Bored Review – Clavicle Fracture

A fit, young female dressed in cycling gear presents to your emergency department with a chief complaint of shoulder pain. Just prior to arrival, she was participating in a bike race in Prospect Park. As she was sprinting to the finish, a menacing squirrel leaps out aggressively and tries to take a bite out of her legs!

She slammed on the brakes trying to avoid the rabid squirrel, but ended up flipping right over her handlebars, landing on her outstretched arm.

She immediately felt pain in her shoulder and developed a noticeable bulge. As an astute emergency physician, you’ve heard and seen this story before. This young female has a clavicle fracture and is yet another victim of the rabid squirrel of Prospect Park.

 

What is the anatomy of the clavicle?

The clavicle is the only bony connection between the arm and the trunk, articulating distally with the acromion (acromioclavicular joint) and proximally with the sternum (sternoclavicular joint). The clavicle protects the adjacent lung, brachial plexus, and subclavian and brachial blood vessels.

Picture Credit: UpToDate

What is the typical history and presentation?

The clavicle accounts for 5% of all fractures and is the most commonly fractured bone in children. The mechanism of injury is usually from high-energy trauma to the shoulder or from a fall on an outstretched hand.

Patients will present with pain over the fracture site and tend to hold the affected extremity close to his or her body.

Of note, clavicle fractures also occur in newborns during delivery, though this article will focus on injuries of children, adolescents, and adults.

What are the key physical exam features of clavicle fracture?

It is important to perform a neurovascular exam in patients with clavicle fractures because the clavicle overlies the subclavian artery, the subclavian vein, and the brachial plexus. Although rare, high-impact anterior forces to the proximal clavicle can lead to pneumothorax and/or pulmonary injuries.

The skin over the area of injury may show tenting, ecchymosis, or bleeding. Since the clavicle is very superficial, any skin tenting (see arrow below) can progress to an open fracture due to pressure necrosis of the skin from the clavicle itself.

Picture credit: Medscape

How are clavicle fractures diagnosed?

Standard shoulder and clavicle X-rays are very sensitive. For more subtle fractures, positioning the patient in the upright position or a 45-degree cephalad tilt view may be used. CT should be considered if it is not clear on X-ray and clinical suspicion for fracture is high and/or if there is concern for neurovascular or pulmonary injury.

Mid-Clavicular Fracture

Picture credit: Rosen’s Emergency Medicine

Clavicle fractures can also be seen on ultrasound, which can be especially helpful in saving younger children from exposure to radiation.

Normal Clavicle Ultrasound

Fractured Clavicle Ultrasound

 

How are clavicle fractures classified?

Clavicle fractures are classified anatomically into three groups. It is important to recognize these groups, because it has an influence on additional workup and disposition. The groups are listed below in order of incidence.

  1. Middle (~ 80% of fractures) – The usual mechanism is a direct force applied to lateral aspect of the shoulder as a result of fall, sporting injury, or motor vehicle collision.
  2. Lateral (~15% of fractures) – The usual mechanism is a direct blow to the top of the shoulder. There are 3 types of lateral fractures.
    • Type I – The coracoclavicular ligament is intact.
    • Type II – The coracoclavicular ligament is torn. These tend to displace because the proximal fragment lacks any stabilizing forces. There is a high risk of nonunion, so operative management may be indicated.
    • Type III – These are intra-articular fractures through the acromioclavicular (AC) joint.
  1. Medial/Proximal (~5% of fractures) – The usual mechanism is a direct blow to the anterior chest. Medial/Proximal injuries result from high impact and are often associated with intrathoracic injuries. As a result, there should be a low threshold to explore for associated neurovascular or pulmonary injuries.

How do we manage clavicle fractures?

In the ED, immediate orthopedic consultation should be sought for open fractures or fractures associated with neurovascular injuries, skin tenting, or interposition of soft tissues.

Otherwise, clavicle fractures can usually be managed non-operatively with immobilization. Patients should wear a sling until repeat X-rays of the clavicle show callus formation. This can take up to 2 to 4 weeks in younger children and 4 to 8 weeks in adolescents and adults. This can either be done with primary care follow up (for mild, nondisplaced fractures) or orthopedic follow up (for more displaced fractures with significant shortening).

Sling Over Swathe (Left) | Velpeau Sling Immobilization (Right) 

Picture Credit: Rosen’s Emergency Medicine

The orthopedic literature also suggests clavicular or figure-of-eight splints which can be applied after closed reduction of the clavicle fracture, though the evidence for its efficacy in the emergency setting is limited.

Figure-of-Eight Splint

Picture Credit: Rosen’s Emergency Medicine

There is growing evidence that operative management improves outcomes. This is especially true for any patients with risk factors for non-union such as shortening greater than 2 cm, comminuted fractures, or 100% displaced fractures. Orthopedics evaluation should be offered to all patients with these injury characteristics.

 

Sources:

Hatch, Robert L, James r. Clugston, and Jonathan Taffe. Clavicle fractures. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on July 30, 2017.)

Marx, John A, Robert S. Hockberger, Ron M. Walls, Michelle H. Biros, and Peter Rosen. Rosen’s Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Elsevier/Saunders, 2014. Print.

Tintinalli, Judith E, J S. Stapczynski, O J. Ma, David Cline, Garth D. Meckler, and Donald M. Yealy. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. , 2016. Print.

 

 

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Derick

PGY-2 Emergency Medicine Resident at SUNY Downstate Medical Center/King's County Hospital Center
Clinical Monster in Training @DrAlfonsoEM

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