Clavicle Fracture

The clavicle, extending from the scapular acromion process to the manubrium sterni, serves as the sole skeletal connection between the upper extremity and the trunk and absorbs all medial forces imposed upon the upper arm. The clavicle consists of a double curve in the horizontal plane. Viewed from the front, the medial two-thirds is convex, while the lateral one-third is concave. The junction between the two curves represents its structurally weakest area and most frequently fractured site. The clavicle is the most commonly fractured bone in children.

Clavicle fractures may occur in the newborn as a result of shoulder compression during a difficult delivery. In the older infant, toddler, or child, the usual mechanism of fracture is a fall onto an outstretched hand or elbow or onto the side of a shoulder. Often, in younger children, the fracture is of the incomplete, or greenstick, type. A direct blow to the clavicle may also cause a fracture.

Diagnosis of clavicular fracture is facilitated by its subcutaneous location and the ease of its palpation on examination. Newborns with clavicle fractures may not be symptomatic. When they are symptomatic, it may come in the form of "pseudoparalysis," or nonuse of the ipsilateral upper extremity. Alternatively, parents or health care providers may notice the bone callus at 2 to 3 weeks of age, indicative of a fracture previously unappreciated.

Older infants and children with clavicular fractures have pain on attempted range-of-motion movement of the neck or upper extremity. Soft tissue swelling, point tenderness, and bone crepitance are indicative of the fracture site. In view of the close proximity of the clavicle to the subclavian vessels and lung, careful assessment of the circulation to the ipsilateral upper extremity and chest auscultation are important. Anteroposterior radiographs of the clavicle and shoulder are principally useful in excluding other associated skeletal injuries, particularly those involving the proximal humerus and scapular prominences. Dislocations of the sternoclavicular joint, particularly posterior dislocations of the proximal clavicle, are optimally visualized by lordotic views.

Care of the child with a clavicle fracture is principally directed toward comfort and analgesia for the child. The child's future bone growth and the modeling potential confer great healing and restorative capability to the fractured clavicle. Even displaced fractures nearly always heal well, whether or not strict anatomic reduction is accomplished in the emergency department.

"Figure-of-eight" shoulder abduction restraints are available in various sizes and can be offered to children outside infancy. Application should ensure a snug, symmetrical fit without excessive tightness or pinching. As is the case with the application of any orthopedic appliance, subsequent assessment of the child's neurovascular status in the upper extremities is mandatory. Some children, however, complain of greater discomfort with the figure-of-eight restraint than without. In such instances, the use of an upper extremity sling-and-swathe or shoulder immobilizer will offer adequate protection from the discomfort associated with shoulder and upper extremity movements.

Children with either type of immobilizing or restraint device are encouraged to wear the restraint day and night for 2 weeks, followed by daytime use for another 2 to 3 weeks. Oral analgesia sufficient to ensure the child's comfort is of paramount importance. Follow-up care can be arranged through the child's primary care physician or an orthopedic surgeon.

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