AUTHOR AND EDITOR INFORMATION

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• Clinical
• Differentials
• Workup
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• Medication
• Follow-up
• Miscellaneous
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INTRODUCTION

Section 2 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
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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.

CLINICAL

Section 3 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

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

DIFFERENTIALS

Section 4 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

WORKUP

Section 5 of 11  

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• Differentials
• Workup
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• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

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

TREATMENT

Section 6 of 11  

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• Follow-up
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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.

MEDICATION

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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 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	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	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.

FOLLOW-UP

Section 8 of 11  

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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.

MISCELLANEOUS

Section 9 of 11  

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Medical/Legal Pitfalls

• Failure to recognize and treat associated severe injuries
• Failure to refer patients at risk of complications to an orthopedist

MULTIMEDIA

Section 10 of 11  

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Media file 1:  Anatomy of the clavicle indicating potential fracture sites.
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Media type:  Illustration

Media file 2:  Nondisplaced middle clavicle fracture.
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Media type:  Radiograph

Media file 3:  Displaced fracture of middle clavicle.
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Media type:  Radiograph

Media file 4:  Displaced middle clavicle fracture.
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Media type:  Radiograph

Media file 5:  Clavicle fracture with rib fractures. Remember to look for associated injuries.
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Media type:  Radiograph

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
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• Follow-up
• Miscellaneous
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• References

• 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].

Article Last Updated: Aug 13, 2007