eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics
Fracture, Clavicle: Treatment & Medication
Updated: Jul 28, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
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.
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
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
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
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.
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
Rifampin can reduce analgesic effects; barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Documented hypersensitivity; known G-6-PD deficiency
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.
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
Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants increase toxicity
Documented hypersensitivity; high-altitude cerebral edema; elevated intracranial pressure
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.
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
CNS depressants or tricyclic antidepressants increase toxicity
Documented hypersensitivity
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.
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
Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants increase toxicity
Documented hypersensitivity
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.
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
Probenecid prolongs effects; aminoglycosides may increase renal toxicity; may yield false-positive urine-dip test result for glucose
Documented hypersensitivity
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.
Adult
1.5 mg/kg IV; not to exceed 80 mg
Pediatric
2 mg/kg IV
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)
Documented hypersensitivity; non–dialysis-dependent renal insufficiency
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.
Adult
2 g IV/IM
Pediatric
50 mg/kg IV/IM
Probenecid and disulfiram elevate levels; allopurinol decreases effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
Documented hypersensitivity
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.
Adult
1 g IV infused over 1 h
Pediatric
10-15 mg/kg IV over 1 h
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
Documented hypersensitivity
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.
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
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)
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
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
More on Fracture, Clavicle |
| Overview: Fracture, Clavicle |
| Differential Diagnoses & Workup: Fracture, Clavicle |
 Treatment & Medication: Fracture, Clavicle |
| Follow-up: Fracture, Clavicle |
| Multimedia: Fracture, Clavicle |
| References |
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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].
Further Reading
Keywords
clavicle fracture, clavicle fracture treatment, clavicular fractures, fractured clavicle, clavicula, collar bone, collarbone, displaced clavicle fractures
