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Approach to the Critical Patient
Triage and immediate priorities
Immediate priorities
Airway compromise concern
Expanding neck hematoma concern
Tracheal deviation concern
Breathing compromise concern
Pneumothorax concern
Hemothorax concern
Circulation compromise concern
Major hemorrhage concern
Shock index elevation
Disability concern
New focal neurologic deficit
Altered mental status
Exposure and secondary survey completion
Skin tenting over fracture site
Open wound over clavicle
Limb threat and neurovascular status
Neurovascular status
Distal pulses
Radial pulse symmetry
Ulnar pulse symmetry
Perfusion
Capillary refill hand
Skin temperature hand
Motor function
Median nerve motor
Ulnar nerve motor
Radial nerve motor
Axillary nerve motor
Sensation
Median nerve sensation
Ulnar nerve sensation
Radial nerve sensation
Axillary nerve sensation over deltoid
Brachial plexus red flags
Diffuse paresthesia
Global weakness
Documentation timing
Before immobilization
After immobilization
Open fracture pathway when open possible
Open fracture pathway
Open injury indicators
Wound over fracture site
Subcutaneous emphysema over clavicle
Bone visible
Antibiotics and tetanus timing
Antibiotics as early as feasible
Tetanus status review
Wound handling
Sterile saline gauze coverage
Gross contamination removal only
Urgent orthopedics escalation
Immediate consultation
Transfer if operative resources unavailable
Consultation and transfer triggers
Escalation triggers
Neurovascular compromise
Absent distal pulse
Progressive neurologic deficit
Vascular injury suspicion
Expanding hematoma
Bruit or thrill
Active bleeding
Threatened skin
Skin blanching
Skin tenting with impending open injury
Medial clavicle posterior displacement concern
Dyspnea
Dysphagia
Hoarseness
Upper extremity swelling
Polytrauma
High energy mechanism
Multiple injuries requiring trauma service
History
Mechanism and timing
Injury context
Mechanism category
Fall on shoulder
Direct blow to clavicle
Fall on outstretched hand
Motor vehicle collision
Sports collision
Energy level
Low energy fall
High energy trauma
Time since injury
Less than 6 hours
Same day
More than 24 hours
Prior reduction attempts
Prehospital manipulation
Patient self manipulation
Symptoms and associated injury mapping
Symptom map
Pain location
Medial clavicle pain
Midshaft clavicle pain
Lateral clavicle pain
Respiratory symptoms
Dyspnea
Pleuritic chest pain
Neurovascular symptoms
Hand numbness
Hand weakness
Arm coolness
Swallowing and voice symptoms
Dysphagia
Hoarseness
Shoulder girdle function
Inability to elevate arm
Scapular pain
Risk factors and modifiers
Patient factors
Anticoagulant use
DOAC use
Warfarin use
Bone health
Osteoporosis
Chronic glucocorticoid use
Smoking status
Current tobacco use
Heavy tobacco exposure history
Prior clavicle fracture
Prior nonunion history
Prior surgery hardware
Hand dominance
Dominant arm injured
Non dominant arm injured
Baseline function
Athletic overhead activity
Manual labor demands
Physical Exam
Inspection and palpation
Local exam
Deformity
Visible step off
Shortening appearance
Skin integrity
Abrasion
Laceration
Ecchymosis
Threatened skin
Tenting
Blanching
Palpation findings
Point tenderness clavicle
Crepitus
Chest wall screening
Rib tenderness
Sternal tenderness
Shoulder girdle and joint above and below
Regional exam
Shoulder joint motion limits
Active range limited by pain
Passive range limited by pain
AC joint findings
Point tenderness AC joint
Step off at AC joint
SC joint findings
Medial clavicle prominence
Medial clavicle depression
Scapula screening
Scapular body tenderness
Scapular spine tenderness
Cervical spine screening when high energy
Midline neck tenderness
Neurologic symptoms in both arms
Neurovascular and neurologic
Neurovascular exam
Pulse and perfusion
Radial pulse
Ulnar pulse
Capillary refill
Motor and sensory exam
Median nerve
Ulnar nerve
Radial nerve
Axillary nerve
Brachial plexus screening
Diffuse sensory loss pattern
Multi myotome weakness
PITFALLS
Pitfalls
Normal distal pulses despite proximal vascular injury
Collateral circulation masking deficit
Evolving thrombosis over hours
Medial end injuries missed on standard clavicle films
Overlap with mediastinum
Need dedicated views or CT
Lateral clavicle fractures mistaken for isolated AC sprain
Coracoclavicular ligament injury association
High nonunion risk patterns
Differential Diagnosis
Shoulder girdle trauma differentials
Alternative and co injuries
AC separation
Type I to III
Type IV to VI
SC dislocation
Anterior
Posterior
Proximal humerus fracture
Surgical neck fracture
Greater tuberosity fracture
Scapula fracture
Scapular body fracture
Glenoid fracture
Rotator cuff tear
Acute traumatic tear
Massive tear with pseudoparalysis
Brachial plexus injury
Neuropraxia
Traction injury
Thoracic and vascular differentials
Life threatening mimics and complications
Pneumothorax
Apical pneumothorax
Tension pneumothorax
Hemothorax
Traumatic hemothorax
Massive hemothorax
Subclavian vessel injury
Arterial injury
Venous injury
First rib fracture
Marker of high energy trauma
Vascular injury association
Cervical spine injury
High energy mechanism association
