Clinical Practice Guidelines

Clavicle fractures - Emergency Department

  • Fracture Guideline Index

    See also: Clavicle fractures - Fracture clinics

    1. Summary
    2. How are they classified?
    3. How common are they and how do they occur?
    4. What do they look like - clinically?
    5.  What radiological investigations should be ordered?
    6. What do they look like on x-ray?
    7. When is reduction (non operative and operative) required?
    8. Do I need to refer to orthopaedics now?
    9. What is the usual ED management for this fracture?
    10. What follow-up is required?
    11. What advice should I give to parents?
    12. What are the potential complications associated with this injury?
    13. Parent information fact sheet (PDF)

    1. Summary

    Fracture type

    ED management

    Follow-up

    Middle third (most common)

    Broad arm sling to support limb for 2 weeks or until comfortable.  No evidence to support Figure of 8 bandage or brace

    If age >12 years and shortened >2 cm refer to orthopaedics for opinion

    Give parent fracture of the clavicle (collarbone) fact sheet.  Advise to give regular analgesia as required

    If <11 years and undisplaced, follow-up by a GP or fracture clinic is usually not required.  Repeat x-rays are usually not required

    If displaced or ≥11 years, follow up with GP or fracture clinic in 1 week

    Lateral third

    Broad arm sling to support limb for 2 weeks or until comfortable.  No evidence to support Figure of 8 bandage or brace

    If displaced, refer to the nearest orthopaedic service on call

    Fracture clinic in 5-7 days with x-ray

    Medial third

    If displaced, urgent referral to the nearest orthopaedic on call service

    To be arranged by orthopaedic service

     

    2. How are they classified?

    Fractures of the clavicle can be classified by its anatomical location (Table 1):

    CLAVICLE-FRACTURE-CLASSIFICATION

     

    Table 1: Classification of clavicle fractures by location.

    Location

    Frequency

    Description

    Lateral third

    15%

    Around and lateral to coracoclavicular ligaments

    Middle third or midshaft

    80%

    Defined by shortening/comminution/angulation

    Medial third

    5%

    • Bony injury alone

    • Associated with sternoclavicular dislocation (may be a physeal sleeve separation)
     

    3. How common are they and how do they occur?

    The clavicle is one of the most common fractured bones in children.  It is the most common perinatal fracture associated with birth trauma.  Half of all paediatric clavicle fractures occur under the age of seven years.  These heal quickly and recover fully. 

    Injuries are usually the result of a fall on an outstretched hand with the force transmitted up the arm.  A direct blow to the outer end of the clavicle (such as a fall onto the point of the shoulder during sporting activities or a striking injury) can be associated with distal third injuries and acromioclavicular joint disruption.

    4. What do they look like - clinically?

    Most present with pain, swelling and deformity along the line of the clavicle, and a history of a fall.  Toddlers and infants may present having been observed not using the arm, without a witnessed trauma.

    Fractures of the medial third are usually the result of direct trauma to the anterior chest (such as in a motor vehicle accident), and can be associated with neurovascular, pulmonary and cardiac (rare) injuries.  Careful airway protection and neurovascular assessment is required.

    All fractures should be assessed using the Advanced Trauma Life Support (ATLS) principles to ensure associated and potentially significant injuries are identified.

    !   Careful neurological examination should be performed to define potential (but rare) associated brachial plexus injury.
    Vascular assessment of the arm should also be performed as the subclavian artery runs closely apposed to the clavicle in the middle third.
     
     

    5. What radiological investigations should be ordered?

    Standard anteroposterior (AP) and AP with 15 degrees cephalic tilt x-ray of the clavicle will show the fracture in two planes and define displacement.

    A CT scan may be required for medial third injuries with sternoclavicular dislocation to assess tracheal impingement and thoracic anatomy.

    6. What do they look like on x-ray?

    Middle third fracture

    Fracture-Clavicle-Figure1_1150875-Clavicle_middlejpg

    Figure 1:  Seven year old boy with fracture of the middle third of the clavicle.

    Lateral third

    Fracture-Clavicle-Figure2_1252812-Clavicle_lateral_third.jpg

    Figure 2:  Undisplaced lateral third fracture of the clavicle in a 12 year old boy.

