Wednesday, May 23, 2012

Clavicle fractures - to fix or not to fix

In children 10 years of age and under 90% of clavicle fractures occur in the middle third, 60 percent of which are nondisplaced. Above age 10, the majority are displaced (as in adults). immobilization with sling and swathe for 3-4 weeks is generally sufficient for most uncomplicated fractures.

Outpatient Orthopedic referral is recommended for:

  • Patients with a completely displaced clavicle fracture, which is defined as displacement greater than one bone width.
  • Shortening greater than 18 mm in males and 14 mm in females because of the risk of significant morbidity, including local tenderness, numbness, pain when lying on the affected side, impaired range of motion, impaired strength, and cosmetic abnormalities
  • Comminuted fracture

Emergent referral is required for:
  • open fractures
  • neurovascular compromise
  • tenting of the skin (skin stretched tautly over a displaced fracture)

An open fracture should be suspected anytime there is a break in the skin near a fracture site. After puncturing the skin during the initial injury, fractured bone ends often retract under the skin and cannot be seen with simple inspection. If respiratory compromise or hemodynamic instability exists, serious injury to intrathoracic or other structures should be suspected and immediately addressed. proximal third clavicle fractures are generally associated with more significant trauma, and have a higher potential for internal injuries.

Traditionally the management his followed the dictum "If both ends of the bone are in the same room, then sling and swathe alone is sufficient." New evidence has suggested otherwise.There may be advantages to repairing select medial fractures in the OR. See this article for more information.

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