Managing Clavicle Fractures in Urgent Care

Clavicle fractures are among the most common orthopedic injuries that we encounter in the Urgent Care setting. That makes them the perfect topic for a quick review!

The vast majority of clavicle fractures can be managed definitely by urgent care clinicians, but there are a few sneaky times when the patient may need emergent orthopedic evaluation.

Thinking Anatomically: The Rule of Thirds

Dividing the clavicle into medial, middle, and lateral thirds provides a practical framework for assessment and management:

• Middle-third fractures: The most common, accounting for nearly 70% of clavicle fractures. In pediatric patients, this number jumps to 90%.
• Lateral-third fractures: Less common but often mistaken for acromioclavicular (AC) joint separations.
• Medial-third fractures: The least common (about 2%) but the most concerning due to their association with severe trauma.

Mechanism Matters

Understanding how the injury occurred is crucial:

• Falls onto the shoulder are the most common cause of clavicle fractures.
• High-speed motor vehicle collisions (MVCs) raise suspicion for polytrauma.
• Low-impact falls, like a simple bicycle tip-over, are less concerning but still warrant evaluation.

Diagnostic Imaging

Plain radiographs remain the primary imaging modality:

• AP view: Often sufficient for middle-third fractures.
• Cephalic tilt view: Useful if an AP view does not clearly demonstrate the fracture.
• PA chest film: Can help compare clavicular lengths to detect subtle injuries.

Associated Injuries to Consider

The location of the clavicle fracture guides concern for associated injuries:

• Middle-third fractures: Check for scapular, rib, and sternal fractures.
• Lateral-third fractures: Consider AC joint injuries and possible "floating shoulder" (clavicle and glenoid neck fractures together, requiring urgent orthopedic evaluation).
• Medial-third fractures: These should set off alarm bells—80% result from MVCs, and 90% involve multisystem trauma. High mortality is associated with these injuries, warranting thorough assessment.

When to Refer for Surgical Evaluation

Send patients for immediate orthopedic evaluation if you see:

• Open fractures
• Neurovascular compromise
• Skin tenting (discoloration of skin suggested threatened perfusion over the injury)
• Severe displacement, comminution, or significant shortening

Any patient with respiratory distress or hemodynamic instability requires urgent stabilization and transfer to a trauma-capable facility.

Fracture Patterns of Lateral-Third Clavicle Injuries

Distal clavicle fractures can be subtle and difficult to distinguish from AC separations. They are classified into three types:

• Type 1: Non-displaced, ligaments intact.
• Type 2: Ligamentous disruption with displacement.
• Type 3: Intra-articular fractures extending into the AC joint.

Medial-Third Clavicle Injuries: Red Flags

Medial clavicle fractures demand heightened vigilance due to their strong association with severe trauma. Key considerations:

• MVCs cause 80% of these injuries.
• 90% involve multisystem trauma, with a 20% one-month mortality rate.
• For atraumatic cases (e.g., repetitive stress fractures from sports like gymnastics or rowing), conservative management with a sling, ice, NSAIDs, and rest is appropriate.

Management of Uncomplicated Middle-Third Clavicle Fractures

For standard, non-displaced middle-third clavicle fractures, initial management focuses on pain control and immobilization:

• Sling vs. Figure-8 Bandage: Evidence shows similar outcomes, but slings are generally more comfortable.
• Ice and NSAIDs: Help manage pain and swelling.
• Follow-Up: Recommended within 1-2 weeks. Most primary care physicians will be comfortable managing this and these patients do not necessarily need orthopedic follow up.

Top Take-Home Points

• Think anatomically: Divide the clavicle into medial, middle, and lateral thirds to guide management.
• Medial-third fractures are rare but serious: High suspicion for multisystem trauma is warranted.
• Immediate ortho referral for red flags: Open fractures, skin tenting, or neurovascular compromise demand emergent evaluation.
• Most clavicle fractures are treated nonoperatively: Sling, ice, and pain control are the first-line management strategies.