0:00

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

0:03

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

0:09

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

0:13

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

0:17

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

0:21

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

0:24

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

0:27

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

0:31

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

0:35

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

0:40

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

0:43

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

0:48

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

0:51

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

0:55

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

0:57

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

1:00

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

1:04

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

1:09

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

1:13

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

1:17

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

1:20

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

1:24

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

1:27

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

1:30

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

1:34

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

1:39

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

1:44

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

1:48

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

1:52

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

1:57

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

2:02

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

2:05

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

2:09

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

2:13

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

2:17

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

2:21

an acute minimally displaced comminuted distal left clavicular fracture.

2:28

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