eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics
Fracture, Clavicle
Updated: Jul 28, 2009
Introduction
Background
The clavicle is an oblong bone that connects the shoulder girdle to the trunk. It provides support and mobility for upper extremity function. Clavicle fractures account for 5% of all fractures and nearly half of significant injuries to the shoulder girdle. They are the most common of all childhood fractures.
Anatomically, the acromioclavicular and coracoclavicular ligament attach the clavicle to the scapula laterally. The sternoclavicular and the costoclavicular ligaments anchor the clavicle medially. The sternocleidomastoid and the subclavius muscles also have points of attachment to the clavicle. The clavicle also protects the adjacent brachial plexus, lung, and blood vessels.
Pathophysiology
Clavicular fractures are classified mechanistically and anatomically into 3 types. Approximately 80% of clavicle fractures occur in the middle third (class A), 15% involve the distal or lateral third (class B), and less than 5% involve the proximal or medial third (class C). The anatomy of the clavicle with potential fracture sites marked is shown in Media file 1.
Anatomy of the clavicle indicating potential fracture sites.
Most class A fractures occur medial to the coracoclavicular ligament, at the junction of the middle and outer thirds of the clavicle. The proximal fragment is typically displaced upward because of the pull of the sternocleidomastoid muscle. The usual mechanism of injury involves adirect force applied to the lateral aspect of the shoulder as a result of a fall, sporting injury, or motor vehicle accident. See Media files 2-4.
Nondisplaced middle clavicle fracture.
Displaced fracture of middle clavicle.
Displaced middle clavicle fracture.
Fractures of the lateral third (class B) result from a direct blow to the top of the shoulder. They occur distal to the coracoclavicular ligament and are classified further into 3 subtypes. Type I fractures are nondisplaced, and the coracoclavicular ligaments remain intact. Type II fractures are displaced, and there is associated rupture of the coracoclavicular ligament with the proximal clavicular segment typically pulled upward by the sternocleidomastoid muscle. Type III injuries involve the articular surface of the acromioclavicular joint.1
Fractures of the medial third (class C) occur as a result of a direct blow to the anterior chest. A diligent search for associated injuries should accompany all of these fractures because considerably strong forces are required to fracture this area of the clavicle.
Greenstick or buckle-type fractures are common in children. Most of these fractures are nondisplaced and heal uneventfully.
Frequency
International
The annual incidence rate of clavicular fractures is estimated to be between 30 and 60 cases per 100,000 population.2
Mortality/Morbidity
While the overwhelming majority of clavicle fractures are benign, associated life-threatening intrathoracic injuries are possible. Complications vary based on location of fracture (see Complications).
Sex
The male-to-female ratio is 2:1 for clavicle fractures.
Age
Clavicle fractures are the most common of all pediatric fractures. They can present in the newborn period, especially following a difficult delivery, and nearly half of all clavicle fractures occur in children younger than 7 years. A large peak incidence occurs in males younger than 30 years due to sports injuries. A smaller peak of incidence occurs in elderly patients in whom the injury is sustained during low-energy falls and is related to osteoporosis.2
Clinical
History
- The patient typically reports a fall onto an outstretched upper extremity, a fall onto a shoulder, or direct clavicular trauma.
- Pain, especially with upper extremity movement
- Swelling
Physical
- The affected extremity is held close to the body, adducted against the chest wall, supported by the other extremity.
- Inferior and anterior displacement of the shoulder occurs secondary to loss of support.
- Tenderness
- Crepitus
- Edema
- Deformity
- Ecchymosis, especially when severe displacement causes tenting of skin
- Bleeding from open fracture (rare)
- Decreased breath sounds on auscultation, indicating possible pneumothorax
- Decreased pulses or evidence of decreased perfusion on vascular examination, suggesting vascular compromise
- Diminished sensation or weakness on distal neurovascular examination, suggesting neurologic compromise
- Nonuse of the arm on the affected side in neonates
Causes
- Fall onto a shoulder or an outstretched upper extremity
- Direct blow to the clavicle
Differential Diagnoses
Dislocations, Shoulder
Fractures, Rib
Pneumothorax, Tension and Traumatic
Rotator Cuff Injuries
Sternoclavicular Joint Injury
Workup
Imaging Studies
- Routine clavicle radiography
- Fracture is usually demonstrated on an anteroposterior (AP) view.
