Clavicular Fractures
Emergency Department Management of Clavicle Fractures
Written by: Nicole Messenger, MD. Faculty Reviewed by: Roseanne Naunheim MD. Edited by Adam Rieves, MD
Scenario:
It’s July 2, 2018 and you are the newly-minted MD on overnight in the emergency department. You’re up for a patient, and you see that a 19-year-old female has been slotted from triage into room 5 with the chief complaint on the chart reading “chest pain”. You got this—a healthy, young adult—starting your shift off on the right foot. You review the vitals charted, they all appear within normal limits. You review what history in the chart the triage staff obtained—19 year-old-female with acute left-sided chest discomfort that involves the shoulder and arm after trauma suffered during field hockey practice today. You also notice the triage doctor protocoled a single-view chest X-ray which you review. Ouch! The left clavicle appears to have seen better days. As you finish reviewing what is charted from triage, you ponder what else you will need to do for the patient while she is in the Emergency Department. Does she need to see a specialist? What further imaging would be necessary? What should you definitely not miss on examination…. What should you definitely examine on the patient? You grab your stethoscope and head for the patient’s room.
Epidemiology
Clavicle fractures occur frequently, representing 2.6% to 15% of all fractures [1]. In relation to shoulder girdle fractures, 44% are attributed to isolated clavicular fractures. Men more commonly experience these injuries, at 68%, and the left clavicle is most commonly injured at 61%. The clavicle bone is divided into three anatomical regions—the medial, midshaft, and lateral components. The midshaft is most frequently fractured (81%) while the medial region is least fractured (2%). The midshaft of the clavicle is also the most commonly fractured region in the first decade of life (88.2%) [1].
Phadnis J., Bain G.I. (2015) Clavicle Anatomy. In: Bain G., Itoi E., Di Giacomo G., Sugaya H. (eds) Normal and Pathological Anatomy of the Shoulder. Springer, Berlin, Heidelberg
Anatomy
The clavicle bones come into contact with multiple osseous and ligamentous structures. They are responsible for assisting with shoulder movement and protecting vital neurovascular and pulmonary structures. The medial end of the clavicle comes into contact with subclavian vessels, brachial plexus, and lung tissue. The lateral end completes the shoulder girdle and facilitates movement at the joint. The clavicle has two epiphyses, one at the medial and lateral end. The medial epiphysis is responsible for 80% of bone lengthening and the growth plate closes by 25 years of age. However, it is the midshaft of the clavicle that is most vulnerable to trauma as it has no surrounding soft tissue structures or muscle insertions to protect it.
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Normal shoulder ligaments: Anterior view
Imaging
Anterior-posterior (AP) radiographic imaging of the shoulder should be obtained to visualize the clavicles. If suspicion for fracture is high, but AP films do not reveal a fracture, then serendipity or 45-degree cephalic tilt views should be performed. Of note, medial-end clavicular fractures may not be visualized on plain radiographs. One study found 22% of medial clavicle fractures found on computed tomography (CT) imaging were missed on plain x-rays [5].
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.
Reproduced with permission from: Eiff, MP, Hatch, RL, Calmbach, W (Eds). Fracture Management for Primary Care, 2nd Edition, W.B. Saunders Company, Philadelphia 2002. Illustration used with permission of Elsevier Inc. All right reserved. Copyright ©2002 Elsevier Inc.
Emergency Department Treatment
Patients who will need prompt Orthopedic consultation or transfer for evaluation by an Orthopedic Surgeon for absolute surgical indications are those with open fractures, compromised skin involving the fracture site, neurovascular injury related to the fracture, fracture displacement equivocal to the width of the bone, and/or shortening of 15mm or more. If the fracture involves the lateral end of the clavicle, a discussion with an Orthopedic surgeon should be performed as these fractures carry a high rate of nonunion.
Courtesy of Robert L Hatch, MD, MPH. From Uptodate 2018. Shortening of greater than 4cm requires surgical consultation.
Medial component fractures of the clavicle are rare. They usually occur secondary to high-energy mechanisms like motor vehicle accidents. These fractures tend to be the least concerning injury as there are high associations of more life-threatening injuries secondary to the mechanism, such as pneumothorax and cervical spine injuries. Medial clavicle fractures have low incidence of neurovascular injuries or open fractures. The majority of these injuries are treated nonoperatively unless there is an absolute indication for surgery. Of note, recent studies show that patients with acute displaced fractures of 10mm or more do well with operative fixation [6]. A study by Robison et al. evaluated nonunion and malunion of fractures treated nonoperatively at 24 weeks post fracture. In this study, 8.3% of fractures at the medial aspect were found to not be united at 24 weeks [4].
