Fractures are caused by high-energy forces on bones and may result from blunt or penetrating trauma. Fracture size and shape is determined by the amount of energy absorbed, the focus of energy, and mass and resistance of the affected bone. Obvious deformities may or may not be present, depending on the degree of fracture angulation and the presence of associated joint dislocation. Patients present with swelling and tenderness. If mental status is intact and there is no associated nerve damage, patients will complain of pain on palpation. Ecchymosis may not be present for minutes to hours and is dependent on associated tissue damage, thickness and integrity of overlying skin, and the degree of vascular injury.
Figure 19.1 ▪ Open Fractures.
(A) A picture of a wrist showing obvious severe deformity. (B) A puncture wound at the site of the deformity is diagnostic for an open fracture. (C) X-ray demonstrating a markedly displaced fracture of the distal radius and ulna. There is also a dislocation of the distal radioulnar joint. (Photo contributor: Binita R. Shah, MD.)
Obtain plain films that ensure the entire injured area is evaluated at various angles, as fractures are often present on one view but not another. Provide analgesia, elevate the fractured bone, and apply cold compresses after more serious, associated injuries have been ruled out. Provide intravenous (IV) antibiotics for all patients with open fractures to prevent osteomyelitis. Consult orthopedics for all fractures, emergently in the case of open fractures, which may require wound irrigation by the consultant in the operating room. After adequate immobilization and consultation, most patients with isolated closed extremity fracture can be discharged with expeditious follow-up. Admit all patients with open fractures for observation and continued parenteral antibiotics.
Figure 19.2 ▪ Complete Fractures.
(A) Frontal view of the humerus demonstrates a complete, nondisplaced fracture of the diametaphysis. (B) Frontal view of the humerus in a different patient shows complete fracture of the diametaphysis with lateral displacement of the proximal fragment by one bone shaft’s width. (Photo/legend contributors: Carlos Barahona, MD/John Amodio, MD.)
| Fracture Type | Defining Features |
|---|---|
| Open fractures | Perforation or avulsion of skin and soft tissue overlying fracture site, often caused by sharp bony fragments forcing their way through skin. A high propensity toward infection |
| Closed fractures | Skin and soft tissue overlying fracture intact |
| Complete fractures | Complete separation or discontinuity of bone |
| Incomplete fractures | Do not extend completely through bone; leaves portion of cortex intact |
| Occult fractures | Fracture not immediately apparent on x-ray, but clinically has a high index of suspicion because of physical findings. Often detected on follow-up radiologic studies |
| Transverse fractures | Perpendicular to long axis of bone |
| Oblique fractures | Not perpendicular to long axis of bone |
| Comminuted fractures | More than 2 fragments of bone present and has typical shattered appearance (often pieces are large and form typical Y or T shape) |
| Avulsion fractures | Bone fragment pulled away from cortex at the site of tendon insertion, which may be extremely small and appears as a chip or flake in proximity to a bony tuberosity. |
| Impacted fractures | Fragmented segments driven into each other; these may be complete or incomplete and the fracture line may not appear as a lucency but as a more dense area |
| Torus fractures | An incomplete fracture in which one side of long bone cortex buckles outward and typically occurs at the base of long bones (fracture named from Greek architecture in which a torus is typically a bump at base of a column). These are often subtle on x-ray. |
Figure 19.3 ▪ Transverse Fracture.
Anteroposterior view of the right femur demonstrates a displaced transverse fracture of the distal right femoral diaphyseal shaft. The fracture is displaced half a femoral shaft width and the distal fracture fragment is angulated laterally. There is contrast in the bladder. (Photo/legend contributors: Carlos Barahona, MD/Rachelle Goldfisher, MD.)
Treat any fracture with an open wound as an open fracture until proven otherwise.
Use a radiologic marker in the area of the laceration or puncture to aid in identifying possible foreign bodies.