- Apical lordotic views (an AP view with the tube directed 45° cephalad) may be required to define the degree of displacement.
- Initial radiographs may appear normal despite suggestive clinical findings. In these instances, the arm should be immobilized in a simple sling, and the radiographs repeated in 7-10 days if symptoms persist.
- CT scan may be required because routine clavicle radiographs may miss fractures due to overlap of surrounding structures, particularly at either end of the bone.
Also see, Clavicle, Fractures and Dislocations.
Other Tests
- Other tests may be required when clinically indicated to assess the possibility of life-threatening associated injuries.
- Chest radiography, if pneumothorax suspected
- Angiography, if vascular injury suspected
Treatment
Prehospital Care
- Identify and treat associated life-threatening injuries.
- Initiate ATLS protocol, and stabilize the patient.
- Perform a careful secondary survey.
- Apply a cold pack to the injury.
- Immobilize the upper extremity with a sling.
Emergency Department Care
- Identify and treat associated life- and limb-threatening injuries. If fracture is open, treat the patient with prophylactic antibiotics, tetanus immunization (if needed), irrigation, and placement of a sterile dressing while awaiting urgent orthopedic consultation.
- Class A (middle third fractures)
- Some orthopedists recommend an immobilization technique for midclavicular fractures; this is the clavicular (figure-of-eight) splint. This splint is applied after closed reduction of the fracture, which is accomplished by pulling the shoulders up and back. Such reductions are difficult to maintain and may be associated with increased discomfort at the fracture site. The advantage of the figure-of-eight harness is that it gives patients the ability to use both hands. The literature, however, shows no real difference in outcomes between patients treated with a figure-of-eight splint versus a sling.3 Healing may occur as rapidly as 2 weeks for infants, with most adults healing in 4-6 weeks. Immobilization should remain until repeat radiographs show callus formation and healing across the fracture site.
- Historically, class A fractures were treated conservatively. However, recent studies demonstrate that operative treatment of displaced midshaft clavicle fractures may result in improved functional outcome and a lower rate of malunion and nonunion, compared with nonoperative management.4 Midclavicular fractures that have more than 2 cm of initial shortening also may benefit from early orthopedic referral because these have been associated with a higher incidence of nonunion.
- Class B (distal third fractures): Type I (nondisplaced) and type III (articular surface involvement) fractures are treated symptomatically with ice, analgesics, and a sling for support. Early motion with passive shoulder range-of-motion exercises is strongly urged to prevent the development of degenerative arthritis and to reduce the risk of adhesive capsulitis. More urgent orthopedic consultation (before 72 hours) is recommended for type II (displaced) lateral clavicle fractures because these fractures have a 30% incidence of nonunion and may require surgical repair.5
- Class C (proximal third): Medial third clavicle fracture management includes ice, analgesics, and a sling for support. Displaced medial-third fractures require orthopedic referral for reduction. Medial clavicle fractures may be associated with intrathoracic injuries or the development of late complications, such as arthritis.6
Consultations
- Consult a trauma surgeon immediately when the patient has evidence of multisystem involvement.
- Orthopedic surgery
- Open fractures necessitate immediate consultation.
- Displaced fractures may need surgical repair, necessitating referral.
- Primary care provider may manage uncomplicated clavicle fractures.
Medication
Prophylactic intravenous antibiotics that cover typical skin flora (eg, cefazolin sodium) are necessary with open fractures. Control discomfort with nonsteroidal anti-inflammatory drugs (NSAIDs), and if pain continues, add a narcotic analgesic. Tetanus immunization also may be indicated.
Nonsteroidal anti-inflammatory agents (NSAIDs)
These agents are used most commonly for relief of mild to moderately severe pain. Effects of NSAIDs in treatment of pain tend to be patient specific, yet ibuprofen is usually the DOC for initial therapy.
Ibuprofen (Ibuprin, Advil, Motrin)
Usually, DOC for treatment of mild to moderately severe pain, if no contraindications. Inhibits inflammatory reactions and pain, probably by decreasing activity of enzyme cyclooxygenase, which inhibits prostaglandin synthesis.
