Abstract
Case Report
A right-hand-dominant male in his 40s presented to the ski clinic shortly after falling on his left shoulder while skiing. He was brought to the clinic by ski patrol because he was not able to ski. He was unable to move his left arm because of pain in the anterior aspect of his left shoulder. He had no past history of left shoulder injuries. On physical examination, he had a deformity of the left shoulder (Figure 1). Sensation was intact in his left upper extremity on evaluation for potential axillary nerve and brachial plexus injuries. He had normal radial and ulnar pulses. What is the most likely diagnosis?
Photographs of the left shoulder on arrival showing skin redundancy (arrowheads) and skin tenting (open arrows).
Diagnosis
Skin entrapment as a result of a comminuted clavicle fracture.
Management and Case Resolution
The deformity was consistent with skin tenting and skin entrapment (Figure 1). Plain radiography demonstrated a comminuted and displaced midshaft left clavicle fracture (Figure 2). The initial attempt at releasing the entrapped skin was unsuccessful because of pain. The ski clinic physician (MK) used a hematoma block with 2 mL of lidocaine 1% without epinephrine and 2 mL of bupivacaine 0.25%. He then manually released the entrapped skin by applying opposing forces on either side of the deformity. The skin deformity and tenting resolved (Figure 3). The patient’s pain improved significantly. His left arm was placed in a sling for comfort, and he was discharged in stable condition. The patient underwent surgical fixation of his left clavicle in his hometown a few days later.
Left clavicle x-rays; anteroposterior (A) and cephalad (B) views demonstrating a comminuted and displaced midshaft clavicle fracture.
Photograph (A) and anteroposterior x-ray view (B) of the left shoulder after release of the skin entrapment.
Discussion
Clavicle fractures are among the most common fractures. They are typically caused by a fall on an outstretched hand or by direct impact on the shoulder. 1 The most common anatomic location is the midshaft. 1 These fractures are often comminuted and displaced, which, although rarely, can result in neurovascular complications.1–5 In such cases, vascular compromise may occur, potentially leading to skin necrosis. 6 Skin abnormalities such as tenting, dimpling, and puckering are uncommon in upper extremity fractures and dislocations.6–11 Skin tenting refers to the elevation of the skin over a fracture site, typically caused by underlying displaced bone fragments projecting toward the dermal surface, creating a tentlike appearance. Urgent surgical intervention is mandatory for skin tenting to prevent skin necrosis.1,3,6 Skin entrapment refers to the condition in which the skin becomes pinched or compressed, typically between displaced fracture fragments or by surgical instruments. Cases of skin puckering, dimpling, and entrapment have not been previously reported in association with midshaft clavicle fractures. Skin entrapment, if present, can cause vascular compromise and must be managed promptly. If manual skin release fails, timely transport to a facility with surgical capabilities is critical.
Conclusion
We present a case of a comminuted midshaft clavicle fracture with skin tenting and entrapment. We successfully released the skin entrapment manually and restored normal vascular supply. In cases of skin entrapment due to clavicle fractures, particularly in wilderness settings, immediate skin release should be attempted to preserve the skin tissue.
Footnotes
Author Contribution(s)
Patient Consent
The patient signed a consent form permitting use of his images and medical care for educational and publication purposes.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