The midshaft fractures are managed 80-90% nonoperatively. Relative indications for obtaining a surgical consultation with this specific fracture would be for evaluation of increased risk for significant nonunion and malunion. Patients at significant risk for this include the elderly, female sex, fracture comminution or any combinations of these factors [3]. Robinson’s study found only 4.5% of patients with midshaft fractures had nonunion at 24 weeks post injury. Nonoperative treatment ca be reserved for children and adolescents even with displacement of the fracture, those with simple, and those with little to no displacement of multi-fragmentary fractures as they are also low risk for nonunion or malunion [3]
Lateral-end clavicular injuries commonly require surgery secondary to high rates of nonunion when managed conservatively. One review found that patients who did not receive surgery for their distal clavicular fracture, 33.3% resulted in nonunion. Of those who did not receive surgery, their complication rate was only 6.7%. However, surgical treatment resulted in 1.6% of nonunion, but had an elevated complication rate of 22.2%. When compared to surgery, there were no significant differences between the different modalities of surgery and their rates of nonunion. Of note, this review does comment that non-operative patients did not suffer from poor functional outcome despite the nonunion. They stress that a complete conversation should be had with the patient [2]. Robinson’s study found nonunion occurred in 8.3% of lateral end fractures that were treated nonoperatively [4].
Sling immobilizer vs. Figure-of-eight bandage
For the nonoperative patient who can be managed conservatively, an arm sling immobilizer is ideal. Previously, figure-of-eight bandages were employed, however, studies showed patients had increased measures of discomfort and skin compromise with this immobilizer. Studies also showed no difference in outcomes between these two modalities for immobilization [7]. And, one study evaluated upper extremity deep venous thrombosis (dvt) and found an increased number of dvt in patients treated with figure-of-eight bandages compared to arm slings [8].
Scenario:
After obtaining your history, you perform a thorough physical exam. You note point tenderness over the left midshaft of the clavicle with no crepitus. Your examination of the left upper extremity shows no neurological deficits, 2+ palpable radial pulse, and capillary refill of less than 2 seconds. The range of motion of the left shoulder is limited only to pain. After ordering appropriate radiographic imaging and ensuring only a left midshaft fracture without displacement or comminution is seen on the film, you order oral pain control and an arm sling for the left upper extremity. You explain in detail the diagnosis of simple left clavicle midshaft fracture and reassure the patient she has no neurovascular injury or other reason to see an orthopedic surgeon immediately. You prescribe her adequate oral pain control and give her a referral to the orthopedist clinic for outpatient evaluation. You instruct her on gentle range of motion techniques and provide strict return precautions which she states complete understanding of. Your attending gives you a nod of approval before agreeing with your assessment and plan for the patient, and she is discharged home.
Reference:
1. Postacchini F, et al. Epidemiology of clavicle fractures. Journal of Shoulder and Elbow Surgery. Volume 11, Issue 5. Pages 452-456.
2. Oh JH and Kim SH. Treatment of distal clavicle facture: a systemic review of treatment modalities in 425 fractures. Archives of Orthopaedic and Trauma Surgery. April 2011, volume 131, issue 4, p ages 525-533.
3. Smekal V, et al. Shaft fractures of the clavicle: current concepts. Archives of orthopaedic and trauma surgery. June 2009, volume 129, issue 6, pp 807-815.
4. Robinson M, et al. Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. The journal of bone and joint surgery-American. July 2004. Volume 86, issue 7, pages 1359-1365
5. Throckmorton T and Kuhn J. Fractures of the medial end of the clavicle. Journal of shoulder and elbow surgery. Volume 16, Issue 1. Pages 49-54
6. Sidhu V, et al. The operative outcomes of displaced medial-end clavicle fractures. Journal of shoulder and elbow surgery. Volume 24. Issue 11. Pages 1728-1734
7. Ropars M, Thomazeau H, and Huten D. Clavicle fractures. Orthopaedics & Traumatoloy: surgery and research. Volume 103, issue 1. Pages S53-S59. Feb 2017
8. X. Ghislandy, N. Lecomte, T. Zapaterra, P. Garbuio, D. Lepage, L. Obert
Incidence of early venous thrombosis in functional treatment of middle-third clavicle fracture. Orthop Traumatol Surg Res, 98 (S) (2012), pp. 111-117