Clavicle Fractures

In the US, we love to have Turkey on Thanksgiving… and on the next day (or maybe 2 days) we love to make a wish as we snap the poor turkey’s clavicles. In the ED, we encounter clavicle fractures all of the time… and feel like they are easy to deal with… so let’s just take a minute to ensure that we are managing them correctly.

1. Clavicle fractures account for 10-15% of all fractures in children
2. In children the majority (~90%) occur in the midshaft area

3. Therapy should be “individualized based on fracture characteristics and patient expectations.”
⇒ Medial Third fracture
(1) Most uncommon
(2) Frequently non-displaced or minimally displaced.
(3) Nearly always treated non-surgically
(a) Sling has shown to have similar outcomes to figure 8 brace, but is better tolerated.
(b) 2 – 6 weeks
(4) Surgery would be indicated for:
(a) Fracture segment encroaches on mediastinal structures
(b) Soft-tissue tenting or open fracture
(c) Involved with multiple trauma and/or “floating shoulder”
(5) The medial epiphysis of the clavicle does not ossify until age 20 and rarely fuses before 25 years.
(a) CT scan may be needed to distinguish between physeal separation from true sternoclavicular joint dislocation
(b) Treatment differs considerably.
(6) AVOID contact sports for 4 – 5 MONTHS.

⇒ Middle Third fracture
(1) Most common site of clavicle fracture
(2) Most are treated non-operatively
(a) Children have overall better outcomes than adults and rarely require surgery
(b) Better remodeling allows for less non-union and malunion.
(c) Sling (or figure 8 brace)
(3) Surgery required for:
(a) Skin tenting
(b) Open fracture
(c) Neurovascular compromise (big blood vessels and nerves live right under it!)
(d) Multiple trauma and/or “floating shoulder”
(4) Surgery may also be needed for:
(a) Clavicular shortening greater than 1.5 – 2cm
(b) > 100% displacement or significant comminution
(c) Active, young patients (ex. athletes)
(d) Cosmetic deformities
(5) AVOID contact sports until radiographic evidence of healing is noted (~6-8 weeks)

⇒ Lateral Third fracture
(1) 2nd most common site of clavicle fracture
(2) Less likely to be displaced than middle third fractures
(3) The physis of the lateral clavicle fuses around age 25 yrs.
(a) Most injuries of the lateral end of the clavicle are physeal separation, not fractures
(b) The Acromioclavicular and the Coracoclavicular (CC) ligaments are stronger than the physis.
(4) Most heal well without surgery
(a) Do well when there is no or minimal displacement
(b) Sling and analgesics.
(5) The indication for surgery is based on the stability of the fracture segments
(a) The integrity of the CC ligaments plays key role in stabilizing the fracture fragments.
(b) If the CC is disrupted, then there is a high (~28%) rate of non-union.
(6) Surgery required for:
(a) Moderate or significant displacement of fracture fragments
(b) Open fracture
(c) Skin tenting

So, when you are diagnosing a clavicle fracture, before you say “these heal just fine,” take a moment and consider:
– Where is this fracture… and what lies beneath it?
– What does my patient do (Athlete? Carpenter throwing a hammer at nails all day?)?
– Is there 2 cm of shortening or >100 % displacement for the middle third fractures?
– Is there any significant displacement for the later third fractures?
– What is the cosmetic outcome? May my patient want to wear an off-the-shoulder dress one day? {Stop laughing… I have a daughter and have to consider these things!!}

van der Meijden OA, Gaskill TR, Millett PJ. Treatment of clavicle fractures: current concepts review. J Shoulder Elbow Surgery (2011) Nov 5.

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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