![]() This can result in a considerable time lag between the first presentation of the clavicular fracture and recognition that it is in fact pathological. Therefore clavicular fractures are not routinely investigated for an underlying pathological condition. These fractures are not routinely suspected to be pathological, unless associated with obvious clinical or radiological features of an underlying disease. However, clavicular fractures are common in all age groups and occur due to various types of injury and variable-energy trauma. Clinicians are alert to suspecting a pathological fracture in unusual circumstances of injury in bones such as vertebrae and long bones of the limbs. The patient in this case was treated for a primary non-pathological fracture of the clavicle and the proper diagnosis was made four months after the patient's initial presentation. This case report demonstrates the difficulty in diagnosing a pathological fracture of the clavicle. Failure to recognise and appropriately treat a pathological fracture and the associated underlying condition can be detrimental to the patient's life or the affected limb. A pathological fracture occurs in a bone that is not normal. The medial clavicle is the most frequent site of pathological fractures in the clavicle. In their study, 37 patients presented with a pathological fracture and an additional 34 patients experienced a pathological fracture in the course of the disease. ![]() Swanson et al found that the symptoms secondary to bone metastases were the presenting complaint that subsequently led to a diagnosis of renal cell carcinoma in 121 of 252 (48%) patients. Clavicular metastases comprise 6–18% of all bone metastases from renal cell carcinoma. Up to a third of patients with renal cell carcinoma develop bone metastases, most of which are lytic and predominantly affect the axial skeleton. Renal cell carcinoma accounts for 2% of all malignancies. Acute medial clavicular fractures are commonly caused by high-energy trauma and are associated with other multisystem injuries. All clavicular fractures are more common in men, and in Robin's case series of 1000 clavicular fractures the male to female ratio for medial clavicular fracture was 3.7:1. Postacchini et al found that the incidence of medial clavicular fractures increases in the elderly, comprising 2% of clavicular fractures in 18–30 years age group and 10% of clavicular fractures in 61–80 years age groups. ![]() Medial clavicular fractures are the least common of clavicular fractures, comprising between 2% to 10% of all clavicular fractures. A further two-phase technetium-99m-methylene diphosphonate (Tc99M MDP) bone scan confirmed only two bone metastases (figure (figure3), 3), and an open biopsy of the clavicle revealed a metastatic renal cell carcinoma. The bone metastases were to the left clavicle and the right ilium. A computed tomography (CT) scan of the thorax, abdomen and pelvis revealed a right renal tumour with metastases to the lungs, liver and bone. This was considered malignant and urgently investigated further. On examination there was a large, mildly tender bony lump at the fracture site, and a repeat radiograph of the left shoulder revealed a large lytic lesion over the medial aspect of the clavicle (figure (figure2). She gave a past medical history of hypertension, a left mastectomy for breast cancer eight years ago, and admitted to smoking for many years. In the clinic she was systemically well with no concerning symptoms other than an enlarging swelling at the fracture site. Four months later the patient was referred by the GP to the orthopaedic clinic with an enlarging lump over the fracture site. The patient failed to attend the follow-up appointment and was discharged from the clinic because of non-attendance. One week later, the patient was reviewed in the fracture clinic by an orthopaedic registrar who attributed the pain, swelling and the fracture of the clavicle to the mechanism of injury and advised follow-up in one month's time. The radiograph demonstrates a medial clavicular fracture (arrow) that was later diagnosed as pathological. Plain radiograph of the left shoulder at the first presentation.
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