Dosing
Adult
200-400 mg PO q4-6h prn; not to exceed 3.2 g/d
Pediatric
<6 months: Not established
6 months to 12 years: 20-40 mg/kg/d PO divided tid/qid
>12 years: Administer as in adults
Interactions
Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants (monitor PT closely and instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; may increase phenytoin levels
Contraindications
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy
Analgesics
Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained fractures.
Acetaminophen (Tylenol, Panadol, aspirin-free Anacin)
DOC for treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs or in those with upper GI disease or taking oral anticoagulants.
Dosing
Adult
325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d
Pediatric
<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg q4h; not to exceed 5 doses/d
Interactions
Rifampin can reduce analgesic effects; barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Contraindications
Documented hypersensitivity; known G-6-PD deficiency
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity possible in chronic alcoholics following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products and combined use with these products may result in cumulative acetaminophen doses exceeding recommended maximum dose
Hydrocodone bitartrate and acetaminophen (Vicodin ES)
Drug combination indicated for relief of moderately severe to severe pain.
Dosing
Adult
1-2 tabs or caps PO q4-6h prn
Pediatric
<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d of acetaminophen
>12 years: 750 mg acetaminophen PO q4h; single dose not to exceed 10 mg of hydrocodone bitartrate; not to exceed 5 doses/d
Interactions
Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants increase toxicity
Contraindications
Documented hypersensitivity; high-altitude cerebral edema; elevated intracranial pressure
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus
Precautions
Tablets contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction
Acetaminophen and codeine (Tylenol #3)
Drug combination indicated for treatment of mild to moderately severe pain.
Dosing
Adult
30-60 mg/dose based on codeine content PO q4-6h or 1-2 tab q4h; not to exceed 12 tab/d
Pediatric
0.5-1 mg/kg/dose based on codeine content PO q4-6h; 10-15 mg/kg/dose PO based on acetaminophen content; not to exceed 2.6 g/d of acetaminophen
Interactions
CNS depressants or tricyclic antidepressants increase toxicity
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients dependent on opiates since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction
Oxycodone and acetaminophen (Percocet)
Drug combination indicated for relief of moderately severe to severe pain. DOC for aspirin-hypersensitive patients.
Dosing
Adult
1-2 tab or cap PO q4-6h prn
Pediatric
0.05-0.15 mg/kg/dose oxycodone PO q4-6h prn; not to exceed 5 mg/dose oxycodone
Interactions
Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants increase toxicity
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus
Precautions
Duration of action may increase in elderly persons; be aware of total daily dose of acetaminophen patient is receiving; do not exceed 4000 mg/24 h of acetaminophen; higher doses may cause liver toxicity
Antibiotics
Therapy must cover all likely pathogens in the clinical setting.
Cefazolin (Ancef, Kefzol, Zolicef)
First-generation semisynthetic cephalosporin that, by binding to 1 or more penicillin-binding proteins, arrests bacterial cell wall synthesis and inhibits bacterial replication. Primarily active against skin flora, including Staphylococcus aureus.
Dosing
Adult
2 g IV/IM q6-12h; not to exceed 12 g/d
Pediatric
25-100 mg/kg/d IV/IM divided q6-8h, depending on severity of infection; not to exceed 6 g/d
Interactions
Probenecid prolongs effects; aminoglycosides may increase renal toxicity; may yield false-positive urine-dip test result for glucose
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy
Gentamicin (Gentacidin, Garamycin)
Aminoglycoside antibiotic used for gram-negative bacterial coverage. Commonly used in combination with both an agent against gram-positive organisms and one that covers anaerobes. Used in conjunction with ampicillin or vancomycin for prophylaxis in patients with open fractures.
Dosing regimens are numerous and are adjusted based on CrCl and changes in volume of distribution. Gentamicin may be given IV/IM.
Dosing
Adult
1.5 mg/kg IV; not to exceed 80 mg
Pediatric
2 mg/kg IV
Interactions
Other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents, thus prolonged respiratory depression may occur; loop diuretics may increase auditory toxicity of aminoglycosides—possible irreversible hearing loss of varying degrees may occur (monitor regularly)
Contraindications
Documented hypersensitivity; non–dialysis-dependent renal insufficiency
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus
Precautions
Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not taking dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment
Ampicillin (Omnipen, Marcillin)
Used along with gentamicin for prophylaxis in patients with open fractures. Interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms.