    Sternoclavicular dislocation (posterior displaced)

    Fracture-Clavicle-Figure3A_0868387-SC-joint.jpg
    A

    Fracture-Clavicle-Figure3B_0868387-SC-joint-CT.jpg 
    B

    Figure 3:  A) 14 year old with posterior dislocation of the medial end of right clavicle.  This is difficult to see on x-ray.  B) The posterior dislocation (red arrow) is more evident on CT scan. 

    7. When is reduction (non operative and operative) required?

    Reduction of the middle third is almost never required.  Manipulation can lead to neurovascular injury.

    Displaced lateral and medial third fractures require orthopedic referral for assessment.

    Open fractures, severely displaced fractures with skin at risk, or fractures with neurovascular injury may require surgical reduction and fixation.  These should be referred to the orthopaedic service as a matter of urgency.

    8. Do I need to refer to orthopaedics now?

    The majority of clavicle fractures are easily managed with a sling and analgesia.

    Indications for prompt consultation include:

    1. Severely comminuted or shortened middle third (>2 cm if over 12 years of age)
    2. Open fractures
    3. Displaced medial third fractures
    4. Neurovascular injury with fracture
    5. Skin at risk over fracture
    6. Displaced lateral third fractures
    7. Pathological fractures

    Congenital pseudoathrosis of clavicle - multiple previous fractures in same location

    9. What is the usual ED management for this fracture?

    Fracture type

    Type of reduction

    Immobilisation method & duration

    Middle third

    No reduction required

    Broad arm sling to support limb for 2 weeks or until comfortable

    No evidence to support Figure of 8 bandage or brace

    Regular analgesia as required

    Lateral third

    If undisplaced, no reduction required

    If displaced, refer to the nearest orthopaedic service on call

    Broad arm sling to support limb for 2 weeks or until comfortable

    Regular analgesia as required

    No evidence to support Figure of 8 bandage or brace

    Medial third

    If undisplaced, no reduction required

    If displaced, urgent referral to the nearest orthopaedic service on call

    Broad arm sling to support limb

    No evidence to support Figure of 8 bandage or brace

     

    10. What follow-up is required?

    Children <11 years old with undisplaced fractures do not usually require follow-up by a GP or fracture clinic.  Repeat x-rays are usually not required.

    For children ≥11 years old or those with displaced fractures, follow up should occur with a GP or in fracture clinic in one week with x-ray.  Radiographs are usually not required.  Mobilisation out of the sling commences at two weeks depending on pain control.

    11. What advice should I give to parents?

    The majority of uncomplicated middle third fractures will have excellent functional and cosmetic outcomes.

    Provide parent with fracture of the clavicle (collarbone) fact sheet.

    Pain from the fracture and restriction of movement are usual for 2-3 weeks and will require regular analgesia.

    The child should re-attend if pain is increasing, or sensation changes abruptly.   Contact sports and activities should be avoided for approximately six weeks post removal of sling.  A lump usually develops at the fracture site, which may be visible and palpable for at least one year. 

    12. What are the potential complications associated with this injury?

    • Neurovascular complications are rare
    • Nonunion is uncommon
    • Malunion - palpable or visual lump, which diminishes with remodelling
    • Degenerative arthritis if acromioclavicular joint intra-articular incongruence

    See fracture clinics for other potential complications.

    References (ED setting)

    Hunter JB. Fractures around the shoulder and humerus. In Children's Orthopaedics and Fractures,3rd Ed. Benson M, Fixsen J, Macnicol M, Parsch K (Eds). Springer, London 2010. p.717-30.

    Lenza M, Belloti JC, Andriolo RB, Gomes Dos Santos JB, Faloppa F. Conservative interventions for treating middle third clavicle fractures in adolescents and adults. Cochrane Database Syst Rev 2009; CD007121.

    Klein SM, Badman BL, Keating CJ, Devinney DS, Frankle MA, Mighell MA. Results of surgical treatment for unstable distal clavicular fractures. J Shoulder Elbow Surg 2010; 19: 1049-55.

    Simon RR, Sherman SC, Koenigsknecht SJ. Clavicle fractures. In Emergency Orthopaedics - The Extremities. 5th Ed. McGraw-Hill, Chicago 2007. p.285-7.

    Young SJ, Barnett PL, Oakley EA. Fractures and minor head injuries: Minor injuries in children II. Med J Aust 2005; 182: 644-8.

     

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