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Anteroposterior radiograph of a 19-year-old man with a left clavicle fracture sustained after falling off his dirt bike.
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Zanca view radiograph of the patient
A 19-year-old man presents with a left clavicle fracture that he sustained 2 days earlier. He was riding his dirt bike when he fell off, landing directly on the shoulder. He denies any numbness or tingling in the left upper extremity. On examination, his skin over the clavicle is intact without tenting. Anteroposterior and Zanca view radiographs are taken in the emergency department.
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The patient sustained a midshaft clavicle fracture, the most common location of all clavicle fractures. The management of clavicle fractures varies among orthopedic surgeons, although it is well understood that most midshaft clavicle fractures heal uneventfully with nonoperative treatment. Excellent healing rates with nonoperative treatment have been reported in several studies, with nonunion rates less than 1%.
Absolute indications for surgery may include shortening >2 cm, open injury, severe skin tenting causing impending skin disruption, or neurovascular injury. Relative indications may include displacement >2 cm, multitrauma, intolerance to immobilization, or cosmesis. Surgical management of fractures displaced or shortened >2 cm increases the union rate and improves shoulder strength compared with nonoperative treatment.1
Nonoperative treatment with immobilization can be accomplished using either a sling or figure-8 brace. Both forms of immobilization require the same time for healing and provide equal fracture alignment. Immobilization with a simple sling is often preferred because a figure-8 brace causes more discomfort and can be difficult to put on.
During nonoperative treatment, when pain is tolerable, patients should begin working on forward flexion and external rotation while maintaining a supine position to negate the displacing forces of gravity on the arm. Early pendulum exercises should be avoided, because this motion increases the displacing forces of the arm on the fracture. Generally, a simple sling is used for 4 to 6 weeks until pain improves and the patient can tolerate gradual progression to full activities.2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
References
- Lazarus MD, Seon C. Fractures of the clavicle. In: Heckman JD, Bucholz RW, eds. Rockwood and Green’s Fractures in Adults. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins;2001:1212-1234.
- Sheth U. Clavicle fractures. http://www.orthobullets.com/trauma/1011/clavicle-fractures. Accessed December 15, 2016.
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