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Distal clavicle fractures

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Instructions for authors
One or two sentences that describes the injury. Try to say something beyond the obvious. An apt comment might be “Geriatric hip fractures are low energy injuries typically associated with osteoporosis, and a (perhaps shockingly high) one year mortality rate of 20% or more” or “Tears of the anterior cruciate ligament of the knee are often sustained while playing sports and often require surgical intervention to give the patient sufficient anterior tibial stability to return to high levels of play”)

Structure and function

Instructions for authors
Please include a brief review of the relevant anatomy, enough to make clear what is disturbed by the injury and why such a disturbance is clinically important. It is possible that there may not be much to say (a femoral shaft fracture is clinically important for obvious reasons) but even in such cases there probably is something to say (eg the femur is the largest bone in the body and therefore associated blood loss can be significant, or that because of its size the amount of intravascular debris and accompanying risk of fat embolism is higher)


Instructions for authors
Who gets this? How rare is it? What is the disease burden in various populations of interest?
The goal here is not to inundate with facts (who cares that back pain causes $6,476,400,000 in lost work productivity) but to give a general sense of importance (lost time from work is very costly!). Is this rare or common? If it is rare, what is its impact nonetheless?

Clinical presentation

Instructions for authors
Here include mechanism of injury and how the patient presents. Describe how this injury is sustained, especially the points that may be relevant to differential diagnosis, treatment, outcome etc. Examples: Geriatric hip fractures are from falls – so maybe a syncope work up is needed; Geriatric hip fractures patients may have altered mental state from dehydration and pain and may “perk up” when these are addressed. Or, ACL tears are from twisting injuries, so the meniscus may be damaged then too. There may be a lot of pain from bleeding into the knee or from a bone bruise (the former gets better with aspiration, the latter will resolve over time. We don’t fix ACLs because of pain)

Red flags

Instructions for authors
Make special note, please, of “don’t miss this!” things that deserve particular mental attention or prompt referral to a specialist . This section is, in a way, a subsection of “clinical presentation” but should be listed distinctly.

Differential diagnosis

Instructions for authors
For many injuries, the question is not ‘do you have it?’ (for the x-rays show it) but rather ‘what else do you have?’ So this section is really a review of the associated injuries, but also take the opportunity here to briefly discuss how “your’ condition is unique.

Objective evidence

Instructions for authors
Don’t assume that the correct x-rays are always obtained. So first, describe what films are needed (the view, the extent, etc: 3 views of the shoulder (why?), getting a ‘joint above and joint below’ on the picture, etc) Next describe for what one should scrutinize the films-what exactly are we looking for? Example: for ankle fractures, the status of the syndesmosis is key; for tibial plateau fractures, depression is important; for clavicular fractures, the location relative to the CC ligaments is important.
Then discuss need for supplemental imaging (CT, MRI, etc) with some parameters, ie, who needs one, and what question does this test answer?
Are any other tests needed? Metabolic work up? (distal radius fractures) Blood tests of any sort (hemoglobin after femur fracture?)

Risk factors and prevention

Instructions for authors
List here risk factors for this injury.
Example: geriatric hip fracture = Propensity for falling (eg due to alcoholism or neuromuscular disease) What can be done to prevent this? Is this cost effective? Does it work?

Treatment options

Instructions for authors
Note the treatment options. Offhand, injuries can be treated with benign neglect; casual immobilization; rigorous immobilization; functional rehabilitation; surgical repair; surgical replacement; or some combination.
For each treatment, describe the rationale/method for each treatment, and whether it is evidence based.


Instructions for authors
This should list the expected outcomes of treatment if all goes well; the possible complications of treatment; the presentation of untreated disease; and the long term consequences of the injury.

Holistic medicine

Instructions for authors
Nutritional factors, psychosocial impact of disease and economic effects.


Instructions for authors
In this section include everything a professor can mumble, without necessarily having evidence to support the assertions:

  • Random factoids to help students remember important stuff. E.g.: Why are sailors called “limey”? Sailors at sea where prone to scurvy from Vit C deficiency (imagine the toothless deck hand). Once that was known, they were issued limes to eat - to help the collagen cross link
  • Clinical pearls
  • Favorite facts for exam writers. it would be great if you can compose a question or two for students to ponder
  • Frontier of science - what is coming down the pike from our basic science friends
  • What we don’t know

Key terms

Instructions for authors
For learning and indexing purposes, suggest the key terms associated with this condition.


Instructions for authors
Students, according to the Association of American Medical Colleges, must acquire the necessary “knowledge, skills and attitudes” to practice medicine. Obviously, a book concentrates on “knowledge”. Attitudes are perhaps more nebulous and taught implicitly. Skills, on the other hand, can be taught----but perhaps not in a book. Therefore, please list here the skills related to the knowledge presented above for which students must seek bedside instruction.
This section should also prove useful to for those who want to map this text to a competency based curriculum.


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