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Emergency And Acute Medicine – Clavicle Fracture
Description And Classification
Clavicle fractures account for approximately 5% of all fractures across all age groups. The majority involve the middle third of the clavicle (about 80%), followed by distal-third fractures (15%) and medial-third fractures (5%). Fractures are classified anatomically into middle-third fractures (Group I), distal-third fractures (Group II), and medial-third fractures (Group III). Distal-third fractures are further subdivided based on ligament involvement: type I fractures have intact coracoclavicular ligaments and are nondisplaced, type II fractures involve disruption of the coracoclavicular ligaments, and type III fractures extend into the acromioclavicular joint.
Etiology And Risk Factors
Clavicle fractures most commonly result from direct trauma to the clavicle, a fall onto the lateral shoulder, or a fall onto an outstretched hand. In children, clavicle fracture is the most common pediatric fracture and may also occur in newborns as a result of birth trauma. In older adults, these injuries may significantly impair activities of daily living, making assessment of social support and home safety essential. In pregnant patients, clavicle fractures are caused by trauma, and evaluation must include assessment for associated injuries and fetal monitoring, as even minor trauma can affect fetal well-being.
Clinical Presentation
Patients typically present with localized pain, tenderness, and swelling over the clavicle. Crepitus is common because of the subcutaneous position of the bone. The affected arm is often held adducted against the chest wall with limited range of motion, and the shoulder may appear displaced anteriorly and inferiorly. Physical examination should include careful palpation of the clavicle and assessment of the shoulder and humerus for associated fractures, dislocations, or subluxations. It is essential to determine whether the fracture is open or closed and to evaluate for associated injuries, including cervical spine trauma, first-rib fractures with possible aortic injury, and sternoclavicular or acromioclavicular joint injuries.
Diagnostic Evaluation
Imaging is essential for diagnosis and assessment of associated injuries. Anteroposterior radiographs of both clavicles are mandatory and should include views of the upper humerus, shoulder girdle, and upper lung fields to exclude pneumothorax. Oblique and apical lordotic views may help visualize medial or distal fractures not clearly seen on standard views. Stress views are no longer routinely recommended for distal clavicle fractures. Angiography should be obtained if there is any concern for vascular injury, particularly involving the subclavian vessels.
Differential Diagnosis
Distal clavicle fractures should be differentiated from acromioclavicular joint separations, while medial fractures may mimic sternoclavicular joint injuries. Shoulder fracture–dislocations should also be considered.
Initial And Emergency Management
Prehospital care includes application of ice, pain control with nonsteroidal anti-inflammatory drugs or narcotics, and immobilization of the affected arm in a sling. Initial emergency department management focuses on airway stabilization and resuscitation as needed. Open clavicle fractures are uncommon but require immediate orthopedic consultation for surgical debridement and internal fixation. Closed fractures are managed based on fracture location and displacement. Nondisplaced middle-third fractures are typically treated with a sling or shoulder immobilizer. Although closed reduction may be attempted for displaced fractures, alignment is often difficult to maintain regardless of splinting technique. Distal-third fractures generally require immobilization, analgesia, and orthopedic follow-up, with type II and III fractures more likely to need operative repair. Medial-third fractures are treated with sling immobilization, pain control, and close orthopedic follow-up. Neurovascular status must be reassessed after immobilization.
Medication And Pain Control
Pain management may include acetaminophen or ibuprofen, with opioid analgesics reserved for adults with severe pain. Care must be taken to avoid excessive acetaminophen dosing, and opioid-containing medications should generally be avoided in pediatric patients.
Disposition And Follow-Up
Admission is indicated for open fractures or when associated life-threatening injuries are present. Patients with isolated, closed clavicle fractures may be discharged if pain is controlled, adequate home support is available, and orthopedic follow-up is arranged. Immediate orthopedic referral is required for open fractures, complex injuries, or any signs of neurovascular compromise.
Clinical Pearls And Pitfalls
Always maintain a high index of suspicion for associated life-threatening injuries, including cervical spine, aortic, and cardiopulmonary trauma. A careful neurologic and vascular examination is essential in all patients with clavicle fractures, as these associated injuries may be subtle on initial presentation.
