Clavicular fractures are common and represent approximately 5% of all fractures.1–3 Most of these occur at the junction of the middle and distal third of the clavicle, just medial to the coracoclavicular ligament. The clavicular fracture is the most common fracture encountered in childhood and occurs most often as a result of a fall. These fractures are usually detectable clinically, with plain radiographs helping to confirm the diagnosis. Although these fractures are relatively common, there is a small but definite risk of associated complications.
Anatomy and Pathophysiology
The clavicle is the only bony attachment of the upper extremity to the axial skeleton. It serves as a strut to support the shoulder girdle. It provides support and stabilization of the upper limb while allowing a broad range of movements. The clavicle is securely attached at both the acromioclavicular and sternoclavicular joints by ligaments (Figure 90-1). The great vessels of the upper extremity and nerves of the brachial plexus pass posteriorly to the clavicle at its midportion where it overlies the first rib. The proximity of these neurovascular structures, as well as the underlying lung, accounts for most of the potential complications of clavicular fractures.
The clavicle serves as a strut between the torso and upper extremity; it is held firmly by the acromioclavicular and sternoclavicular ligaments. The brachial plexus and great vessels pass behind the middle third of the clavicle.
The most commonly used classification for clavicular fractures was proposed by Allman.4 This simple classification is useful clinically and mechanistically to the EP. Group I fractures are midclavicular and account for approximately 80% of clavicular fractures. These most often result from a shearing force applied to the lateral aspect of the shoulder. Group II fractures involve the distal third of the clavicle and account for approximately 15% of all clavicular fractures. These most often result from a direct blow to the top of the shoulder. Several additional subclassifications have been proposed for these fractures based on the location of the fracture and associated ligamentous injury. Operative repair is suggested for some of these subtypes. All distal clavicular fractures should therefore be referred for follow-up within 24 hours to an Orthopedic Surgeon.1,2 Group III fractures represent about 5% of clavicular fractures and involve the proximal third of the clavicle. They often result from a direct blow to the chest.
Patients with clavicular fractures are easily identified clinically. The clavicle is almost entirely subcutaneous, allowing most fractures to be palpated. Presenting signs and symptoms include localized pain, ecchymoses, and edema. Physical examination findings include superior and posterior displacement of the proximal portion of the clavicle due to traction from the sternocleidomastoid muscle (Figure 90-2). The shoulder is often displaced inferiorly by the weight of the upper extremity and the force of gravity. Medial displacement of the shoulder may be seen due to traction from the pectoral and the latissimus dorsi muscles.
Displacement of the clavicle and shoulder after a clavicular fracture. The clavicular head of the sternocleidomastoid muscle displaces the proximal clavicular fragment superiorly and posteriorly (1). The pectoralis major and latissimus dorsi muscles pull the shoulder medially (2). The force of gravity displaces the distal clavicle and shoulder inferiorly (3).
Most fractures are readily identifiable on standard anteroposterior radiographs. Some group II and III fractures may not be readily identifiable.1 Additional views at a 45° angle cephalad (apical lordotic view) or 15° posteroanterior radiograph may be useful to assess displacement.1,3,11 Evaluation of fracture union with spiral computed tomography may allow the best assessment of displacement. Computed tomography is usually required for adequate visualization of medial-end fractures, particularly those extending into the sternoclavicular joint.12 Special views (e.g., cone views, tomograms, and upper rib films) may be required and are best determined in consultation with an Orthopedic Surgeon.
Clavicular injury and pain in children present two concerns. First, nondisplaced greenstick fractures to the clavicle may not be radiographically visible for 7 to 10 days.2,3 Clinical suspicion of a clavicular fracture with a negative radiograph should prompt conservative management. Follow-up should be arranged for 7 to 10 days after the injury to obtain repeat radiographs. Second, it may be unclear if the epiphyses are involved in some group II and III fractures.2,3 Any fracture through the epiphysis, or possibly through the epiphyses, requires an urgent referral to an Orthopedic Surgeon.
Reduction of clavicular fractures is necessary in a few circumstances. It is required if neurologic and/or vascular compromise is present in the affected extremity. This includes medial fracture displacement producing superior mediastinal compromise. In these circumstances, an emergent attempt at closed reduction should be made.11,13 Consider patients who are actively involved in athletics or have jobs that require overhead use of their arms (e.g., painters) for operative reduction by an Orthopedic Surgeon. Distal clavicular fractures that are displaced should be reduced. Otherwise, reduction is optional and at the discretion of the treating physician.
