eMedicine Specialties > Sports Medicine > Shoulder
Clavicular Injuries: Treatment & Medication
Updated: Aug 18, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Acute Phase
Medical Issues/Complications
Icing, rest, and medication (see the Medication section) are used for pain relief. The vast majority of clavicle fractures heal uneventfully no matter which treatment is instituted.9,10 A sling to support the weight of the upper extremity is recommended for nondisplaced or minimally displaced fractures for 2-6 weeks' duration, depending on the patient’s pain. Types 1 and 3 fractures of the distal clavicle can also be treated with a sling.
A figure-of-8 bandage has been used in attempt to bring displaced fracture fragments into better opposition, however, no evidence exists that a figure-of-8 bandage can hold a fracture in reduction. In order for it to effectively reduce the fracture, the splint would have to be so tight that skin breakdown, increased pain, and nerve injury could result. No improvement in the healing rate or fracture alignment with the figure-of-8 bandage has been found.11 The general consensus is that changing the amount of displacement observed on the initial radiographs is not possible without surgery. Fortunately, the fracture healing with a modest amount of angulation does not usually result in significant functional limitations.
Surgical Intervention
Patients with the following injuries should be sent to a surgeon to determine if operative intervention is necessary:
- Severe fracture displacement (>100% displacement or fracture ends are >1.5 cm apart)
- Tenting of the skin with the risk of puncture: This is often seen with type 2 fractures of the distal clavicle.
- Fractures with 2 cm of shortening
- Neurovascular compromise
- Polytrauma, (with multiple fractures) to expedite rehabilitation
- Open fractures
- An inability to tolerate closed treatment
- Fractures with interposed muscle
- Established symptomatic nonunion: Note that many nonunions are asymptomatic, and no treatment is needed.
- Concomitant glenoid neck fracture (floating shoulder)
The surgical procedure performed is either plate-and-screw fixation or placement of a intramedullary device.6,12 Precontoured plates in an S-shape of the clavicle have also become available.13
Checchia et al reported a new arthroscopic technique to treat distal clavicle fractures in 7 patients with a mean age of 46 years.14 The investigators identified the coracoid through the rotator interval, and using a special needle, a double #5 suture was passed around the coracoid. A hole was then created at the clavicle and, through another guide wire, was sent to the anterior portal. The double #5 suture was transported to the clavicle. Following the fracture reduction, the sutures were tightened. Checchia et al noted that all 7 cases healed without complication. The investigators believe that, with the aid of arthroscopy, the morbidity of surgical treatment of clavicle fractures can be decreased.13
Complication rates with acute surgical treatment have been reported to be as high as 20%. Complications can include infection, failure of fixation, prominent scarring, and nonunion.
Consultations
- Consult an orthopedic surgeon if the athlete has any of the above surgical indications (see Treatment, Surgical Intervention).
- Consult a general surgeon or thoracic surgeon if an associated pneumothorax is identified.
- Consult a vascular surgeon for a suspected subclavian vessel injury.
Recovery Phase
Rehabilitation Program
Physical Therapy
Once the fracture pain begins to subside and the athlete is weaning off the pain medications, begin range-of-motion exercises with the shoulder and elbow out of the sling to prevent stiffening of these joints. Exercises should be performed within the limits of comfort.
As pain continues to improve, isometric exercises of the shoulder girdle and arm musculature can begin. This can be performed under the supervision of a physical therapist or by the athlete on his or her own, with an instructional handout for guidance.
The sling can be used as needed for comfort for up to 2-4 weeks after the injury. As fracture healing progresses based on clinical and radiographic examination findings, isotonic exercises can begin using light weights or elastic bands for resistance.
Related Medscape topics:
Resource Center Exercise and Sports Medicine
Resource Center Pain Management: Advanced Approaches to Chronic Pain Management
Resource Center Pain Management: Pharmacologic Approaches
Maintenance Phase
Rehabilitation Program
Physical Therapy
Therapy includes progressive range-of-motion exercises and strengthening exercises. Functional and sports-specific exercises can be added depending on the athlete’s goals.
Medication
Fractures are very painful. Pain medications are used until the pain is under control or tolerable.
Analgesic, Narcotic
Pain control is essential to quality patient care. Analgesics can reduce patient discomfort and narcotic analgesics often have a sedative effect, which are beneficial for patients who have sustained trauma or who have sustained injuries.
Related eMedicine topics:
Toxicity, Acetaminophen
Toxicity, Narcotics
Related Medscape topics:
Resource Center Adverse Drug Events Reporting
Resource Center Opioids: A Guide to State Opioid Prescribing Policies
Resource Center Pain Management: Advanced Approaches to Chronic Pain Management
Resource Center Pain Management: Pharmacologic Approaches
Acetaminophen and codeine (Tylenol #3)
Indicated for the treatment of mild to moderate pain.
Adult
30-60 mg/dose based on codeine PO q4-6h; not to exceed 12 tab/24 h
Pediatric
Codeine dose is 0.5-1 mg/kg/dose, acetaminophen 10-15 mg/kg/dose q4-6h
Toxicity increases when administered concurrently with CNS depressants.
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
Administer with caution in patients who are dependent on opiates because this substitution may result in acute opiate withdrawal symptoms; exercise caution when patients have severe renal or hepatic dysfunction.
Analgesic, Nonsteroidal Anti-inflammatory Drug
NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. The mechanism of action of these agents is not known, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation and various cell membrane functions. Many NSAIDs are currently on the market. In general, the mechanism of action of these agents is the same. No evidence exists that one NSAID is more efficacious than another; however, individual response may differ.
NSAIDs are discouraged beyond 5 days from the injury. It is thought that they may interfere with fracture healing.
Related eMedicine topic:
Toxicity, Nonsteroidal Anti-inflammatory Agents
Related Medscape topics:
Resource Center Adverse Drug Events Reporting
Resource Center Pain Management: Advanced Approaches to Chronic Pain Management
Resource Center Pain Management: Pharmacologic Approaches
Ibuprofen (Ibuprin, Advil, Motrin)
Member of the propionic acid group of NSAIDs. Available in low-dose form as an over-the-counter medication. Highly protein bound, metabolized in liver, and eliminated primarily in urine. May reversibly inhibit platelet function.
Adult
600-800 mg PO tid/qid
Pediatric
40 mg/kg PO divided tid/qid (recommended maximum daily dose)
Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; monitor PT duration closely (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
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
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of anticoagulation abnormalities or during anticoagulant therapy
More on Clavicular Injuries |
| Overview: Clavicular Injuries |
| Differential Diagnoses & Workup: Clavicular Injuries |
 Treatment & Medication: Clavicular Injuries |
| Follow-up: Clavicular Injuries |
| Multimedia: Clavicular Injuries |
| References |
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References
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Further Reading
Keywords
clavicular injuries, clavicle fracture, clavicle fractures, clavicle dislocation, shoulder injury, shoulder girdle injury, collar bone fractures, broken collar bone
