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Paediatric Orthopaedic Pathways
Paediatric Orthopaedic Pathways

Clavicle fractures

ED Management | Outpatient/Fracture Clinic Management | Operative Management


ED Management

The following information is for use by medical practitioners and trainees in the Emergency Department:  

1.   Treatment pathway  
2.   What are likely findings on history?
3.   What specific information from the patient history should be documented?
4.   What are likely findings on clinical exam?
5.   What specific findings on the physical exam are important to document?
6.   What X-rays should be ordered?
7.   What specific features are found on X-ray?
8.   How should this fracture be treated in the emergency department?
9.   Should this patient be referred urgently to the nearest orthopaedic surgery service on call?
10. Where should this patient be seen for follow-up care?
11. What discharge prescriptions and instructions should be provided?
12. What potential complications could result from this injury or its management?

1. Treatment pathway

Uncomplicated Clavicle Fracture§ 

ED management

Follow-up care

  • Girl under 12 years old
  • Boy under 14 years old   

 

  • Analgesia
  • No reduction needed
  • Immobilize arm in broad arm sling
  • Ibuprofen for post-discharge analgesia
  • Provide SickKids Parent Information sheet- Clavicle fracture (PDF)

 

  • No follow-up care necessary (if emergency department care provider uncertain of diagnosis then follow up in Fracture clinic in 1 week)
  • No repeat X-rays required
  • Removal of sling at home in 3 weeks and begin range of motion exercises
  • Avoid activities that may result in re-injury for 12 weeks following injury
  • Girl over 12 years old with <100% displacement and <2cm shortening
  • Boy over 14 years old with <100% displacement and <2cm shortening

 

     

  • Analgesia
  • No reduction needed
  • Immobilize arm in broad arm sling
  • Ibuprofen for post-discharge analgesia
  • Provide SickKids Parent Information sheet- Clavicle fracture (PDF)
  • No follow-up care necessary (if emergency department care provider uncertain of diagnosis then follow up in Fracture clinic in 1 week)
  • No repeat X-rays required
  • Removal of sling at home in 3 weeks and begin range of motion exercises
  • Avoid activities that may result in re-injury for 12 weeks following injury
  • Girl over 12 years old with ≥100% displacement and ≥2cm shortening
  • Boy over 14 years old with ≥100% displacement and ≥2cm shortening
  • Analgesia
  • Keep NPO
  • Urgent referral to nearest orthopaedic surgeon on call for management
  • To be determined by treating orthopaeedic surgeon

§ Uncomplicated fracture implies the absence of: 

  • Open fracture
  • Skin tenting
  • Neurovascular compromise
  • Sternoclavicular dislocation
  • Medial 1/3rd clavicle fracture
  • Lateral 1/3rd clavicle fracture with 100% displacement
  • Other musculoskeletal injuries
  • Suspected Non-Accidental Injury
  • Re-fracture of the clavicle
  • Fracture through pathologic lesion

Any fracture with one or more of the above features should be referred urgently to the nearest orthopaedic surgeon on call for management

2. What are likely findings on history?

  • Mechanism of injury is usually a fall on an outstretched hand or a direct blow to the shoulder.
  • Clavicle fractures can also be the result of birth trauma.

3. What specific information from the patient history should be documented?

  • Document the date and time of injury.
  • Document the time of the last oral intake (all patients should be kept fasting until a decision has been made regarding the need and timing of orthopaedic intervention).

4. What are likely findings on clinical exam?

  • Pain, swelling and ecchymosis over the clavicle.
  • The arm is often held in adduction at the patient’s side and the patient is reluctant to move the shoulder.
  • Nerve palsies and vascular injuries are rare with isolated fractures but may be present in the presence of polytrauma or ipsilateral humerus fractures.
  • Fractures involving the medial third of the clavicle may be associated with difficulty or pain with breathing or swallowing.

5. What specific findings on the physical exam are important to document?

  • Fractures sustained due to high-energy mechanisms (e.g. motor vehicle collision, cross check during hockey, etc.) should be assessed using Advanced Trauma Life Support (ATLS) principles.
  • The presence of skin tenting.
  • The presence of an open fracture.
  • The presence of a peripheral nerve injury using the SickKids Peripheral Neurovascular Checklist (PDF).
  • The presence of an arterial injury or limb ischemia using the SickKids Peripheral Neurovascular Checklist (PDF).
  • The presence of an injury to the joints or bones above and below the injury (two-level injuries are at increased risk of having a brachial plexus palsy).

