Clavicle Fracture

Clavicle Fracture
OVERVIEW
Clavicle fractures are one of the most common
fractures in children. They usually occur with a
fall onto the arm or shoulder. Usually, there is
mild displacement at the fracture site, but
length is usually maintained. Treatment is usually
with a sling or figure of 8 brace. Pain and
swelling improve after 2-3 weeks and healing is
usually pretty good by 6 weeks, with most
patients returning to full activities by 8 weeks.
The fracture site will fill in with new bone as healing progresses and it is common to have a small
bump or prominence at the fracture site
BACKGROUND
This fracture occurs most commonly in the 3 - 11 year old age group. The usual mechanism is a fall
onto the arm or shoulder. The fracture pattern and the degree of displacement can be variable,
CLINICAL PRESENTATION AND DIAGNOSIS
Children typically fall hard and have focal pain and swelling over the fracture. Xrays of the
clavicle confirm the diagnosis. If the fracture is nondisplaced there may be minimal swelling. A
young child may present with vague pain about the shoulder and the primary concern may be that
the child is not moving the arm, which can confuse the diagnosis. Children with displaced
fractures may show obvious deformity and swelling. Xrays are usually diagnostic.
TREATMENT
Treatment of most clavicle fractures is straight forward. The child is placed in a sling to partially
immobilize the arm or a figure 8 brace to hold the shoulder back. In theory, the figure 8 brace
pulls the clavicle into a “normal” alignment to help realign a displaced fracture. The figure 8 brace
should be tightened periodically during the day to maintain traction, but excessive tightening can
cause skin problems or swelling. One advantage of the figure of 8 brace is that it may allow more
use of the arm. The goal for early treatment is to minimize motion at the fracture site to reduce
pain and promote healing. Once tolerated, gripping exercises, wrist curls, and elbow flexion and
extension will help to reduce swelling in the lower arm that results from the injury and
immobilization. As pain improves, motion in the arm and shoulder is encouraged. After 3-4 weeks,
the fracture us generally healed enough to start motion, but full activities should not begin until
6 weeks, to avoid causing problems for healing and to avoid recurrent injury. Athletes who suffer
clavicle fractures will return to full athletic participation with little morbidity. Full return in
children is expected in 6 weeks. Full return for adolescents and adults is usually 6 to 12 weeks.
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PAIN MANAGEMENT
Fractures hurt and appropriate pain
management is important. With good pain
management, children will eat better, sleep
better, heal better, and have less
apprehension when they start working on
motion and return to activities. The
primary factors for pain include the injury,
motion and force at the site of injury, pain
medication, and supplemental measures.
Appropriate treatment of the fracture is
important and is described above. Activity should be minimized to reduce motion and force at the
injury site. Pain medications should be used as needed. Supplemental measures like distraction,
ice, elevation, other measures to control swelling, etc, should be used as beneficial.
Pain medications are important and generally, ibuprofen and Tylenol codeine, when given together,
provide good pain relief for most children. It is worth while to set an alarm (even in the middle of
the night) to stick to the schedule. It takes a few minutes to wake up and take the medicine, as
opposed to letting pain build up and spending hours trying to get it under control.
Ibuprofen is a non-steroidal anti-inflammatory medication, which has few side effects and low
risk, but is usually not strong enough for the first few days. For best effect, it should be given
every 8 hours for a least 5 days and as long as needed after that.
Tylenol codeine is a mild narcotic medication, which will provide better pain relief, but also has
more side effects, which often include sleepiness, nausea, constipation, etc. Pain relief is best and
side effects are minimized if dosing is adjusted based on the pain severity. Start by giving a full
dose every 4 hours. If pain relief is good, continue at the same dose or decrease the dose by half.
If pain relief is not adequate, increase the dose. It is best to not skip a dose and to not skip a
step.
In summary, the fracture should be treated as recommended, activity should be limited, and pain
medications should be used as needed according to the recommended schedule. Ibuprofen should
be given every 8 hours and tylenol codeine every 4 hours, adjusting the dose based on the level of
pain. Most kids are off the tylenol codeine within 2-3 days and off the ibuprofen by 5-7 days.
Children usually do very well are usually pain free within 5-10 days.
HYGIENE AND ACTIVITY
Hygiene and skin care is also important. It is acceptable to remove the sling or figure of 8 brace
for washing up and changing clothes. It should be possible to keep the arm relatively still, while
removing the sling or brace and clothes. This will help to minimize pain. A shirt can be removed by
taking the other arm out, lifting the shirt over the head and then sliding the shirt down the
injured arm.
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While the fracture is healing, it is important to take it easy. Sports and gym should be avoided.
There should be no running, jumping, climbing, and definitely no falling. This is best done by
staying off bikes, skates, skateboards, scooters, trampolines, monkey bars, slides, swings, etc. A
general rule of thumb is to keep 2 feet on the ground at all times.
EXPECTED OUTCOMES AND POTENTIAL COMPLICATIONS
For children, clavicle fractures are common and generally heal very reliably and without problems.
The fracture may heal with minor deformity, but motion and function are usually normal. There is
often a small bump or prominence at the fracture. This is rarely a problem and will often
decrease with time and growth. If there is severe deformity (shortening) or healing does not
progress as expected (nonunion), surgery can be done to realign and stabilize the fracture.
Surgery carries risks of infection, poor healing, incisions problems, and the operative site is close
to the lung and major blood vessels.
MORE INFORMATION
Further information can be obtained on the internet. Your local public library can help you explore
these sources if you are interested. Two good sites for expert and peer reviewed information are
the American Academy of Orthopedic Surgeons at www.aaos.org and www.emedicine.com.
FEEDBACK
If you have questions or comments, please contact the office or submit them to the web site at
www.pedortho.com.
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