You are in: eMedicine Specialties >
Emergency Medicine > TRAUMA AND ORTHOPEDICS
Fracture, Clavicle
Article Last Updated: Aug 13, 2007
AUTHOR AND EDITOR INFORMATION
Section 1 of 11  
Author: Lawrence C Brilliant, MD, Clinical Assistant Professor, Department of Primary Care and Community Services, Hahnemann University; Attending Physician, Department of Emergency Medicine, Doylestown Hospital
Lawrence C Brilliant is a member of the following medical societies: American College of Emergency Physicians
Editors: Francis Counselman, MD, Program Director, Chair, Professor, Department of Emergency Medicine, Eastern Virginia Medical School; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Tom Scaletta, MD, Past-President, American Academy of Emergency Medicine; Chairperson, Department of Emergency Medicine, Edward Hospital; Assistant Professor of Emergency Medicine, Rush Medical College and Cook County Hospital; 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; Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Author and Editor Disclosure
Synonyms and related keywords:
clavicular fractures, clavicula, collar bone, collarbone, displaced clavicle fractures
Background
Clavicular fractures are common injuries that account for approximately 5% of all fractures seen in the ED. In neonates and children, these fractures are very common and generally heal well. In adults, the force required to fracture the clavicle is greater, healing occurs at a slower rate, and risk of potential complications is higher.
Pathophysiology
The clavicle is the sole articulation of the shoulder girdle to the trunk. It protects major underlying vessels, lung, and brachial plexus. Displaced clavicle fractures can injure these structures because of their proximity and sharp edges. Approximately 80% of clavicle fractures occur in the middle third (class A), 15% involve the distal or lateral third (class B), and 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. Class B fractures are classified further as type I or nondisplaced, in which supporting ligaments remain intact with no significant displacement of fracture fragments (see Media file 2); type II or displaced, in which the coracoclavicular ligament ruptures with resultant upward displacement of the proximal segment because of sternocleidomastoid muscle (see Media files 3-4); and type III or articular surface, involving the acromioclavicular joint.
Frequency
United States
Clavicular fractures account for approximately 5% of ED visits for fractures.
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).
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. In young children, the fracture is often incomplete (ie, greenstick fracture) or a bowing deformity without definite fracture.
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
- 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
Dislocations, Shoulder
Fractures, Rib
Pneumothorax, Tension and Traumatic
Rotator Cuff Injuries
Sternoclavicular Joint Injury
Imaging Studies
- Routine clavicle radiography
- Fracture is usually demonstrated on an anteroposterior (AP) view.
- Apical lordotic views may be required to define the degree of displacement.
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
Prehospital Care
- Identify and treat associated life-threatening injuries.
- Use the ABC approach to the evaluation, 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): Treat with sling immobilization. Some prefer using a figure-of-eight clavicular splint, especially for displaced fractures.
- Class B (distal third fractures): Treat type I (nondisplaced) and type III (articular surface) fractures with sling immobilization. Immobilize type II (displaced) fractures in a sling and swathe. These may require orthopedic surgical fixation.
- Class C (proximal third): Treat nondisplaced fractures with sling immobilization. Displaced injuries may require orthopedic referral for surgical reduction. Neonatal fractures generally heal spontaneously in several weeks without special treatment.
Consultations
- Consult a trauma surgeon immediately when the patient has evidence of multisystem involvement.
- Orthopedic surgery
- Open fractures necessitate urgent consultation.
- Displaced fractures may need surgical repair, necessitating referral.
- Primary care provider may manage uncomplicated clavicle fractures.
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.
Drug Category: 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.
| Drug Name | Ibuprofen (Ibuprin, Advil, Motrin) |
|---|
| Description | 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 Dose | 200-400 mg PO q4-6h prn; not to exceed 3.2 g/d |
|---|
| Pediatric Dose | <6 months: Not established
6 months to 12 years: 20-40 mg/kg/d PO divided tid/qid
>12 years: Administer as in adults |
|---|
| Contraindications | Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding |
|---|
| 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 |
|---|
| 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 |
|---|
Drug Category: 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.