6. What X-rays should be ordered?

  • AP radiograph of the clavicle*.
  • No other views of the clavicle are routinely necessary.
  • If there are concerns of adjacent injuries, additional radiographs may be warranted.
  • If there are concerns of a medial physeal fracture or sternoclavicular dislocation then a CT scan may be warranted to assess compression of vital structures within the thorax.

*In order to minimize radiation exposure, point-of-care ultrasound is a diagnostic option if it is available and within the skill set of the emergency department physician

7. What specific features are found on X-rays?

If you are unfamiliar with interpreting clavicle radiographs, or need a refresher, click here.

Evaluation of the X-ray should include the location of the fracture (medial, middle, or lateral third), the amount of displacement (a percentage of the clavicle shaft diameter), the amount of fracture shortening (overlap), angulation and whether or not the fracture involves either the medial physis or lateral physis.  

Undisplaced midshaft left clavicle fracture with minimal angulation and no shortening compared to the uninjured right clavicle.

 


Minimally displaced lateral left clavicle fracture.


 

100% displaced midshaft left clavicle fracture with less than 2 cm of shortening. 


100% displaced midshaft left clavicle fracture with more than 2 cm of shortening.


3D CT reconstruction of right sternoclavicular posterior dislocation. Injuries to the sternoclavicular joint and fractures of the medial clavicle may be associated with compression of vital structures within the thorax. 


8. How should this fracture be treated in the emergency department?

  • Girl under 12 years old or Boy under 14 years old:
    • Analgesia: 
      • Oral:  Ibuprofen (10 mg/kg/dose, max. 600 mg) every 6 hours as needed, acetaminophen (15mg/kg/dose, max. 1000mg) every 6 hours as needed, and/or morphine (0.2-0.5mg/kg/dose) every 4 hours as needed. Ibuprofen is as effective as morphine in children with non-operative upper extremity fractures.
      • Intravenous:  morphine (0.1 mg/kg/dose), ketorolac (0.5 mg/kg/dose).
    • Uncomplicated clavicle fractures do not need a reduction in the ED.
    • Immobilize arm in broad arm sling.
  • Girl over 12 years old with < 100% displacement and < 2cm shortening or Boy over 14 years old with < 100% displacement and < 2cm shortening:
    • Analgesia: 
      • Oral:  Ibuprofen (10 mg/kg/dose, max. 600 mg) every 6 hours as needed, acetaminophen (15mg/kg/dose, max. 1000mg) every 6 hours as needed, and/or morphine (0.2-0.5mg/kg/dose) every 4 hours as needed. Ibuprofen is as effective as morphine in children with non-operative upper extremity fractures.
      • Intravenous:  morphine (0.1 mg/kg/dose), ketorolac (0.5 mg/kg/dose).
    • Uncomplicated clavicle fractures do not need a reduction in the ED.
    • Immobilize arm in broad arm sling.
  • Girl over 12 years old with ≥ 100% displacement and ≥ 2cm shortening and Boy over 14 years old with ≥ 100% displacement and ≥ 2cm shortening
    • Analgesia: 
      • Oral:  Ibuprofen (10 mg/kg/dose, max. 600 mg) every 6 hours as needed, acetaminophen (15mg/kg/dose, max. 1000mg) every 6 hours as needed, and/or morphine (0.2-0.5mg/kg/dose) every 4 hours as needed. Ibuprofen is as effective as morphine in children with non-operative upper extremity fractures.
      • Intravenous:  morphine (0.1 mg/kg/dose), ketorolac (0.5 mg/kg/dose).
    • Uncomplicated clavicle fractures do not need a reduction in the ED   
    • Immobilize arm in broad arm sling
    • Keep NPO
    • Urgent referral to nearest orthopaedic surgeon on call for management

9. Should this patient be referred urgently to the nearest orthopaedic surgery service on call?

Indications for emergent (within 1 hour) referral to the nearest orthopaedic surgeon on call include:

    • Loss of axillary, brachial or radial pulse or a cool, white hand.
    • Signs or symptoms of esophageal or tracheal compression.

