Fractures - Clavicle

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

Read the full PCH Emergency Department disclaimer.

Aim

To guide PCH ED staff with the assessment and management of clavicle fractures in children.

Background

  • Three quarters of clavicle fractures are midshaft
  • The majority of clavicle fractures are managed with analgesia and a broad arm sling
  • Most clavicle fractures do not require Orthopaedic follow up.

General

  • Clavicle fractures are common in all ages
  • The most common site is the mid shaft (75%)
  • Approximately half are greenstick
  • Epiphyseal (Salter-Harris I and II) fractures are very rare.

Aetiology

  • The most common mechanism of injury is a fall onto the shoulder
  • In neonates, it may be the result of birth injury – the clavicle is the most common obstetric fracture site
  • Examine for tenderness and swelling along the line of the clavicle
  • Infants may present with reluctance to use an arm without a good history of trauma.

Assessment

History

  • There is usually a history of a fall onto the shoulder or outstretched arm or a direct blow to the clavicle
  • Consider Non-Accidental Injury (NAI) in young children if there is an inadequate explanation for the fracture. Complete an Injury Proforma form for children < 2 years. 

Examination

  • There is usually tenderness or swelling along the clavicle
  • In the child with multiple injuries, clavicle fractures and upper rib fractures may be associated with injury of the great vessels or brachial plexus. Careful neurovascular examination of the ipsilateral arm should be performed.

Investigations

Radiology:

  • On the X-Ray request form, write clavicle, rather than shoulder – AP view of clavicle and 15 degree cephalad AP view will be done
  • A CT scan may be required for medial sternoclavicular dislocation
  • For general description of the types of fractures, see Fractures – Overview
  • The majority of clavicle fractures managed in a broad arm sling will heal uneventfully and without complication
  • Open fractures, tenting or blanching over overlying skin, maximal tenderness over acromioclavicular joint or altered sensation should be discussed urgently with the Orthopaedic Surgical Team.

Management

Initial management

  • Analgesia
  • Examine for neurovascular injury (if deficits evident manage immediately) – urgent Orthopaedic team referral
  • Ice the affected area
  • Consider tetanus and antibiotics for compound fractures

Further management

Middle third fractures

  • Middle third clavicle fractures rarely need reduction
  • Support in a broad arm sling for 3 weeks and provide adequate analgesia advice

Minimally displaced middle third clavicle fracture

Minimally displaced middle third clavicle fracture

Displaced middle third clavicle fracture

Displaced middle third clavicle fracture

Fractures requiring orthopaedic referral

  • Medial and lateral third clavicle fractures should be discussed with the Orthopaedic team and managed on their advice
  • Urgent Orthopaedic referral is required for displaced medial or lateral third fractures, open fractures, compromise of overlying skin or neurovascular compromise

Lateral third clavicle fracture

Lateral third clavicle fracture

Referrals and follow-up

Middle third fractures:

  • GP follow up in 1-2 weeks in non or minimially displaced fractures (no repeat X-Ray is required)
  • Orthopaedic Fracture Clinic follow up in 1-2 weeks if significant displacement. 

Lateral or medial third fractures:

  • Management as per Orthopaedic team’s advice
  • Orthopaedic Fracture clinic in 1-2 weeks. See Outpatient Clinics.

Health information (for carers)

  • Analgesia
  • Use of sling – child should wear the sling at all times (unless having a shower, bath). Sling should be a broad arm sling, appropriately sized for the child, and worn for 3 weeks.
  • No contact sport for 6 weeks
  • Provide GP letter
  • Advise parents that a bony lump usually develops at the fracture site and will be visible for up to a year
  • Care following fractured clavicle (PDF 61KB)
  • Pain management (PDF 188KB)



Endorsed by:  Director, Emergency Department   Date:  Jun 2017


 Review date:   Jun 2020


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