Paediatric Acute care Guidelines PMH Emergency Department

This guideline is specific for the assessment and management of clavicle fractures

Background

  • Three quarters of clavicle fractures are midshaft
  • The majority of clavicle fractures are managed with analgesia and a broad arm sling
  • Most clavicle fractures do not require Orthopaedic follow up

General

  • Clavicle fractures are common in all ages
  • The most common site is the mid shaft (three quarters)
  • Approximately half are greenstick
  • Epiphyseal (Salter-Harris I and II) fractures are very rare

Aetiology

  • The most common mechanism of injury is a fall onto the shoulder
  • In neonates, it may be the result of birth injury – the clavicle is the most common obstetric fracture site

Assessment

  • Examine for tenderness and swelling along the line of the clavicle
  • Infants may present with reluctance to use an arm without a good history of trauma

History

  • There is usually a history of a fall onto the shoulder or outstretched arm or a direct blow to the clavicle
  • Consider Non-Accidental Injury (NAI) in young children if there is an inadequate explanation for the fracture. Complete an Injury Proforma form for children < 2 years (A3 folded sheet located in the Doctor’s offices).

Examination

  • There is usually tenderness or swelling along the clavicle
  • In the child with multiple injuries, clavicle fractures and upper rib fractures may be associated with injury of the great vessels or brachial plexus. Careful neurovascular examination of the ipsilateral arm should be performed.

Investigations

Radiology:

  • On the X-Ray request form, write clavicle, rather than shoulder – AP view of clavicle and 15 degree cephalad AP view will be done. See Radiological Requests – Limb X-Rays.
  • A CT scan may be required for medial sternoclavicular dislocation
  • For general description of the types of fractures, see Fractures – Overview

Management

  • The majority of clavicle fractures managed in a broad arm sling will heal uneventfully and without complication
  • Open fractures, tenting or blanching over overlying skin, maximal tenderness over acromioclavicular joint or altered sensation should be discussed urgently with the Orthopaedic Surgical Team

Initial management

  • Analgesia
  • Examine for neurovascular injury (if deficits evident manage immediately) – urgent Orthopaedic Team referral
  • Ice the affected area
  • Consider tetanus and antibiotics for compound fractures

 

Further management

Middle Third Fractures

  • Middle third clavicle fractures rarely need reduction
  • Support in a broad arm sling for 3 weeks and provide adequate analgesia advice
Minimally Displaced Middle Third Fracture
Minimally Displaced Middle Third Clavicle Fracture

 

Displaced Middle Third Clavicle Fracture
Displaced Middle Third Clavicle Fracture

Fractures Requiring Orthopaedic Referral

  • Medial and lateral third clavicle fractures should be discussed with the Orthopaedic Team and managed on their advice
  • Urgent Orthopaedic referral is required for displaced medial or lateral third fractures, open fractures, compromise of overlying skin or neurovascular compromise
Lateral Third Clavicle Fracture
Lateral Third Clavicle Fracture

Referrals and follow-up

Middle Third Fractures:
  • GP follow up in 1-2 weeks in non or minimially displaced fractures (no repeat X-Ray is required)
  • Orthopaedic Fracture Clinic follow up in 1-2 weeks if significant displacement. See Outpatient Clinics.
Lateral or Medial Third Fractures:
  • Management as per Orthopaedic Team’s advice
  • Orthopaedic Fracture clinic in 1-2 weeks. See Outpatient Clinics.

Health information (for carers)

  • Analgesia
  • Use of sling – child should wear the sling at all times (unless having a shower, bath). Sling should be a broad arm sling, appropriately sized for the child, and worn for 3 weeks.
  • No contact sport for 6 weeks
  • Provide GP letter
  • Advise parents that a bony lump usually develops at the fracture site and will be visible for up to a year
  • Care Following Fractured Clavicle Health Fact Sheet
  • Pain Management Health Fact Sheet

Nursing

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