Dosing
Adult
2 g IV/IM
Pediatric
50 mg/kg IV/IM
Interactions
Probenecid and disulfiram elevate levels; allopurinol decreases effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction
Vancomycin (Vancocin)
Potent antibiotic directed against gram-positive organisms and active against enterococcal species. Useful in septicemia and skin structure infections. Used in conjunction with gentamicin for prophylaxis in penicillin-allergic patients with open fractures.
May need to adjust dose in patients with renal impairment.
Dosing
Adult
1 g IV infused over 1 h
Pediatric
10-15 mg/kg IV over 1 h
Interactions
Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal failure, neutropenia; red man syndrome caused by too rapid IV infusion (dose given over a few min) but rarely happens when dose given over 2 h or by PO or IP route; red man syndrome not an allergic reaction
Toxoid
This agent is used for tetanus immunization. A booster injection in previously immunized individuals is recommended to prevent this potentially lethal syndrome.
Tetanus toxoid
Induces active immunity against tetanus in selected patients. Immunizing agents of choice for most adults and children older than 7 years are tetanus and diphtheria toxoids. Administer booster doses to maintain tetanus immunity throughout life.
Pregnant patients should receive only tetanus toxoid, not a diphtheria antigen-containing product.
In children and adults, may administer into deltoid or midlateral thigh muscles. In infants, preferred site of administration is midthigh laterally.
Dosing
Adult
Primary immunization: 0.5 mL IM; give 2 injections 4-8 wk apart and a third dose 6-12 mo after second injection
Booster dose: 0.5 mL q10y
Pediatric
Administer as in adults
Interactions
Patients receiving immunosuppressants, including corticosteroids or radiation therapy, may remain susceptible despite immunization due to poor immune response; cimetidine may enhance or augment delayed-hypersensitivity responses to skin-test antigens; avoid concurrent use of chloramphenicol because it may impair amnestic response to tetanus toxoid; concurrent use of tetanus immune globulin may delay development of active immunity by several days (interaction is nevertheless clinically insignificant and does not preclude its concurrent use)
Contraindications
Documented hypersensitivity; history of any type of neurologic symptoms or signs following administration of this product
FDA recommends that elective tetanus immunization be deferred during any outbreak of poliomyelitis because tetanus toxoid injections are an important cause of provocative poliomyelitis
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use to treat actual tetanus infections or for immediate prophylaxis of unimmunized individuals (use instead tetanus antitoxin, preferably human tetanus immune globulin); diminished antibody response to active immunization may be seen in patients receiving immunosuppressive therapy; better to defer primary diphtheria immunization until immunosuppressive therapy discontinued; routine immunization of symptomatic and asymptomatic HIV-infected persons recommended
Follow-up
Further Inpatient Care
The following require consideration for inpatient management:
- Open fractures
- Associated medical or traumatic conditions
- Pain control
Further Outpatient Care
- Orthopedic follow-up care
- Patient education
- Early physical therapy (eg, range of motion exercises) if indicated
Deterrence/Prevention
- Injury avoidance education
- Adequate protective gear for participation in certain sports
- Seat belt utilization
- Drug and alcohol counseling as needed
Complications
- Fractures of the middle third of the clavicle have been associated with injuries to the neurovascular bundle and the pleural dome.
- Complications after fractures of the medial third resemble complications associated with posterior sternoclavicular dislocations including pneumothorax or compression or laceration of the great vessels, trachea, or esophagus.
- Brachial plexus compression resulting from hypertrophic callus formation (may cause peripheral neuropathy)
- Delayed union or nonunion (especially with type II distal third fractures and fractures with >2 cm of shortening)
- Poor cosmetic appearance
- Posttraumatic arthritis
- Intrathoracic injury
- As with first rib fractures, great force is necessary to cause proximal third clavicle fractures; excluding underlying injuries is imperative (see Media file 5).
Clavicle fracture with rib fractures. Remember to look for associated injuries.