Distracting injury masking neck pain
Laboratory Tests
Routine labs when uncomplicated
Minimal lab strategy
No labs when isolated closed fracture and stable
No planned sedation
No planned operative pathway
Labs for operative pathway or major trauma
Preop and trauma labs
Complete blood count for significant swelling or bleeding concern
Hemoglobin trend for suspected hemorrhage
Leukocytosis nonspecific
Electrolytes and creatinine for contrast CT planning
Baseline renal function for CTA
Medication dosing safety
Coagulation studies when anticoagulants or bleeding concern
INR for warfarin exposure
aPTT for heparin exposure
Type and screen when major trauma or operative expectation
Massive transfusion risk context
Crossmatch if active hemorrhage
Procedural sedation labs when indicated
Sedation context
Point of care glucose when altered mental status
Hypoglycemia exclusion
Hyperglycemia severe illness marker
Pregnancy test when pregnancy possible and imaging sedation considerations
Urine hCG
Serum hCG when uncertain
Diagnostic Tests
Scoring Systems
Classification systems
Allman classification
Group I midshaft
Group II distal third
Group III medial third
Robinson classification for midshaft
Displacement assessment
Comminution assessment
Neer classification for distal clavicle
Stable patterns
Unstable patterns with coracoclavicular ligament disruption
AO OTA classification
Clavicle location code mapping
Simple versus wedge versus complex patterns
Radiographs
Radiographs
Standard views
Clavicle AP
Clavicle cephalic tilt view
Shoulder girdle screening
Shoulder AP
Scapular Y view when dislocation concern
Lateral clavicle and AC joint evaluation
Zanca view
Comparative bilateral views when uncertain
Medial clavicle and SC joint evaluation
Serendipity view
Chest radiograph for pneumothorax screening
Post immobilization imaging
No routine repeat imaging after sling placement
Repeat films when clinical deformity worsens
MRI
MRI
Indications
Occult fracture with normal radiographs and persistent focal tenderness
Brachial plexus injury assessment when CT nondiagnostic
Limitations
Limited availability in acute trauma workflows
Motion artifact with pain
CT
CT
Indications
Medial clavicle fracture with posterior displacement concern
SC joint posterior dislocation concern
Intraarticular extension suspicion
Polytrauma chest CT integration
CT angiography indications
Hard signs of vascular injury
Expanding hematoma
Active hemorrhage
Pulse deficit
Soft signs of vascular injury with high risk pattern
Supraclavicular bruit
First rib fracture on imaging
Evidence and recommendations
Class I recommendation for immediate vascular surgery involvement for hard signs
Class IIa recommendation for CTA when soft signs and high risk pattern
Disposition
Discharge criteria and follow up
Discharge pathway
Stability criteria
Hemodynamic stability
No respiratory distress
Intact neurovascular exam
Pain control
Acceptable pain on oral regimen
Ability to sleep and mobilize safely
Follow up timing
Orthopedics follow up 5 to 10 days
Earlier follow up for displaced fractures
Repeat imaging plan
Outpatient repeat radiographs per orthopedics
Earlier imaging if worsening deformity or neurovascular symptoms
Admission, urgent consult, and transfer criteria
Admission and transfer triggers
Open fracture
Immediate orthopedics consultation
Transfer for operative management when needed
Threatened skin
Urgent orthopedics consultation
Temporary padding and immobilization
Neurovascular compromise
Immediate escalation
Vascular surgery consultation when indicated
Medial clavicle posterior displacement concern
CT chest with mediastinal evaluation
Thoracic surgery or ENT consultation as locally appropriate
Polytrauma
Trauma service admission
Chest injury management integration
Treatment
Immediate life-saving interventions
Immediate threats
If respiratory distress or chest injury concern then chest imaging priority
Chest radiograph
POCUS pleural evaluation when available
If tension pneumothorax concern then immediate decompression
Needle decompression per local protocol
Tube thoracostomy preparation
If hard signs of vascular injury then immediate surgical escalation
Vascular surgery notification
CTA when not delaying operative control
If open fracture then antibiotics and tetanus pathway without delay
Sterile coverage
Hemorrhage control with direct pressure
Immobilization and Splinting
Immobilization selection
Upper extremity options list
Sling
Shoulder immobilizer
Figure of eight brace
Posterior long arm splint
Coaptation splint
Typical selection for clavicle fracture
Sling
Shoulder immobilizer when additional comfort needed
Principles
Hand and wrist free for motion
Elbow supported for comfort
Swelling phase avoidance of tight straps
Reassessment after immobilization
Pain trend
Neurovascular exam repeat
Reduction
Reduction considerations
Routine closed reduction not performed for isolated clavicle fractures
Outcomes not improved with manipulation in most patterns
Pain and swelling limitation
If threatened skin from sharp fragment then urgent orthopedics management
Class I recommendation for emergent specialist evaluation for impending open fracture
Avoid repeated manipulation attempts in ED