Exploration and irrigation should be done by someone with expertise in open-wound care.
Maintain a high suspicion for child abuse when mechanisms of injury do not fit the injury pattern, particularly spiral long bone fractures.
Immobilize occult fractures, and if they are in the area of the physis treat these as Salter-Harris type I fractures.
Figure 19.5 ▪ Spiral Fracture.
A single anteroposterior view of the left ankle shows a spiral fracture through the tibial metaphysis with minimal displacement and extension to the growth plate consistent with a Salter II injury. (Photo/legend contributors: Shashidhar Rao Marneni, MD/Rachelle Goldfisher, MD.)
| Fracture Type | Defining Features |
|---|---|
| Epiphyseal fractures | (see Table 19.3) |
| Spiral fractures | Occurs down shaft of long bone in a circumferential manner and caused by a twisting around long axis of bone. Often seen in child abuse |
| Greenstick fractures | Limited to infancy and early childhood, these occur along the shaft of long bone transversely through one side of the cortex and then abruptly along the longitudinal axis of bone without disrupting the opposite cortex. Similar to the pattern of breaking a green stick |
| Stress fractures | Seen in healthy people, usually athletes, in response to a repeated stress, and often not radiologically apparent until weeks after symptoms appear. Eventually fractures manifest as thin line of radiolucency or periosteal callus without an underlying fracture. |
| Pathologic fractures | Occur in diseased bone with characteristically minor injury and are often transverse and surrounded by areas of demineralized bone. Often seen in metastatic bony disease, areas with bone cysts, or in patients with osteogenesis imperfecta |
Figure 19.10 ▪ Torus Fracture.
(A) Lateral view of the forearm shows subtle buckling of the distal radial cortex (arrow) compatible with a torus fracture. (B) Frontal projection of the forearm demonstrates an angulated buckle fracture of the distal radius (arrow). (Photo/legend contributors: Chaiya Laoteppitaks, MD/John Amodio, MD.)
Figure 19.11 ▪ Pathologic Fracture.
(A, B) Frontal and lateral views of the left knee demonstrate a pathologic fracture through a large cortically based predominantly lucent lesion. There are well-defined margins and narrow zone of transition; as such this lesion is most compatible with a nonossifying fibroma. Additional nonossifying fibromas noted in lateral distal femur. (Photo/legend contributor: Shashidhar Rao Marneni MD/Rachael Goldfisher, MD.)
| The Salter-Harris classification is the most widely used for epiphyseal fractures and gives a general prognosis for risk of premature closure of physes, as well as generalized treatment guidelines. There are 5 types differentiated by location and involvement of physeal growth plate. | ||
| Type | Features | Management |
| Type I: | Fracture line goes through physis, not involving epiphysis or metaphysis. | Usually managed by closed reduction (joint space not involved and perfect alignment not required) |
| Type II: | Fracture line through a portion of physis and extends through metaphysis on either side of bone. | Closed reduction except for type II fracture of distal femur, which requires anatomical alignment by either open or closed technique |
| Type III: | Fracture line goes through portion of physis and extends through epiphysis into joint space on either side of bone. | Fractures usually require open alignment of physis and articular surface. |
| Type IV: | Fracture line goes through portion of metaphysis, extends through physis, involves portion of epiphysis, and thus enters joint space. | Fractures require open alignment of physis and articular surface. |
| Type V: | Fracture is a crush injury, compressing physis, and is not always initially recognized. Often diagnosed retrospectively with premature physeal closure | |
Figure 19.13 ▪ Salter-Harris Type II Fracture.
