Clavicle Fracture

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Background

• Secondary to shoulder trauma (not as much direct clavicle trauma)
  • Tackled to ground
  • FOOSH
  • Direct impact to lateral shoulder
• 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

 
Clinical Features

• Swelling, deformity, tenderness, pain over anterior shoulder
• Patient may be supporting affected arm with the contralateral arm
• Displaced fractures
  • Medial fragment displaced posteriorly and superiorly (SCM pulls)
  • Lateral fragment displaced inferiorly and medically (Pectoralis and weight of arm pulls)
  • Open fractures usually result from medial fragment buttonholing through platysma

 
Evaluation

• Assess distal pulses, motor, and sensation
• XR (CXR, SXR, Dedicated clavicle films)
  • Associated injuries are rare, but can see rib fractures, PTX, neurovascular injuries
  • Additional XR view = ZANCA view (15-degree cephalic tilt)
    • Determines superior/inferior displacement
    • Have patient hold 5-10 lbs weight in affected hand
• Consider CT for further eval and possible vascular injury

 
Classification

• Neer, Allman, Craig, Robinson

• AO Classification:
  • Type A, B, C (A = Simple; B = Wedge; C = Complex)

 
Management

• Non-operative
  • Sling or figure-of-eight immobilization with early ROM exercises at 2-4 weeks; start strength training at 6-10 weeks
  • Best for minimally displaced, <2 cm shortening, no neuro deficits
  • Nonunion rate = 1-5 %
    • Most often in elderly and females
• Operative
  • ORIF
    • Open fractures
    • Displaced fracture with skin tenting
    • Neurovascular injury
    • Risk of need for future procedures, implant removal or debridement for infection
• Pain control
  • Chang AK, Bijur PE, Esses D, et al. Effect of a Single Dose of Oral Opioid and Nonopioid Analgesics on Acute Extremity Pain in the Emergency Department: A Randomized Clinical Trial. JAMA2017;318:1661-7

 
Disposition

• Discharge with ortho/sports follow-up
• Possible surgical intervention for comminuted fractures, significant displacement or >2 cm of shortening
• Consult orthopedics in the ED if patient has an open fracture, Neurovascular compromise or skin tenting