Clavicle Fracture in Emergency Medicine Treatment & Management
- Author: Amir Estephan, MD; Chief Editor: Rick Kulkarni, MD more...
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.[4] 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.[5] 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.[6] If surgery is delayed, the results of treatment may be more problematic.[7]
- 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.[8]
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.
Simon RR, Koenigsknecht SJ. Clavicle fractures. In: Emergency Orthopedics: The Extremities. 5th ed. McGraw-Hill; 2007.
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Cross KP, Warkentine FH, Kim IK, Gracely E, Paul RI. Bedside ultrasound diagnosis of clavicle fractures in the pediatric emergency department. Acad Emerg Med. Jul 2010;17(7):687-93. [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].
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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. Mar 23 2010;[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].
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