What is your diagnosis?

Midshaft clavicle fracture which is the most common site of fracture [1].  Medial and lateral ends are fractured less commonly but tend to be associated with more complications [1,2]. The clavicle is the most commonly fractured bone in children and adolescents. 

Image 2. Illustration courtesy of Tabitha Ford, MD

• Pearl: The frequency of fracture by Allman Classification is as follows: I - 69-85%, II - 12-28%, III - 3-6%

What is your management in the ED?

Radiographs of the shoulder or clavicle to make diagnosis. Remember that medial fractures can cause sternoclavicular injuries or other associated intrathoracic injuries.  Lateral fractures tend to cause disruption of the AC joint but also consider associated scapular fracture (floating shoulder).

• Pearl: Special views
  
  
• Zanca view (10-15° cephalic tilt) to delineate displacement and comminution in all fracture types

Image 2. Case courtesy of Andrew Murphy, Radiopaedia.org, rID:48068

• Serendipity view (40°cephalic tilt) of the SC joint can rule out SC dislocations

Image 3. Case courtesy of Andrew Murphy, Radiopaedia.org, rID: 29939

What is your disposition?

Most fractures are managed non-operatively [1,2]. The patient may be placed in a sling or sling and swathe for comfort.  Figure of 8 splints are no longer recommended because of discomfort, non-compliance and higher complication rates [2]. Treat pain with NSAIDs and short course of oral narcotic if necessary. 

Do you consult orthopaedics emergently?

Consult orthopedics emergently if open fracture, skin tenting or neurovascular compromise is present [1,2]   If displaced > 2 cm or associated scapular neck fracture (floating shoulder) consider earlier referral for surgical correction [2,3].  Follow up with sports medicine or orthopedics in 5 to 7 days otherwise.