Basics
Description
- Clavicular fractures account for 5% of all fractures in all age groups.
- 80% of clavicular fractures involve the middle 3rd.
- 15% occur in the distal 3rd.
- 5% occur in the medial 3rd.
Classification
- Group I: Middle-3rd fractures
- Group II: Distal-3rd fractures:
- Type I: Coracoclavicular ligaments are intact (nondisplaced).
- Type II: Severing of the coracoclavicular ligaments (conoid)
- Type III: Articular surface involvement of the acromioclavicular joint
- Group III: Medial (proximal)-3rd fractures
Etiology
Mechanism:
- Direct trauma to the clavicle
- Fall on the lateral shoulder
- Fall on the outstretched hand
- Most common of all pediatric fractures
- May occur in newborns secondary to birth trauma
Geriatric patients who sustain a clavicular fracture may have difficulty performing activities of daily living. The patients social and living situations should be assessed to determine a safe discharge plan that may require additional assistance at home.
Clavicular fractures are the result of direct trauma. Patients who are pregnant should be appropriately worked up for other injuries but also should receive fetal monitoring to ensure the health of the fetus. Even minor injuries can result in trauma or harm to the fetus.
Diagnosis
Signs and Symptoms
History
- Local pain, tenderness, and swelling over the fracture site
- Crepitus is often present owing to the clavicles SC position
- Arm held in adduction against the chest wall with resistance to motion
- Shoulder displaced anteriorly and inferiorly
Physical Exam
- Palpate the clavicle for tenderness, crepitus, and swelling.
- Examine the humerus and shoulder joint for other fractures, dislocations, or subluxations.
- Determine whether the fracture is open or closed.
- Evaluate for associated injuries (often serious and life threatening) that must be excluded:
- Skeletal injuries:
- 1st rib fracture with underlying aortic injury
- Sternoclavicular joint separation/fracture-dislocation
- Acromioclavicular joint separation/fracture-dislocation
- Cervical spine injuries
Diagnosis Tests & Interpretation
Imaging
- AP radiographs of both clavicles are mandatory and must include:
- Upper 3rd of the humerus
- Shoulder girdle (rule out other fractures)
- Upper lung fields (rule out pneumothorax)
- Oblique and apical lordotic views:
- May be helpful, especially for medial and distal clavicle fractures that are not easily visualized on the AP view
- Stress views (weight bearing) for distal clavicle fractures are no longer routinely recommended.
- Angiography:
- Should be performed if there is any evidence or suspicion of vascular injuries (most commonly subclavian vessels)
Differential Diagnosis
- Distal fractures: Consider acromioclavicular separation.
- Medial fractures: Consider sternoclavicular separation.
- Shoulder fracture-dislocation
Treatment
Pre-Hospital
- Ice packs to affected area
- Pain management using either narcotics or NSAIDs
- Immobilize affected side in a sling.
Initial Stabilization/Therapy
Airway management and resuscitate as indicated
Ed Treatment/Procedures
- Open fracture: Uncommon occurrence, but usually requires open d ©bridement and internal fixation (obtain immediate orthopedic referral)
- Closed fracture: If severely displaced, attempt closed reduction and immobilize depending on type of fracture:
- Middle 3rd:
- If nondisplaced, a sling or shoulder immobilizer is enough to provide support.
- Controversy exists as to whether closed reduction is necessary because the alignment is rarely maintained regardless of splinting technique.
- To perform a closed reduction, 1% lidocaine should be injected into the fracture hematoma. The shoulders are pulled upward, outward, and backward, and the fracture is then manipulated into place.
- Sedation may be given to alleviate pain or anxiety.
- A figure-of-eight splint or shoulder immobilizer is then applied.
- Ice should be applied for the 1st 24 hr.
- Analgesia (narcotics or NSAIDs) for pain
- Distal 3rd type I:
- Ice for the 1st 24 hr.
- Immobilization with a sling or shoulder immobilizer
- Orthopedic referral
- Analgesia (narcotics or NSAIDs) for pain
- Early range of motion
- Distal 3rd type II:
- Ice for the 1st 24 hr.
- Immobilization with a sling or shoulder immobilizer
- Orthopedic referral (may require operative repair)
- Analgesia (narcotics or NSAIDs) for pain
- Distal 3rd type III: Same as type II
- Medial (proximal) 3rd:
- Ice for the 1st 24 hr.
