Abstract
Introduction: Pathological fracture of the clavicle is not such a rare condition. By definition the fracture occurs either without or with minimal trauma. We present a case of pathological fracture where there was a definite history of trauma; clouding the true malignant diagnosis.
Case Report: A 73 year old man first presented to the Accident & Emergency Dept. of our hospital with a history of having fallen on to his left shoulder after throwing a piece of concrete, and to have developed swelling and pain around the shoulder immediately following the fall. On examination the main findings were swelling and bony tenderness over the proximal clavicle and inability to use his left shoulder due to pain. X-ray showed a fracture at the junction between the proximal 1/3 and distal 2/3 of the left clavicle, and he was given a broad arm sling for support and a one week appointment for review in the fracture clinic.
Two clinic appointments later he was still complaining of pain. X-rays taken at that time showed what appeared to be some evidence of callus formation at the fracture site. Six weeks later he had clinical and radiological signs of what appeared to be “huge callus formation”. He was given a 3 month appointment for what was expected to be a final review.
Before his next fracture clinic appointment, however, he became jaundiced and complained about this to his GP who felt it was obstructive jaundice and referred him to the physicians who admitted him to the hospital, and began to investigate him as to the cause of the jaundice. These investigations included an Ultrasound Scan of the abdomen which showed a bulky head of pancreas with biliary and pancreatic ductal dilatation; and a CT scan of the upper abdomen which showed the presence of a cystic mass within the caudate lobe of the liver. Soft tissue vascular encasement around the portal vein and hepatic artery were reported as in keeping with malignant infiltration. Extensive tumour was present within the retroperitoneum involving local vascular structures.
He came down to the fracture clinic for his next clinic appointment from the ward. At this point he was very ill, deeply jaundiced and frail. The swelling of the clavicle was the size of a large orange, firm to touch with dilated veins. X-ray at this point showed complete radiological destruction of the medial 1/3 of the left clavicle. At this point palliative care was the mainstay of his management.
A week later the chest x-ray report came back as showing collapse of the left upper lobe with whiteout appearance and bulky hilum indicating an underlying bronchogenic carcinoma.
Three days later, almost 5 months after initial presentation following a fall, this patient finally succumbed to his disease.
Conclusion: This patient presented with a simple fracture and was given the standard treatment for the condition. However because his treatment was compartmentalized, i.e., orthopaedics treating the orthopaedic condition, radiology doing x-rays, and physicians managing the jaundice; it took some months before the different pieces of the jig-saw puzzle were put together and the malignant diagnosis arrived at.
Correspondence should be addressed to BOOS at the Royal College of Surgeons, 35 - 43 Lincoln’s Inn Fields, London WC2A 3PN
