9.03 Collarbone (clavicle) fracture

agk’s Library of Common Simple Emergencies

Presentation

The patient has fallen onto his shoulder or outstretched arm or more commonly has received a direct blow to the clavicle, and now presents with pain to direct palpation over the clavicle or with movement of the arm or neck. there may be deformity of the bone with swelling and ecchymosis. An infant or small child might present after a fall, not moving the arm, with a normal examination of the arm, but with the bove findings.

What to do:

• After completing a musculoskeletal examination, evaluate the neurovascular status of the arm.
• Fit a sling or clavicle strap which comfortably immobilizes the arm. Patients probably experience fewer complications and less pain with a simple sling and there is no difference in healing time.
• Prescribe analgesics, usually anti-inflammatories like ibuprofen or naproxen, but narcotics when significant pain is present or anticipated.
• Obtain x rays to rule out other injuries and document the fracture for follow up.
• Arrange for orthopedic follow up in a week, to evaluate healing and begin pendulum excersises of the shoulder. Obtain rapid orthopedic consultation if there is any evidence of neurovascular compromise.

What not to do:

• Do not apply a figure-of-eight dressing or clavicle strap if this form of splinting increases patient discomfort.
• Do not leave an arm immobilized in a sling for more than a week. This can result in loss of range of motion or “frozen shoulder.”

Discussion

In children, fracture of the clavicle requires very little force and usually heals rapidly and without complication. In acults, however, this fracture usually results from a greater force and is associated with other injuries and complications. Clavicle fractures are sometimes associated with a hematoma from the subclavian vein, but other nearby structures, including the carotid artery, brachial plexus and lung, are usually protected by the underlying anterior scalene muscle and the tendency of the sternocleido-mastoid muscle to pull up the medial fragment of bone. A great deal of angulation deformity and distraction on x ray are usually acceptable, because the clavicle mends and reforms itself so well and does not have to support the body in the meantime. As with rib fractures, respiration prevents immobilization, so the relief that comes with callus formation may be delayed another week.

References

• Anderson K, Jensen PO, Lauritzen J: Treatment of clavicular fractures: figure-of-eight bandage versus a simple sling. Acta Orthop Scand 1987;58:71-74.
• Stanley D, Norris SH: Recovery following fractures of the clavicle treated conservatively. Injury 1988;19:162-164.
• Eskola A, Vainionpaa S, Myllynen P et al: Outcome of clavicular fracture in 89 patients. Arch Orthop Trauma Surg 1986;105:337-338.

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