- Immobilization in a sling or shoulder immobilizer for support
- Analgesia (narcotics or NSAIDs) for pain
- Orthopedic follow-up
- Reassess neurovascular status after all splints are applied.
- Children who do not cooperate with the figure-of-eight splint should be referred to an orthopedic surgeon for possible shoulder spica placement.
- Most children will tolerate a shoulder immobilizer best.
Medication
- Acetaminophen: 650 mg to 1000 mg (peds: 10-15 mg/kg) PO q6h prn. Do not exceed 3 g/24 hr
- Ibuprofen: 600-800 mg PO q6h PRN with meals (peds: 10 mg/kg PO q6h PRN)
- Adults: Hydrocodone/Acetaminophen 5 mg/325 mg one to two tablets PO q6h prn. Do not exceed 3 g/24 hr of acetaminophen. Avoid concomittant use of acetaminophen-containing medications
- Hydrocodone, oxycodone, and codeine-containing medications should be avoided in pediatric patients
Follow-Up
Disposition
Admission Criteria
- Open fracture
- Associated injuries that are potentially life threatening
Discharge Criteria
- Isolated closed clavicle fracture without other injuries
- Appropriate support services at home (especially for elderly patients)
- Orthopedic follow-up
- Adequate pain management
Issues for Referral
Open fracture, complex injury, signs of neurovascular injury require immediate orthopedic referral.
Followup Recommendations
Follow-up with an orthopedic surgeon:
- Seek medical care immediately with any changes in neurologic function, sensation, or motor strength.
Pearls and Pitfalls
- Always be wary of associated injuries that can be life threatening including cervical spine injury, aortic injury, and other cardiopulmonary injuries:
- Always assess for any neurologic deficits associated with the fracture.
Additional Reading
- Banerjee R, Waterman B, Padalecki J, et al. Management of distal clavicle fractures. J Am Acad Orthop Surg. 2011;19:392-401.
- Heckman J, Bucholz R. Rockwood and Greens Fractures in Adults. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001.
- Judd DB, Pallis MP, Smith E, et al. Acute operative stabilization versus nonoperative management of clavicle fractures. Am J Orthop. 2009;38(7):341-345.
- Malik S, Chiampas G, Leonard H. Emergent evaluation of injuries to the shoulder, clavicle, and humerus. Emerg Med Clin North Am. 2010;28:739-763.
- Toogood P, Horst P, Samagh S, et al. Clavicle fractures: A review of the literature and update on treatment. Phys Sportsmed. 2011;39:142-150.
- van der Meijden OA, Gaskill TR, Millett PJ. Treatment of clavicle fractures: Current concepts review. J Shoulder Elbow Surg. 2012;21:423-429.
Codes
ICD9
- 810.00 Closed fracture of clavicle, unspecified part
- 810.02 Closed fracture of shaft of clavicle
- 810.10 Open fracture of clavicle, unspecified part
- 767.2 Fracture of clavicle due to birth trauma
- 810.01 Closed fracture of sternal end of clavicle
- 810.03 Closed fracture of acromial end of clavicle
- 810.0 Closed fracture of clavicle
- 810.11 Open fracture of sternal end of clavicle
- 810.12 Open fracture of shaft of clavicle
- 810.13 Open fracture of acromial end of clavicle
- 810.1 Open fracture of clavicle
- 810 Fracture of clavicle
ICD10
- S42.009A Fracture of unsp part of unsp clavicle, init for clos fx
- S42.026A Nondisp fx of shaft of unsp clavicle, init for clos fx
- S42.009B Fracture of unsp part of unsp clavicle, init for opn fx
- P13.4 Fracture of clavicle due to birth injury
- S42.013A Anterior disp fx of sternal end of unsp clavicle, init
- S42.016A Posterior disp fx of sternal end of unsp clavicle, init
- S42.019A Nondisp fx of sternal end of unsp clavicle, init for clos fx
- S42.033A Disp fx of lateral end of unsp clavicle, init for clos fx
- S42.036A Nondisp fx of lateral end of unsp clavicle, init for clos fx
SNOMED
- 58150001 fracture of clavicle (disorder)
- 33173003 closed fracture of clavicle (disorder)
- 111637008 open fracture of clavicle (disorder)
- 41972004 Fracture of shaft of clavicle (disorder)
- 206209004 Fracture of clavicle due to birth trauma (disorder)
- 52784000 Fracture of acromial end of clavicle (disorder)
- 56642004 Fracture of sternal end of clavicle (disorder)