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. OrthoInfo Clavicle Fracture Page 1 of 3 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. OrthoInfo Clavicle Fracture Page 2 of 3 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. OrthoInfo Clavicle Fracture Page 3 of 3