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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. 

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

Image 2. Illustration courtesy of Tabitha Ford, MD 

What is your management in the ED?

Radiographs of the shoulder or clavicle to make the 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 you should also consider an associated scapular fracture (floating shoulder).

• Pearl: Special views: Zanca and Serendipity, see Image 3 & 4

Image 3. Zanca view (10-15° cephalic tilt) to delineate displacement and comminution in all fracture types. Case courtesy of Andrew Murphy, Radiopaedia.org, rID: https://radiopaedia.org/cases/48068 

Image 4. Serendipity view (40°cephalic tilt) of the SC joint can rule out SC dislocations. Case courtesy of Andrew Murphy, Radiopaedia.org, rID: https://radiopaedia.org/articles/54319 

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 their pain with over the counter pain medication and a short course of oral narcotics 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 an 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.