- Pneumothorax
- Subclavian artery and vein injury
- Internal jugular vein injury
- Axillary artery injury
Prognosis
- The prognosis of clavicle fractures is excellent in children.
- The prognosis of clavicle fractures is excellent in adults with proper follow-up care, early detection, and treatment of complications.
- Younger children generally require shorter periods ofimmobilization (2-4 wk) than adolescents and adults (4-8 wk).
Patient Education
- Patients should use of a sling or sling and swathe.
- Vigorous competitive play should be avoided until the bone healing is solid.
- A figure-of-eight bandage (clavicle strap) should be used.
- Educate patients about proper placement and adjustment techniques.
- Paresthesias or edema in the hands or fingers indicate that the strap is too tight and should be removed.
- The purpose of this bandage is to reduce pain by decreasing fracture fragment movement, not necessarily to maintain perfect alignment.
- This strap may be combined with a sling for added comfort.
- Neonatal clavicle fracture
- Advise parents to minimize pressure and movement of the ipsilateral arm during handling of the child.
- The parent may try to pin the infant’s shirt sleeve of the affected arm to the front of the shirt to minimize movement.
- For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education articles, Broken Collarbone and Shoulder Dislocation.
Miscellaneous
Medicolegal Pitfalls
- Failure to recognize and treat associated severe injuries
- Failure to refer patients at risk of complications to an orthopedist
Multimedia
Media file 1: Anatomy of the clavicle indicating potential fracture sites.
Media file 2: Nondisplaced middle clavicle fracture.
Media file 3: Displaced fracture of middle clavicle.
Media file 4: Displaced middle clavicle fracture.
Media file 5: Clavicle fracture with rib fractures. Remember to look for associated injuries.
References
Simon RR, Koenigsknecht SJ. Clavicle fractures. In: Emergency Orthopedics: The Extremities. 5th ed. McGraw-Hill; 2007.
Khan LA, Bradnock TJ, Scott C, Robinson CM. Fractures of the clavicle. J Bone Joint Surg Am. Feb 2009;91(2):447-60. [Medline].
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. Apr 15 2009;CD007121. [Medline].
Smekal V, Irenberger A, Struve P, Wambacher M, Krappinger D, Kralinger FS. Elastic stable intramedullary nailing versus nonoperative treatment of displaced midshaft clavicular fractures-a randomized, controlled, clinical trial. J Orthop Trauma. Feb 2009;23(2):106-12. [Medline].
Pujalte GG, Housner JA. Management of clavicle fractures. Curr Sports Med Rep. Sep-Oct 2008;7(5):275-80. [Medline].
Low AK, Duckworth DG, Bokor DJ. Operative outcome of displaced medial-end clavicle fractures in adults. J Shoulder Elbow Surg. Sep-Oct 2008;17(5):751-4. [Medline].
Keywords
clavicle fracture, clavicle fracture treatment, clavicular fractures, fractured clavicle, clavicula, collar bone, collarbone, displaced clavicle fractures
Contributor Information and Disclosures
Author
Amir Estephan, MD,, Resident Physician, Department of Emergency Medicine, Kings County Hospital Center, Brooklyn
Amir Estephan, MD, is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, and Emergency Medicine Residents Association
Disclosure: Nothing to disclose.
Coauthor(s)
Robert J Gore, MD, Clinical Assistant Professor, Attending Physician, Assistant Residency Director, Department of Emergency Medicine, Kings County/State University of New York Downstate Hospital
Robert J Gore, MD is a member of the following medical societies: American College of Emergency Physicians, National Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Medical Editor
Francis Counselman, MD, Program Director, Chair, Professor, Department of Emergency Medicine, Eastern Virginia Medical School
Francis Counselman, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Association of Academic Chairs of Emergency Medicine (AACEM), Norfolk Academy of Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Pharmacy Editor
Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment
Managing Editor
Tom Scaletta, MD, President, Emergency Excellence (EmEx) (www.emergencyexcellence.com); Assistant Professor of Emergency Medicine, Rush Medical College, Cook County Hospital; Chairperson, Department of Emergency Medicine, Edward Hospital; Past-President, American Academy of Emergency Medicine
Tom Scaletta, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
CME Editor
John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Chief Editor
Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
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