Reduction of most clavicular fractures is not usually necessary in either the pediatric or adult patient.1,2 A sling for simple arm support provides results comparable to the figure-of-eight reduction without the risk of brachial plexus injury or patient discomfort.1–3 The sling may be additionally supported by a swath (Figure 90-3A) or a Velpeau wrap (Figure 90-3B). However, many physicians still prefer the use of a figure-of-eight strap (Figures 90-3C & D). The figure-of-eight splint still represents the treatment of choice in patients over the age of 10 years in the presence of greatly displaced fragments.2,3 Despite this, there is no evidence that the figure-of-eight splint offers any advantage over a simple sling for midclavicular fractures. It is of note that the rates of compression of the neurovascular bundle, axillary pressure sores, and nonunion are higher in patients treated with the figure-of-eight splint.11,12
Treatment of clavicular fractures. A. Sling-over-swath immobilization. B. Velpeau sling immobilization. C. Anterior view of the figure-of-eight splint D. Posterior view of the figure-of-eight splint.
Contraindications to the reduction of a clavicular fracture include other injuries that represent a threat to life or limb. The patient's airway, breathing, and circulation must first be addressed and stabilized. Patients with open clavicular fractures require emergent consultation with an Orthopedic Surgeon, intravenous antibiotics, and hospital admission for possible open reduction and internal fixation. Reduction is also contraindicated if an expanding hematoma, indicative of a vascular injury, is observed. Finally, unfamiliarity with technique is a relative contraindication.
Explain the risks, and benefits of the reduction technique and aftercare to the patient and/or their representative. As with any procedure, informed consent should be obtained. Consider the administration of oral, intramuscular, or intravenous analgesics for patient comfort during the procedure. Procedural sedation is not needed or required for this fracture reduction.
Sit the patient upright on the side of the stretcher with their feet on the floor. Alternatively, the patient may be standing upright. Stand behind the patient. Grasp and pull both of the patient's shoulders backward as if the patient were standing at attention. Instruct an assistant to apply the figure-of-eight splint while the patient is in this position. Apply the splint like a backpack and tighten the straps (Figures 90-3C & D). Reassess the neurologic and vascular integrity of the affected extremity after applying the splint.
The neurologic and vascular integrity of the upper extremity should be assessed for all patients both initially, following any reduction attempts, and after the application of a figure-of-eight splint. Any neurologic and/or vascular compromise requires an emergent consultation with an Orthopedic Surgeon.
Patients with uncomplicated fractures should be referred to an Orthopedic Surgeon in 7 to 10 days. Patients with group II distal fractures and any fracture in a child potentially involving the epiphysis should have an urgent consultation with an Orthopedic Surgeon within 24 to 48 hours. Any patient with neurologic or vascular compromise, a pneumothorax, or signs of vascular injury should be admitted to the hospital after an emergent consultation with an Orthopedic Surgeon.
Once the acute pain has subsided, the use of the sling can normally be discontinued and patients are encouraged to participate normal activities as pain allows. Most patients respond well to self-administered range-of-motion exercises. Recovery of the range of motion of the shoulder is usually swift, and supervised physiotherapy is very rarely required.13
General principles of orthopedic care are recommended. These include the application of ice, rest, nonsteroidal anti-inflammatory drugs, and narcotic analgesics as needed. Most patients find the figure-of-eight splint difficult to apply, extremely uncomfortable, and remove it shortly after its application. If the patient tolerates the splint, it should be tightened daily. The figure-of-eight splint should be worn until there is evidence of clinical union and the arm can be abducted without pain. This generally requires 3 to 5 weeks in children and 6 or more weeks in adults.1,2 It may be more advantageous to apply a sling and swath or a sling and Velpeau wrap for patient comfort and compliance (Figures 90-3A & B). The outcomes of applying a figure-of-eight splint versus a sling are equivalent.18,19 Alternatively, apply a shoulder immobilizer.
The sling is used to immobilize and elevate the elbow, forearm, and hand. It is also used to support the upper extremity. Slings are often used to support casts or splints of the upper extremity. These devices are simple, inexpensive, and effective. It is imperative that the sling not be too short to allow the wrist and hand to hang over the sling. This can result in an ulnar nerve neuropraxia.
The addition of a swath to a sling is used to immobilize dislocated shoulders that have been reduced and proximal humeral fractures (Figure 90-3A). The swath immobilizes the humerus against the torso to limit motion at the shoulder. A shoulder immobilizer may be substituted for a sling and swath.
The Velpeau wrap is a sling-and-swath technique that positions the forearm diagonally rather than horizontally (Figure 90-3B). The Velpeau wrap has no practical advantages over a sling and swath.
Complications of the reduction procedure include injuries to the brachial plexus, subclavian artery, and/or vein.1,2 Commonly, these are the result of the initial injury and not the reduction procedure. It is imperative to perform a neurologic and vascular examination prior to and after any attempt at reducing a clavicular fracture. Any neurologic or vascular deficit requires an immediate consultation with an Orthopedic Surgeon.
Clavicular fractures are common, easily diagnosed, and often treated in the ED. Fractures of the distal or medial third may be more challenging. Although the incidence of complications is low, a thorough search for resultant or concomitant injury is required. Any evidence of neurologic or vascular compromise requires an emergent consultation with an Orthopedic Surgeon.