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HWN Suggests

Clavicular Fractures

Patients who will need prompt Orthopedic consultation or transfer for evaluation by an Orthopedic Surgeon for absolute surgical indications are those with open fractures, compromised skin involving the fracture site, neurovascular injury related to the fracture, fracture displacement equivocal to the width of the bone, and/or shortening of 15mm or more. If the fracture involves the lateral end of the clavicle, a discussion with an Orthopedic surgeon should be performed as these fractures carry a high rate of nonunion.

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  Wait, you want to admit that clavicular fracture?

Medial or lateral clavicle fractures; non-displaced, no soft tissue compromise: Generally non-operative with a sling for 6-8 weeks. Middle third fractures that are displaced >100% the clavicle width, shortened, or a young active patient: Generally delayed operative intervention. Soft tissue compromise (skin tenting), neurovascular compromise, mediastinal risk: Likely admission for urgent repair.

Articles of Interest

Clavicle Fracture

In the ED, immediate orthopedic consultation should be sought for open fractures or fractures associated with neurovascular injuries, skin tenting, or interposition of soft tissues. Otherwise, clavicle fractures can usually be managed non-operatively with immobilization. Patients should wear a sling until repeat X-rays of the clavicle show callus formation. This can take up to 2 to 4 weeks in younger children and 4 to 8 weeks in adolescents and adults. This can either be done with primary care follow up (for mild, nondisplaced fractures) or orthopedic follow up (for more displaced fractures with significant shortening).

Clavicle Fractures

2-4% of all fractures, 44-66% of all shoulder fractures. Most often seen in young, active individuals. The majority of clavicle fractures can be managed non-operatively but operative indications depend on the fracture’s location, stability, and amount of displacement for midshaft fractures

Clavicle Fractures - Peds

In the ED, we encounter clavicle fractures all of the time… and feel like they are easy to deal with… so let’s just take a minute to ensure that we are managing them correctly.

Left Middle Clavicle Fracture

In general, these fractures can be treated with a sling, analgesia, and outpatient follow-up with an orthopedist. Exceptions to this include any signs of neurovascular compromise to the upper extremity, open or skin tenting from the fracture fragments, or severely displaced fractures. Displacement of greater than 20 mm between fracture fragments is more likely to result in nonunion, particularly in adults. Controversy exists about the proper management of these fractures.

Lightning Learning: Clavicle Fractures

It is commonly fractured following a fall onto the shoulder, though occasionally it can result from a fall onto an outstretched hand. This type of fracture is common in all age groups but is most common in younger people. The majority of fractures involve the middle third (~80%) of the clavicle.

Midshaft clavicle fractures—when to operate

Midshaft clavicle fractures are some of the most commonly encountered musculoskeletal injuries in orthopaedics. Non-operative treatment for minimally displaced fractures has been widely accepted as the standard of care, while treatment for displaced fractures has remained controversial. However, the last two decades has seen an increase in randomized controlled trials comparing operative and non-operative management of these fractures.

Pearl of the Day: Clavicle Fractures

Clavicle Fractures - clavicle articulates with sternum proximally and acromion distally - protects adjacent lung, brachial plexus, subclavian and brachial blood vessels - mid-portion of clavicle is thinnest and does not contain ligamentous or muscular attachments - signs/symptoms: swelling, deformity, tenderness overlying clavicle; arm is slumped inward and downward; limited ROM at shoulder - diagnosis: usually standard shoulder and clavicle X-rays, but may require 45-degree cephalad tilt view or CT - management: emergent orthopedic consult for open fractures, fractures with neurovascular injuries, fractures with persistent skin tenting

PoCUS and Clavicle Fractures

This case provides an example of how PoCUS can be used to diagnose clavicle fractures in the emergency department. In a rural or office setting where radiography is not always available, PoCUS can be used to triage patients efficiently into groups of those with a fracture and those with a low likelihood of a fracture.

Resources

Emergency Medicine Guidewire

Majority of fractures involves the middle third (75-80%); Distal third (15%); Medial third (5%). Distal third associated with AC joint injury and/or coracoclavicular ligament rupture. Medial fracture àintrathoracic injuries.

Life in the Fastlane

The traditional figure-of-eight bandage has generally been abandoned, as it is uncomfortable and difficult to keep tight. Displaced or communited fractures, and fractures with more than 15 to 20mm clavicle shortening, should be referred immediately to the orthopaedic surgeon, for operative management to prevent nonunion.

Physiopedia

A clavicle fracture is also known as a broken collarbone. Clavicle fractures are very common injuries in adults (2–5%) and children (10–15%) and represent the 44–66% of all shoulder fractures. It is the most common fracture of childhood.