Clavicle fracture - emergency management

Related Summaries
Acromioclavicular separation - emergency management
Anterior shoulder dislocation - emergency management
Inferior shoulder dislocation (luxatio erecta) - emergency management
Posterior shoulder dislocation - emergency management

General Information
Description

Fracture to the clavicular bone

Anatomy

Clavicle
o S-shaped bone that articulates with the sternum medially and the acromion
process of the scapula laterally
Stabilizers of the sternoclavicular joint: anterior and posterior joint
capsule
Stabilizers of the acromioclavicular joint: coracoclavicular and the
acromioclavicular ligaments
o Serves as a strut to maintain proper alignment of the shoulder girdle
o Has muscle insertion sites for the sternocleidomastoid, subclavius, and
trapezius, sternohyoid, pectoralis major, and deltoid muscles

Etiology

Most common mechanism of injury: fall directly on shoulder(1)

Can also occur with fall onto an outstretched arm or motor vehicle collision
PEDIATRIC TIP: may occur in birth trauma in infants

Epidemiology

Accounts for 4%-10% of all adult fractures(2)

Most commonly fractured in children(1)
Incidence of clavicle fractures(1, 2)
o Medial third fractures: rare < 2%
o Middle third fractures: 72%-80%
o Lateral third fractures: 25%-30%
 Bimodal distribution occurring in patients < 40 years old and > 70 years old (2)

History and Physical

History

Determine mechanism of injury

Classically patients complain of shoulder pain which worsens with passive
and active movement

Physical

Common findings include focal swelling, deformity, and tenderness over the
clavicle
Assess for the presence of skin tenting overlying the fracture site, because
they may cause skin necrosis and progress to an open fracture
Perform a careful distal neurovascular exam
Look for any wounds and lacerations, which may indicate an open fracture

Diagnostic Studies
Imaging tests

Obtain x-ray views of the shoulder (anteroposterior [AP], scapular Y view) and
clavicle view (AP and 20-degree cephalic tilt)
o Fractures are classified based on their fracture location (medial third,
middle third, lateral third)
May consider adding an additional two views of the clavicle (45-degree
cephalic tilt, and 45-degree caudal tilt) to the AP and 20-degree cephalic tilt
views
o One study found that a 4-view clavicle series allowed better visualization of
the anterior and posterior displacement of clavicle fractures and helped
better identify patients eligible for operative repair(3)
May consider noncontrast shoulder computed tomography (CT) to help
characterize complex clavicle fractures and fractures of the medial clavicle
that may be associated with a posterior sternoclavicular dislocation
 Clavicle fracture : Fracture of the left midshaft clavicle

Clavicle fracture : Fracture of the left lateral clavicle

Management
Overview
 Historically, clavicle fractures have been treated conservatively with a sling or
figure-of-eight brace(4)
Over the past 60 years, there has been an increasing trend toward operative
repair for fractures with > 2 cm overlap of fractured ends because of higher
rates of nonunion, malunion, chronic pain, and disability compared to
conservative management(2, 5)
Fractures that have any of the following should be considered for operative
repair because of their higher risk of malunion and/or impaired shoulder
function(1, 5, 6)
o Open fracture
o Associated neurovascular injury
o Intra-articular involvement
o Comminuted fracture pattern
o Clavicular length shortening > than 2 cm
o Severe tenting of the skin
o Female gender
o Older age
o Professional athletes or patients that are very active
Lateral clavicle fractures: operative management should also be considered
for significant displacement(2)
Most patients can be managed as an outpatient

Medications

Provide pain medications, as needed

Procedures

Place the patient in a simple sling or figure-of-eight brace for 2-6 weeks(2)
No functional difference between either method(7)

Disposition
Prognosis and complications
Prognosis

Most clavicles fractures heal well, although with various degrees of cosmetic
deformity and limitations of shoulder

Complications

Nonunion (15%-20% for midshaft clavicle fractures)(8)

Malunion
Chronic pain
Degenerative arthritis
Diminished shoulder mobility

Associated conditions

Acromioclavicular injury, especially for lateral clavicle fractures(6)

 Sternal fractures and sternoclavicular dislocation, especially for medial
clavicle fractures(6)
Head and neck injuries(6)
Skull fractures(6)
Maxillofacial fractures(6)
Thoracic injury (primarily rib fractures and pneumothorax)(6)

Indications for hospital admission

Open clavicle fractures

Discharge planning

Patients should be counseled on

o Early range of motion exercises for the shoulder after 2-3 days of
immobilization to avoid an adhesive capsulitis (frozen shoulder)
o Rest and ice to the injured clavicle for the first 2-3 days to reduce pain and
swelling
o Smoking cessation because is an independent predictor for poor healing in
displaced midshaft clavicle fractures(9)
Arrange for follow up with orthopedic surgeon in 5-7 days, although should be
sooner for potentially operative injuries

Consultations
Orthopedic surgeon should be consulted in the emergency department for
fractures with the following findings
o Open fractures
o Neurovascular injury
o Severe tenting of the skin at the fracture site

References
General references used

1. Daya MR, Bengtzen RR. Shoulder. In: Marx, Hockberger, Walls, eds.
Rosens Emergency Medicine: Concepts and Clinical Practice. 8th ed. Mosby,
Inc; 2013
2. Kim W, McKee MD. Management of acute clavicle fractures. Orthop Clin
North Am. 2008 Oct;39(4):491-505
3. Austin LS, O'Brien MJ, Zmistowski B, et al. Additional x-ray views increase
decision to treat clavicular fractures surgically. J Shoulder Elbow Surg. 2012
Oct;21(10):1263-8
4. NEER CS 2nd. Nonunion of the clavicle. J Am Med Assoc. 1960 Mar
5;172:1006-11
5. Wick M, Mller EJ, Kollig E, Muhr G. Midshaft fractures of the clavicle with
a shortening of more than 2 cm predispose to nonunion. Arch Orthop Trauma
Surg. 2001;121(4):207-11
6. van Laarhoven JJ, Ferree S, Houwert MR, Hietbrink F, Verleisdonk EM,
Leenen LP. Demographics of the injury pattern in severely injured patients
 with an associated clavicle fracture: a retrospective observational cohort
study. World J Emerg Surg. 2013 Sep 22;8(1):36
7. Andersen K, Jensen PO, Lauritzen J. Treatment of clavicular fractures.
Figure-of-eight bandage versus a simple sling. Acta Orthop Scand. 1987
Feb;58(1):71-4
8. McKee MD. Clavicle fractures in 2010: sling/swathe or open reduction and
internal fixation? Orthop Clin North Am. 2010 Apr;41(2):225-31
9. Murray IR, Foster CJ, Eros A, Robinson CM. Risk factors for nonunion after
nonoperative treatment of displaced midshaft fractures of the clavicle. J Bone
Joint Surg Am. 2013 Jul 3;95(13):1153-8

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Special acknowledgements

Michelle Lin, MD (Professor of Emergency Medicine, University of California -

San Francisco School of Medicine; California, United States)
Dr. Lin declares a financial relationship with Academic Life in Emergency
Medicine, LLC.