| Drug Name | Acetaminophen (Tylenol, Panadol, aspirin-free Anacin) |
|---|
| Description | 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 Dose | 325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d |
|---|
| Pediatric Dose | <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 |
|---|
| Contraindications | Documented hypersensitivity; known G-6-PD deficiency |
|---|
| Interactions | Rifampin can reduce analgesic effects; barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity |
|---|
| 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 |
|---|
| Drug Name | Hydrocodone bitartrate and acetaminophen (Vicodin ES) |
|---|
| Description | Drug combination indicated for relief of moderately severe to severe pain. |
|---|
| Adult Dose | 1-2 tabs or caps PO q4-6h prn |
|---|
| Pediatric Dose | <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 |
|---|
| Contraindications | Documented hypersensitivity; high-altitude cerebral edema; elevated intracranial pressure |
|---|
| Interactions | Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants increase toxicity |
|---|
| 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 |
|---|
| Drug Name | Acetaminophen and codeine (Tylenol #3) |
|---|
| Description | Drug combination indicated for treatment of mild to moderately severe pain. |
|---|
| Adult Dose | 30-60 mg/dose based on codeine content PO q4-6h or 1-2 tab q4h; not to exceed 12 tab/d |
|---|
| Pediatric Dose | 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 |
|---|
| Contraindications | Documented hypersensitivity |
|---|
| Interactions | CNS depressants or tricyclic antidepressants increase toxicity |
|---|
| 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 |
|---|
| Drug Name | Oxycodone and acetaminophen (Percocet) |
|---|
| Description | Drug combination indicated for relief of moderately severe to severe pain. DOC for aspirin-hypersensitive patients. |
|---|
| Adult Dose | 1-2 tab or cap PO q4-6h prn |
|---|
| Pediatric Dose | 0.05-0.15 mg/kg/dose oxycodone PO q4-6h prn; not to exceed 5 mg/dose oxycodone |
|---|
| Contraindications | Documented hypersensitivity |
|---|
| Interactions | Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants increase toxicity |
|---|
| 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 |
|---|
Drug Category: Antibiotics
Therapy must cover all likely pathogens in the clinical setting.
| Drug Name | Cefazolin (Ancef, Kefzol, Zolicef) |
|---|
| Description | 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 Dose | 2 g IV/IM q6-12h; not to exceed 12 g/d |
|---|
| Pediatric Dose | 25-100 mg/kg/d IV/IM divided q6-8h, depending on severity of infection; not to exceed 6 g/d |
|---|
| Contraindications | Documented hypersensitivity |
|---|
| Interactions | Probenecid prolongs effects; aminoglycosides may increase renal toxicity; may yield false-positive urine-dip test result for glucose |
|---|
| 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 |
|---|
| Drug Name | Gentamicin (Gentacidin, Garamycin) |
|---|
| Description | 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 Dose | 1.5 mg/kg IV; not to exceed 80 mg |
|---|
| Pediatric Dose | 2 mg/kg IV |
|---|
| Contraindications | Documented hypersensitivity; non–dialysis-dependent renal insufficiency |
|---|
| 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) |
|---|
| 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 |
|---|
| Drug Name | Ampicillin (Omnipen, Marcillin) |
|---|
| Description | 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 Dose | 2 g IV/IM |
|---|
| Pediatric Dose | 50 mg/kg IV/IM |
|---|
| Contraindications | Documented hypersensitivity |
|---|
| Interactions | Probenecid and disulfiram elevate levels; allopurinol decreases effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives |
|---|
| 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 |
|---|
| Drug Name | Vancomycin (Vancocin) |
|---|
| Description | 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 Dose | 1 g IV infused over 1 h |
|---|
| Pediatric Dose | 1 g IV over 1 h |
|---|
| Contraindications | Documented hypersensitivity |
|---|
| 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 |
|---|
| 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 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 |
|---|
Drug Category: Toxoid
This agent is used for tetanus immunization. A booster injection in previously immunized individuals is recommended to prevent this potentially lethal syndrome.
| Drug Name | Tetanus toxoid |
|---|
| Description | 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 Dose | 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 Dose | Administer as in adults |
|---|
| 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
|
|---|
| 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) |
|---|
| 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 |
|---|
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
- Brachial plexus compression resulting from hypertrophic callus formation (may cause peripheral neuropathy)
- Delayed union or nonunion (especially with distal third fractures)
- 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).
- Pneumothorax
- Subclavian artery and vein injury
- Internal jugular vein injury
- Axillary artery injury
Prognosis
- The prognosis is excellent in children.
- The prognosis is excellent in adults with proper follow-up care, early detection, and treatment of complications.
Patient Education
- Use of a sling and/or shoulder immobilizer
- Use of a figure-of-eight bandage (clavicle strap)
- 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.
Medical/Legal Pitfalls
- Failure to recognize and treat associated severe injuries
- Failure to refer patients at risk of complications to an orthopedist
| Media file 1:
Anatomy of the clavicle indicating potential fracture sites. |
 |  View Full Size Image | |
Media type: Illustration
|
| Media file 5:
Clavicle fracture with rib fractures. Remember to look for associated injuries. |
 | View Full Size Image | |
Media type: Radiograph
|
- Andersen K, Jensen PO, Lauritzen J. Treatment of clavicular fractures. Figure-of-eight bandage versus a simple sling. Acta Orthop Scand. Feb 1987;58(1):71-4. [Medline].
- Eiff MP. Management of clavicle fractures. Am Fam Physician. Jan 1997;55(1):121-8. [Medline].
- Post M. Current concepts in the treatment of fractures of the clavicle. Clin Orthop Relat Res. Aug 1989;(245):89-101. [Medline].
- Simon RR, Koenigsknecht SJ. The clavicle. In: Emergency Orthopedics-The Extremities. Appleton & Lange; 1996:199-205.
- Williams RJ. Significant pneumothorax complicating a fractured clavicle. J Accid Emerg Med. Sep 1995;12(3):218-9. [Medline].
- Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am. Jan 2007;89(1):1-10. [Medline].
Fracture, Clavicle excerpt Article Last Updated: Aug 13, 2007
|