If SC posterior dislocation suspected then specialist reduction pathway
Reduction in monitored setting
Surgical backup available
Open fracture medications and timing
Antibiotics and tetanus
Antibiotic timing
First dose as early as feasible
Documentation of administration time
Antibiotic selection
Cefazolin IV for type I and II open fracture patterns
Adult dose 2 g IV
If weight 120 kg or greater then 3 g IV
If severe cephalosporin allergy then clindamycin IV
Adult dose 900 mg IV
If gross contamination or farm injury concern then add gram negative coverage per local protocol
Gentamicin IV dosing per weight and renal function
Therapeutic drug monitoring when continued
Tetanus prophylaxis
If unknown or fewer than 3 doses then tetanus vaccine
If dirty wound and unknown or fewer than 3 doses then tetanus immune globulin
DVT prophylaxis when relevant
VTE prophylaxis
Routine pharmacologic prophylaxis not indicated for isolated upper extremity sling
Low baseline VTE risk
Early ambulation typical
Consider prophylaxis when high risk and immobilized or admitted
Active malignancy
Prior VTE history
Prolonged hospitalization
Agent selection aligned with institutional protocol
Enoxaparin prophylaxis dosing
Mechanical prophylaxis when anticoagulation contraindicated
Special Populations
Pregnancy
Pregnancy considerations
Imaging
Radiographs with abdominal shielding when feasible
CT only when benefits outweigh risks
Analgesia
Acetaminophen preferred
NSAID avoidance in third trimester
Trauma evaluation
Maternal stabilization priority
Obstetric consultation when viability threshold met
Geriatric
Geriatric considerations
Fragility mechanism
Low energy fall recognition
Osteoporosis risk
Nonunion risk modifiers
Smoking exposure
Comminution and displacement
Delirium risk with opioids
Lowest effective dose strategy
Avoid polypharmacy sedatives
Pediatrics
Pediatric considerations
Physis and remodeling
High remodeling potential in younger children
Nonoperative management typical
Nonaccidental trauma screening when history inconsistent
Injury mechanism mismatch
Multiple bruises in different stages
Immobilization
Sling or figure of eight brace based on comfort
Neurovascular exam documented with age appropriate approach
Background
Epidemiology
Epidemiology
Frequency
Common shoulder girdle fracture
Midshaft location most frequent
Location distribution
Midshaft majority
Distal third minority
Medial third least common
Mechanism distribution
Falls and sports common in younger patients
Low energy falls common in older patients
Pathophysiology
Pathophysiology
Typical fracture mechanics
Direct blow causing bending force
Fall on shoulder causing compressive force
Deforming forces
Sternocleidomastoid elevates medial fragment
Weight of arm displaces lateral fragment inferiorly
Nearby structure risk
Subclavian vessels under clavicle
Brachial plexus under clavicle
Apex of lung under medial and mid clavicle
Therapeutic Considerations
Therapeutic considerations
Nonoperative management rationale
High union rate in minimally displaced fractures
Functional outcomes often acceptable
Operative management indications
Open fracture
Neurovascular compromise
Threatened skin
Floating shoulder concern
Unstable distal third fracture pattern
Displacement and nonunion risk
Increased risk with complete displacement
Increased risk with comminution
Increased risk with smoking
Evidence statements
Class IIa recommendation for operative fixation in selected displaced midshaft fractures to reduce nonunion risk
Class I recommendation for operative management of open fractures
Patient Discharge Instructions
Copy discharge instructions
Copy discharge instructions
Sling use
Wear sling for comfort
Remove sling for elbow and wrist motion exercises
Activity limits
No lifting with injured arm
Avoid overhead activity
Pain control
Acetaminophen as directed
NSAID use if safe for patient
Opioid only if severe pain and short duration
Ice and elevation
Ice 15 to 20 minutes at a time
Upright sleeping position for comfort
Skin and splint checks
Strap tightness adjustments for swelling
Skin breakdown monitoring
Return to ED now
New numbness or weakness in hand
Hand coldness or color change
Worsening shortness of breath
Increasing chest pain
Skin tenting worsening
Fever or drainage from wound
Follow up
Orthopedics appointment within 5 to 10 days
Earlier review if pain rapidly worsening
References
Clinical guidelines and evidence sources
Evidence sources
AAOS clinical practice guidance for clavicle fracture management
Operative indications for displaced patterns
Nonoperative sling based care for stable patterns
ATLS principles for trauma evaluation
Chest injury screening with shoulder girdle trauma
Vascular injury recognition pathways
ACEP clinical policy procedural sedation and analgesia
Capnography use during deep sedation ACEP Level B
Pre sedation risk assessment and monitoring ACEP Level C
Trauma surgery recommendations for vascular hard signs
Immediate operative or vascular consultation Class I
CTA for soft signs with high risk injury Class IIa
Coding and terminology alignment
ICD 10 S42.0 fracture of clavicle
SNOMED CT fracture of clavicle concept
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