Description And Classification
Clavicle fractures account for approximately 5% of all fractures across all age groups. The majority involve the middle third of the clavicle (about 80%), followed by distal-third fractures (15%) and medial-third fractures (5%). Fractures are classified anatomically into middle-third fractures (Group I), distal-third fractures (Group II), and medial-third fractures (Group III). Distal-third fractures are further subdivided based on ligament involvement: type I fractures have intact coracoclavicular ligaments and are nondisplaced, type II fractures involve disruption of the coracoclavicular ligaments, and type III fractures extend into the acromioclavicular joint.
Etiology And Risk Factors
Clavicle fractures most commonly result from direct trauma to the clavicle, a fall onto the lateral shoulder, or a fall onto an outstretched hand. In children, clavicle fracture is the most common pediatric fracture and may also occur in newborns as a result of birth trauma. In older adults, these injuries may significantly impair activities of daily living, making assessment of social support and home safety essential. In pregnant patients, clavicle fractures are caused by trauma, and evaluation must include assessment for associated injuries and fetal monitoring, as even minor trauma can affect fetal well-being.
Clinical Presentation
Patients typically present with localized pain, tenderness, and swelling over the clavicle. Crepitus is common because of the subcutaneous position of the bone. The affected arm is often held adducted against the chest wall with limited range of motion, and the shoulder may appear displaced anteriorly and inferiorly. Physical examination should include careful palpation of the clavicle and assessment of the shoulder and humerus for associated fractures, dislocations, or subluxations. It is essential to determine whether the fracture is open or closed and to evaluate for associated injuries, including cervical spine trauma, first-rib fractures with possible aortic injury, and sternoclavicular or acromioclavicular joint injuries.
Diagnostic Evaluation
Imaging is essential for diagnosis and assessment of associated injuries. Anteroposterior radiographs of both clavicles are mandatory and should include views of the upper humerus, shoulder girdle, and upper lung fields to exclude pneumothorax. Oblique and apical lordotic views may help visualize medial or distal fractures not clearly seen on standard views. Stress views are no longer routinely recommended for distal clavicle fractures. Angiography should be obtained if there is any concern for vascular injury, particularly involving the subclavian vessels.
Differential Diagnosis
Distal clavicle fractures should be differentiated from acromioclavicular joint separations, while medial fractures may mimic sternoclavicular joint injuries. Shoulder fracture–dislocations should also be considered.
Initial And Emergency Management
Prehospital care includes application of ice, pain control with nonsteroidal anti-inflammatory drugs or narcotics, and immobilization of the affected arm in a sling. Initial emergency department management focuses on airway stabilization and resuscitation as needed. Open clavicle fractures are uncommon but require immediate orthopedic consultation for surgical debridement and internal fixation. Closed fractures are managed based on fracture location and displacement. Nondisplaced middle-third fractures are typically treated with a sling or shoulder immobilizer. Although closed reduction may be attempted for displaced fractures, alignment is often difficult to maintain regardless of splinting technique. Distal-third fractures generally require immobilization, analgesia, and orthopedic follow-up, with type II and III fractures more likely to need operative repair. Medial-third fractures are treated with sling immobilization, pain control, and close orthopedic follow-up. Neurovascular status must be reassessed after immobilization.
Medication And Pain Control
Pain management may include acetaminophen or ibuprofen, with opioid analgesics reserved for adults with severe pain. Care must be taken to avoid excessive acetaminophen dosing, and opioid-containing medications should generally be avoided in pediatric patients.
Disposition And Follow-Up
Admission is indicated for open fractures or when associated life-threatening injuries are present. Patients with isolated, closed clavicle fractures may be discharged if pain is controlled, adequate home support is available, and orthopedic follow-up is arranged. Immediate orthopedic referral is required for open fractures, complex injuries, or any signs of neurovascular compromise.
Clinical Pearls And Pitfalls
Always maintain a high index of suspicion for associated life-threatening injuries, including cervical spine, aortic, and cardiopulmonary trauma. A careful neurologic and vascular examination is essential in all patients with clavicle fractures, as these associated injuries may be subtle on initial presentation.
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