A 16-year-old boy is brought to the emergency department due to left shoulder and hand pain after he fell on his outstretched hand while playing soccer. He immediately heard a crunching sound and had intense pain in the left shoulder following the injury. Blood pressure is 105/72 mm Hg and pulse is 85/min. On examination, he is holding his left arm with his right hand. There is bruising around the left shoulder and a small hematoma is noted at the base of the neck. Neurologic examination reveals intact sensation in the left upper extremity. The right radial pulse is easily palpable, and the left radial pulse is slightly decreased. X-ray of the left shoulder and chest reveals a displaced fracture of the clavicle with a normal cardiac silhouette. Which of the following is the best next step in management of this patient?

Question

A 16-year-old boy is brought to the emergency department due to left shoulder and hand pain after he fell on his outstretched hand while playing soccer.  He immediately heard a crunching sound and had intense pain in the left shoulder following the injury.  Blood pressure is 105/72 mm Hg and pulse is 85/min.  On examination, he is holding his left arm with his right hand.  There is bruising around the left shoulder and a small hematoma is noted at the base of the neck.  Neurologic examination reveals intact sensation in the left upper extremity.  The right radial pulse is easily palpable, and the left radial pulse is slightly decreased.  X-ray of the left shoulder and chest reveals a displaced fracture of the clavicle with a normal cardiac silhouette.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d859_722e_bc81_8bf106c91c10_MD0003_00 Clavicle fracture is a common sports-related injury and can occur following a blow or fall on the shoulder or outstretched arm. The vast majority are uncomplicated and carry a favorable prognosis. However, the middle third of the clavicle overlies the brachial plexus and the subclavian artery and vein in the thoracic outlet. Therefore, clavicular fractures require a careful neurovascular assessment. thoracic outlet The presence of "hard signs" (eg, absent distal pulses, bruit at injury site) following a fracture indicate definite arterial injury and require immediate surgical intervention. However, the presence of a stable hematoma (as in this patient), reduced pulse, documented hemorrhage at the time of injury, unexplained hypotension, or an associated neurologic deficit also suggest an arterial injury may have occurred. These "soft signs" require vascular imaging to confirm and localize the site of injury. CT angiography is the diagnostic modality of choice due to its high sensitivity and specificity and rapid procedure time. (Choices A and D) Uncomplicated fractures of the middle third of the clavicle, which account for most clavicular fractures, are treated nonoperatively with rest, ice, and either a sling or figure of eight bandage. Fractures of the distal third of the clavicle may require open reduction and internal fixation to prevent nonunion. However, this patient has signs of vascular injury, and additional assessment must be performed first. figure of eight bandage (Choice C) A clavicle fracture may rarely injure the brachial plexus. Features suggesting neurologic injury include numbness, paresthesia, and upper extremity weakness. Clinical examination is usually adequate to rule out significant brachial plexus injury in the acute phase. If a chronic thoracic outlet syndrome develops, nerve conduction studies could be considered later. (Choice E) Upper extremity venous duplex imaging is indicated for venous thrombosis or obstruction; signs of venous obstruction include upper extremity edema or cyanosis. This patient's acute hematoma is more consistent with an arterial injury. Although arterial duplex doppler can be used to evaluate arterial injury, it is time consuming and less sensitive than CT angiography. Educational objective: Clavicle fracture can injure the underlying brachial plexus and subclavian artery. Hard signs of arterial injury (eg, absent pulses, distal ischemia) require immediate surgical intervention. Soft signs of vascular injury (eg, unexplained hypotension, stable hematoma, reduced pulse) warrant CT angiography for further evaluation. References: For the patient-evolution in the management of vascular trauma. (http://www.ncbi.nlm.nih.gov/pubmed/28863083)

A 16-Year-Old Boy Is Brought to the Emergency Department Due