this person also had degenerative changes of the AC joint.

Report

Faculty

Jamlik-Omari Johnson, MD, FASER

Chair, Department of Radiology

University of Southern California

Tags

X-Ray (Plain Films)

Trauma

Emergency

Chest

Bone & Soft Tissues

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