Indications for urgent (within 4 hours) referral to the nearest orthopaedic surgeon on call include:

    • Fractures in a girl over 12 years old with ≥ 100% displacement and ≥ 2cm shortening
    • Fractures in a boy over 14 years old with ≥ 100% displacement and ≥ 2cm shortening
    • Associated nerve injuries
    • Open fracture
    • Impending open fracture (e.g. skin tenting)
    • Associated injuries to the elbow, forearm or wrist
    • Fractures through a bone cyst or pathologic lesion

Patients awaiting orthopaedic assessment in the emergency department should be kept nil per os (NPO) until a decision about surgery is made.

For open fractures, tetanus immunization status should be assessed and appropriate IV antibiotics provided.

 10. Where should this patient be seen for follow-up care?

    • Girl under 12 years old or Boy under 14 years old:
      • No follow-up care necessary (if emergency department care provider uncertain of diagnosis then follow up in Fracture clinic in 1 week).
      • No repeat X-rays required.
    • Girl over 12 years old with < 100% displacement and < 2 cm shortening or Boy over 14 years old with < 100% displacement and < 2 cm shortening:
      • No follow-up care necessary (if emergency department care provider uncertain of diagnosis then follow up in Fracture clinic in 1 week).
      • No repeat X-rays required.
    • Girl over 12 years old with ≥ 100% displacement and ≥ 2 cm shortening and Boy over 14 years old with ≥ 100% displacement and ≥ 2 cm shortening
      • To be determined by orthopaedic surgical service on call.

11. What discharge prescriptions and instructions should be provided?

    • Girl under 12 years old or Boy under 14 years old:
      • Ibuprofen (10 mg/kg/dose, max. 600 mg) every 6 hours as needed, acetaminophen (15mg/kg/dose, max. 1000mg), and/or morphine (0.2-0.5mg/kg/dose). Ibuprofen is as effective as morphine in children with non-operative upper extremity fractures.
      • Provide SickKids Parent Information Sheet- Clavicle fracture  (PDF).
      • Removal of sling at home in 3 weeks and begin range of motion exercises.
      • Activities that may result in re-injuring the clavicle should be avoided for approximately 12 weeks from the date of injury.
    • Girl over 12 years old with < 100% displacement and < 2cm shortening or Boy over 14 years old with < 100% displacement and < 2cm shortening:
      • Ibuprofen (10 mg/kg/dose, max. 600 mg) every 6 hours as needed is, acetaminophen (15mg/kg/dose, max. 1000mg) and/or morphine (0.2-0.5mg/kg/dose). Ibuprofen is as effective as morphine in children with non-operative upper extremity fractures.
      • Provide SickKids Parent Information Sheet- Clavicle fracture  (PDF).
      • Removal of sling at home in 3 weeks and begin range of motion exercises.
      • Activities that may result in re-injuring the clavicle should be avoided for approximately 12 weeks from the date of injury.
    • Girl over 12 years old with ≥ 100% displacement and ≥ 2cm shortening and Boy over 14 years old with ≥ 100% displacement and ≥ 2cm shortening:
      •  To be determined by orthopaedic surgical service on call.

12. What potential complications could result from this injury or its management? 

  • Fractures involving the middle third of the clavicle or sternoclavicular dislocations may injure or compress the subclavian artery, the esophagus, or the trachea.
  • Nerve palsies and vascular injuries are rare with isolated fractures but may be present in the presence of Polytrauma or ipsilateral humerus fractures.
  • Due to the remodeling potential of this region, the outcome from this fracture is usually excellent.
  • Due to normal fracture healing, a small bump may develop at the fracture site. The bump may diminish over the first 12 months but in older children and adolescents may not disappear completely.
  • By limiting return to high risk activities for 12 weeks, re-fracture is extremely rare.
  • Nonunion is extremely rare.

