9.03 Collarbone (clavicle) fracture
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agk's Library of Common Simple Emergencies

Presentation
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The patient has fallen onto his shoulder or 
outstretched arm or more commonly has received 
a direct blow to the clavicle, and now presents 
with pain to direct palpation over the clavicle 
or with movement of the arm or neck. there may 
be deformity of the bone with swelling and 
ecchymosis. An infant or small child might 
present after a fall, not moving the arm, with 
a normal examination of the arm, but with the 
above findings.

What to do:
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- After completing a musculoskeletal examinat- 
    ion, evaluate the neurovascular status of 
    the arm.
- Fit a sling or clavicle strap which comfort- 
    ably immobilizes the arm. Patients probably 
    experience fewer complications and less 
    pain with a simple sling and there is no 
    difference in healing time.
- Prescribe analgesics, usually anti-inflamma- 
    tories like ibuprofen or naproxen, but 
    narcotics when significant pain is present 
    or anticipated.
- Obtain x-rays to rule out other injuries and 
    document the fracture for follow up.
- Arrange for orthopedic follow up in a week, 
    to evaluate healing and begin pendulum 
    excersises of the shoulder. Obtain rapid 
    orthopedic consultation if there is any 
    evidence of neurovascular compromise.

What not to do:
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- Do not apply a figure-of-eight dressing or 
    clavicle strap if this form of splinting 
    increases patient discomfort.
- Do not leave an arm immobilized in a sling 
    for more than a week. This can result in 
    loss of range of motion or "frozen 
    shoulder."

Discussion
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In children, fracture of the clavicle requires 
very little force and usually heals rapidly and 
without complication. In adults, however, this 
fracture usually results from a greater force 
and is associated with other injuries and 
complications. Clavicle fractures are sometimes 
associated with a hematoma from the subclavian 
vein, but other nearby structures, including 
the carotid artery, brachial plexus and lung, 
are usually protected by the underlying 
anterior scalene muscle and the tendency of the 
sternocleido-mastoid muscle to pull up the 
medial fragment of bone. A great deal of 
angulation deformity and distraction on x-ray 
are usually acceptable, because the clavicle 
mends and reforms itself so well and does not 
have to support the body in the meantime. As 
with rib fractures, respiration prevents 
immobilization, so the relief that comes with 
callus formation may be delayed another week.

References
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- Anderson K, Jensen PO, Lauritzen J: Treatment 
    of clavicular fractures: figure-of-eight 
    bandage versus a simple sling. *Acta Orthop 
    Scand* 1987;58:71-74.
- Stanley D, Norris SH: Recovery following 
    fractures of the clavicle treated 
    conservatively. *Injury* 1988;19:162-164.
- Eskola A, Vainionpaa S, Myllynen P et al: 
    Outcome of clavicular fracture in 89 
    patients. *Arch Orthop Trauma Surg* 
    1986;105:337-338.

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