A 23-year-old male presents to the emergency department after a fall from a ladder. He states that he did not strike his head or suffer loss of consciousness, but that he “hurts all over.” He is hemodynamically stable. On secondary survey, you note that he is maintaining his left shoulder in adduction and internal rotation, with ninety degrees of flexion at the left elbow. He is tender to palpation over the left clavicle, but there is no tenting of the skin. Pulses and sensation are intact in the left upper extremity. Appropriate imaging is seen in Figure A. What is the most appropriate next step in management?
- Weight-bearing as tolerated
- Figure-of-eight immobilization device
- Coaptation splinting
- Open reduction and internal fixation
- Closed reduction with external fixation
View Explanation
This patient has a closed, minimally displaced fracture of the middle third of his left clavicle. Appropriate treatment is immobilization in a figure-of-eight immobilization device.
Clavicle fractures comprise 5-10% of all fractures. The majority involve the middle third of the clavicle (80-85%), while 10-15% involve the lateral third and 5-8% the medial third. Most occur as a result of either direct trauma or a fall on an outstretched arm and present with guarding of the shoulder and tenderness over the clavicle. It is important to rule out associated injuries to the subclavian artery and brachial plexus, as well as to evaluate breath sounds to rule out a pneumothorax. Diagnosis is confirmed with radiographs, and the vast majority are treated with immobilization in a traditional arm sling or figure-of-eight sling
Pecci and Kreher review the topic of clavicle fractures, stating that they are most common in persons younger than 25 years. The authors note that the superficial location of the clavicle, along with its thin midshaft and ability to transmit large forces from the upper extremity to the axial skeleton, predispose the clavicle to fracture. They also note that, in the absence of trauma, clavicle fractures should prompt a workup for malignancy, rickets, and physical abuse.
Virtanen et al. conducted a randomized clinical trial comparing sling immobilization versus plate osteosynthesis for the treatment of displaced midshaft clavicular fractures in 60 patients. At one year, the authors found no difference in function and disability between the two groups; however, six non-unions occurred in the in the non-operative group compared to zero nonunions in the operative group.