Clavicular Fracture


Pathophysiology

Classification

Diagnosis

Treatment

Indications for Ortho Consult:


Pediatric Clavicular Fx

Background

  • Pathology
    • Birth trauma
    • Falls
  • Incidence
    • Nearly half of all clavicle fxs occur in children under 7 years
    • Most freq broken in children
  • Risk factors
    • Difficult delivery
    • Falls
  • Morbidity/ mortality
    • Complications
      • 5% of clavicle fxs are associated w/brachial plexus injuries
      • Non-healing and neurovascular compromise are very rare

Diagnosis

  • History
    • Fractures of clavicle are common in pediatrics
    • Diagnosis and tx vary by age

NEONATES

  • Due to birth trauma; occur in 3% of live births
    • Most unrecognized
    • May be diagnosed weeks later by presence of a hard lump along clavicle
  • Fracture may be recognized at delivery by
    • Audible "pop"
    • Crepitance at the fracture site
    • Unequal Moro reflex
  • Treatment
    • Reassurance; usually heals within 2 wks
    • Inform parents that a bump will temporarily be felt along clavicle

TODDLERS AND OLDER CHILDREN

  • Most common childhood fx
  • Secondary to falls
    • With arm outstretched
    • On lateral aspect of shoulder
  • Greenstick and buckle fractures common
    • May only see bowing deformity on X-ray
    • Comparison views may be necessary for diagnosis
  • Clavicular physis last to close (age 21-25); Salter I type fx can occur
    • Distal clavicular physeal separation
    • Analogous to adult AC separation
    • Heals spontaneously w/o need for immobilization
  • Clinically findings
    • Pain
    • Swelling
    • Dangling arm or held supported by uninjured hand
    • Depressed shoulder
      • Proximal fragment elevated by sternocleidomastoid muscle
      • Distal fragment pulled down by weight of limb
  • X-rays
    • AP, serendipity views
    • U/S is safe, reliable alternative to radiographs for pediatric pts presenting w/ suspected isolated, closed clavicle fx
  • Treatment
    • Immobilization w/ sling or figure-of-8 bandage
      • Toddlers for 10 days
      • Young children for 2-3 wks
      • Older children 3-4 wks
    • Analgesics
    • Inform parents that callous formation will cause a lump
      • Will eventually be remodeled and unnoticeable
    • Surgery rarely indicated, except with neurovascular or skin compromise

 

Treatment Summary/Table

Middle Third Clavicle Fractures

  Initial Treatment
Splint type & position Figure-of-eight clavicle strap with shoulders in “position of attention” or arm
sling
Sling preferable for nondisplaced fractures or plastic bowing in children
Initial follow-up visit 1 to 2 weeks to assess pain level and healing
Pt instructions If using figure-of-eight, keep strap tight to hold shoulders in position
  Follow-up Care
Cast or Splint type & position Figure-of-eight clavicle strap or arm sling
Length of immobilization 4 to 8 weeks or until fracture site is nontender
3 to 6 weeks in children
Healing time 6 to 12 weeks in adults
3 to 6 weeks in children
Follow-up visit interval Every 2 to 3 weeks
Repeat radiography interval At 6 weeks to assess callus and when clinical healing achieved
Pt instruction Use of the arm as pain permits
Avoid contact sports or activities with potential for falling for 1 to 2 months after clinical and radiographic healing.
Bony deformity possible.
Indications for Ortho consult Tenting of skin
Open fracture
Neurovascular compromise
> 2 cm overlap of bone
Consider referral for all patients with displacement greater than one bone width, especially if comminution or significant shortening is present or if the patient is concerned about cosmetic result.
Symptomatic malunion and nonunion (after 12 weeks)
 

Distal Third Clavicle Fractures

  Initial Treatment
Splint type & position Type I and III: arm sling
Type II: DO NOT use figure-of-eight; sling and swath until seen by orthopedist
Initial follow-up visit 1 to 2 weeks to assess pain level and healing
Pt instructions Wear sling continuously until follow-up visit
  Follow-up Care
Cast or Splint type & position Type I and III: arm sling
Type II: sling and swath postoperatively
Length of immobilization Type I and III: 3 to 6 weeks or until pain subsides
Type II: 6 to 8 weeks
Healing time Type I and III: 6 to 8 weeks
Type II: 8 to 12 weeks
Follow-up visit interval Every 2 to 3 weeks
Repeat radiography interval After clinical healing or for late symptoms
Pt instruction Type I and III: gradual increased activity as symptoms allow
Avoid contact sports or activities with potential for falling for 1 to 2 months after
clinical and radiographic healing
Type II: persistent and painful arthritis of acromioclavicular joint possible
Indications for Ortho consult Type II fractures
If type III fracture remains symptomatic despite conservative therapy, resection of the distal clavicle may be necessary
 

Proximal Third Clavicle Fractures

  Initial Treatment
Splint type & position Arm sling
Initial follow-up visit 1 to 2 weeks to assess pain level and healing
Pt instructions Wear sling continuously until follow-up visit
  Follow-up Care
Cast or Splint type & position Arm sling for comfort
Length of immobilization 3 to 6 weeks or until fracture site is nontender
Healing time 6 to 8 weeks
Follow-up visit interval Every 2 to 3 weeks
Repeat radiography interval After clinical healing or for late symptoms
Pt instruction Use of the arm as pain permits
Avoid contact sports or activities with potential for falling for 1 to 2 months after clinical and radiographic healing
Indications for Ortho consult Neurovascular injury
Symptomatic nonunion
Posttraumatic arthritis
 

Distal clavicle fracture type I



This plain radiograph shows a type I fracture of the distal clavicle with mild angulation. Intact ligaments hold the proximal fragment in normal position.


Distal clavicle fracture type II A

Distal clavicle fracture type II B

Xray of distal clavicle fracture: Type II


Distal clavicle fracture type III


Clavicle fracture with callus


This close up view from a plain radiograph shows a completely displaced middle third fracture, two weeks after injury. In this young male, early callus is already present along the periosteum between the two fracture fragments (arrow). Because the injury was two weeks old and healing was well underway, conservative treatment was instituted


Clavicle fracture with nonunion


Several months after sustaining a clavicle fracture, the patient continued to have daily pain with arm movement. Gentle manipulation of the proximal clavicle produced palpable motion at the fracture site. Careful scrutiny of the radiograph reveals a subtle lucency through the callus (arrow).



 

Cephalic view of clavicle fracture


This midshaft clavicle fracture cannot be appreciated with standard views (radiograph on left). However, by using the 45-degree cephalic tilt view (radiograph on right), bone angulation and a fracture line become apparent

 

Comminuted clavicle fracture


 This plain radiograph shows a middle third clavicle fracture with comminution (3rd bone fragment clearly seen between proximal and distal fragments). Nonoperative management was chosen because the fracture was nondisplaced.

 

Midshaft clavicle fracture with shortening



 This plain radiograph shows complete displacement of a middle-third fracture of the left clavicle, with marked shortening (over 4 cm). Patients with severe fracture displacement have better outcomes with operative treatment.


 

Midshaft clavicle fracture with superior displacement


A fracture of the middle third of the clavicle with complete displacement is shown. Note the typical upward displacement of the proximal fragment caused by the pull of the sternocleidomastoid muscle. Displacement is approximately two and one half times the width of the clavicle, greater than is typically seen


Figure Of 8