 

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Outpatient/Fracture Clinic Management

The following information is for use by medical practitioners and trainees in Fracture clinics or Outpatient clinics

The information below pertains to an uncomplicated fracture. An uncomplicated fracture implies the absence of:

    • Open fracture
    • Skin tenting
    • Neurovascular compromise
    • Sternoclavicular dislocation
    • Medial 1/3rd clavicle fracture
    • Lateral 1/3rd clavicle fracture with 100% displacement
    • Other musculoskeletal injuries
    • Suspected Non-Accidental Injury
    • Re-fracture of the clavicle
    • Fracture through pathologic lesion

1. When should this patient be seen in fracture clinic/outpatient clinic?
2. What should be reviewed at each clinic visit?
3. What are common reasons to deviate from the treatment pathway?
4. Does this patient require long-term follow-up?
5. Instructions for parents and SickKids Parent Information Sheets  

 

1. When should this patient be seen in fracture clinic/outpatient clinic?

  • Girl under 12 years old or Boy under 14 years old:  
    • No follow-up care necessary (if emergency department care provider uncertain of diagnosis then follow up in Fracture clinic in 1 week).
    • No repeat X-rays required.
  • Girl over 12 years old with < 100% displacement and < 2 cm shortening or Boy over 14 years old with < 100% displacement and < 2 cm shortening:
    • No follow-up care necessary (if emergency department care provider uncertain of diagnosis then follow up in Fracture clinic in 1 week).
    • No repeat X-rays required
  • Girl over 12 years old with ≥ 100% displacement and ≥ 2 cm shortening and Boy over 14 years old with ≥ 100% displacement and ≥ 2 cm shortening:
    • If orthopaedic surgeon did not recommended operative management at initial presentation then follow up in Fracture clinic at 1 week with:
      • No repeat X-rays required.
      • Clinical and radiographic review to determine if patient meets indications for operative management.

2. What should be reviewed at each clinic visit?

  • Girl under 12 years old or Boy under 14 years old:   

At first clinic:  

    • Confirm diagnosis
    • Assess analgesic requirements
    • Review range of motion exercises to be initiated at 3 weeks with aim for full function by 12 weeks

       Subsequent clinics:

    • No further follow up routinely required
  • Girl over 12 years old with < 100% displacement and < 2 cm shortening or Boy over 14 years old with < 100% displacement and < 2 cm shortening:

At first clinic:  

    • Confirm diagnosis
    • Measure displacement on initial radiograph (repeat radiographs are not necessary)
    • Measure shortening clinically
    • Assess analgesic requirements
    • Review range of motion exercises to be initiated at 3 weeks with aim for full function by 12 weeks.

        Subsequent clinics:

    • No further follow up routinely required.
  • Girl over 12 years old with ≥ 100% displacement and ≥ 2 cm shortening and Boy over 14 years old with ≥ 100% displacement and ≥ 2 cm shortening.

If orthopaedic surgeon did not recommended operative management at initial presentation then follow up in Fracture clinic at 1 week:

At first clinic:  

    • Confirm diagnosis
    • Measure displacement on initial radiograph
    • Measure shortening clinically
    • Decision for surgical management to be re-evaluated by treating orthopaedic surgeon
    • Assess analgesic requirements
    • Review range of motion exercises to be initiated at 3 weeks with aim for full function by 12 weeks.

Subsequent clinics:

    • To be determined by treating orthopaedic surgeon

3. What are common reasons to deviate from the treatment pathway?

Common reasons to deviate from the treatment pathway include:

    • Displacement or shortening beyond acceptable limits for continued non-operative management.
      • May require more frequent follow-up, additional investigations or referral to subspecialist for operative management.
    • Skin tenting
      • May require surgical management.
    • Patient underwent treatment in the operating room.
      • These patients should be followed up by their treating surgeon.
    • Established neurovascular injury.
      • May require more frequent follow-up, additional investigations or referral to subspecialist.
    • Re-fracture of the clavicle.
      • May require more frequent follow-up, additional investigations or referral to subspecialist for operative management.
    • Fracture through pathologic lesion.
      • May require additional investigations or referral to subspecialist.

4. Does this patient require long-term follow-up?

  • The vast majority of patients with clavicle fractures do not require long-term follow-up.
  • Patients that continue to have pain over the fracture site 6 weeks after the injury should return to clinic for further follow up.
  • Patients that have not regained normal shoulder movement 6 months after the injury should return to clinic for further follow up.

5. Instructions for parents and SickKids Parent Information Sheets

  • Contact sports and high-risk activities should be avoided for approximately 12 weeks from the date of injury to prevent refracture.
  • Instruct patient to return to clinic if they continue to have pain in the shoulder 6 weeks after the injury.
  • Instruct patient to return to clinic if full shoulder range of motion has not returned by 6 months. 
        • SickKids Parent Information Sheet- Clavicle fracture (PDF)

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Operative Management

Content under development

 

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References

  1. Bae DS, Shah AS, Kalish LA, Kwon JY, Waters PM. Shoulder motion, strength, and functional outcomes in children with established malunion of the clavicle. J Pediatr Orthop. 2013; 33(5):544–50.
  2. Caird MS. Clavicle shaft fractures: are children little adults? J Pediatr Orthop. 2012; 32(Suppl 1):S1–4.
  3. Calder JDF, Solan M, Gidwani S, Allen S, Ricketts DM. Management of paediatric clavicle fractures--is follow-up necessary? An audit of 346 cases. Ann R Coll Surg Engl. 2002 Sep; 84(5):331–3.
  4. Carry PM, Koonce R, Pan Z, Polousky JD. A survey of physician opinion: adolescent midshaft clavicle fracture treatment preferences among POSNA members. J Pediatr Orthop. 2011; 31(1):44–9.
  5. Cross KP, Warkentine FH, Kim IK, Gracely E, Paul RI. Bedside ultrasound diagnosis of clavicle fractures in the pediatric emergency department. Acad Emerg Med Off J Soc Acad Emerg Med. 2010 Jul; 17(7):687–93.
  6. Goldberg M. Correspondence: Displaced Clavicle Fractures in Adolescents : Facts , Controversies , and Current Trends.  JAAOS. 2013; 21(4):199.
  7. Hosalkar HS, Parikh G, Bomar JD, Bittersohl B. Open reduction and internal fixation of displaced clavicle fractures in adolescents. Orthop Rev (Pavia). 2012; 4:e1. (Retracted)
  8. Holsalkar H. Correspondence: Displaced Clavicle Fractures in Adolescents : Facts, Controversies, and Current Trends. JAAOS: 2013; 21(1):1–2.
  9. Kubiak R, Slongo T. Operative Treatment of Clavicle Fractures in Children: A Review of 21 Years. 2002; (9):736–9.
  10. Mehlman CT, Yihua G, Bochang C, Zhigang W. Operative Treatment of Completely Displaced Clavicle Shaft Fractures in Children. 2009; 29(8):851–5.
  11. Ogden JA. Distal Clavicular Physeal Injury. Clin Orthop. 1984; 188:68–73.
  12. Pandya H, Namdari S, Holsalkar H. Displaced Clavicle Fractures in Adolescents: Facts, Controversies, and Current Trends. JAAOS 2012; 20:498–505.
  13. Rickert J. Correspondence: Displaced Clavicle Fractures in Adolescents :Facts, Controversies , and Current Trends. JAAOS: 2013; 21(1):1.
  14. Robinson L, Gargoum R, Auer R, Nyland J, Chan G. Sports participation and radiographic findings of adolescents treated non-operatively for displaced clavicle fractures. Injury. 2015 Jul; 46(7):1372–6.
  15. Schulz J, Moor M, Roocroft J, Bastrom TP, Pennock AT. Functional and Radiographic Outcomes of Adolescent Clavicle Fractures. 2013; 1159–65.
  16. Shah RR, Kinder J, Peelman J, Moen TC, Sarwark J. Pediatric clavicle and acromioclavicular injuries. J Pediatr Orthop. 2010; 30(SUPPL. 2): S69–72.
  17. Vander Have KL, Perdue AM, Caird MS, Farley FA. Operative versus Non-operative Treatment of Midshaft Clavicle Fractures in Adolescents. 2010; 30(4): 307–12.

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Content developed by John Adamich and Dr. Mark Camp and approved by the SKPOP Committee on January 1st 2016.
To provide feedback, please email mark.camp@sickkids.ca