A single frontal view of the left ankle demonstrates an oblique fracture through the distal tibial metaphysis with extension to the physis consistent with a Salter Harris II injury. (Photo/legend contributors: Sharon Yellin, MD/Rachelle Goldfisher, MD.)
| Fracture Type | Complication | Features |
|---|---|---|
| All | Ligament injury | Common with fractures near joints or in areas with known ligamentous insertions |
| Neurovascular compromise | Caused by direct damage to or pressure on vessel/ nerve and progresses with time. Manifests as loss of sensation, tingling, diminished pulses. | |
| Direct nerve injury | Immediate loss of function/sensation distal to injury and usually permanent without surgical repair | |
| Compartment syndrome (especially with crush injures) | Edema and swelling cause increased pressure in closed fascial compartments impairing oxygenation to the tissue and initiating a vicious cycle of necrosis, edema, and swelling. | |
| Occurs most frequently in anterior/posterior compartments of thigh/calf, followed by peroneal compartments of legs, volar and dorsal compartments of forearm; less commonly with interossei of hands or gluteus medius | ||
| Manifests as the “5 P’s”: pain, paresthesia (occur first), pallor, pulseless, paralysis (irreversible damage, if all signs present) | ||
| Volkman ischemic contracture | End result of ischemic injury to muscle or nerve (synonymous with irreversible damage). Rare without preceding compartment syndrome | |
| Nonunion of fracture | Occurs when fractured parts not placed in close proximity and more frequent in bones with tenuous blood supply (eg, femoral neck, scaphoid wrist) | |
| Fat embolism | Occurs frequently with trauma (clinically significant in about 30% of cases); manifests with signs of pulmonary embolism | |
| Posttraumatic reflex dystrophy | Manifests weeks to months after injury as weakness or pain in the affected extremity | |
| Open fractures | Contamination | Dirt, sand, glass |
| Bacterial (self-inoculation from normal skin flora or infection from mammalian bite that caused fracture, boxer’s fracture) | ||
| Osteomyelitis | Frequently from contiguous focus of infection or hematogenous | |
| Foreign body | May or may not be seen on x-ray (glass dependent on size/lead content) |
The tuft or the distal portion of the distal phalange is located directly beneath the nail bed and fractures to this area are most often caused by a crush injury. Most tuft fractures do not involve the distal interphalangeal (DIP) joint space. Patients present with swelling, pain, and erythema, and there is often a subungual hematoma. Differential diagnosis includes felon, paronychia, cellulitis foreign body, and onychomycosis.
Obtain x-rays of the digit and consider x-rays of the hand and wrist if there is tenderness in those areas. Subungual hematomas are extremely painful and may act as a distracting injury. Refer all patients for orthopedic follow-up and consult orthopedics emergently for open fractures and phalanx fractures with extension into the joint space, and extensor or flexor tendon rupture. Fractures involving the joint space should have orthopedic follow-up in 48 to 72 hours. Perform cautery drainage for subungual hematoma of 50% or more or as necessary for pain control.
Phalangeal fractures often occur from a fall on an outstretched hand, although they can also occur from a crush injury. Distal phalangeal fractures are most often secondary to crush injuries. Osteomyelitis is often associated with open fractures, including nail plate lacerations and fractures associated with drained subungual hematomas. Swan-neck deformity results from an intra-articular avulsion fracture or tendon tear of the dorsal surface of the distal phalanx. If not treated properly, hyperextension deformity of the proximal interphalangeal (PIP) joint with simultaneous flexion of the distal interphalangeal (DIP) joint may occur. The resultant swan-neck appearance of the finger is the reason for its name.
Obtain x-rays with special attention to chip or avulsion fractures that do not produce a great degree of swelling and may go undetected. If subungual hematoma is present, it may be drained for pain control, especially if more than 50% of the nail is involved. Use cautery through the nail or careful drilling with an 18-gauge needle. Repair any nail bed lacerations with removal of the entire nail after digital block. Consult orthopedics or a hand specialist for all open fractures, comminuted fractures, fractures involving the joint space, and fractures with any degree of digit rotation or any significant degree of angulation. In general, because of the increased mobility from the second to the third to the fourth to the fifth metacarpal bones, a higher degree of angulation is tolerated with greater mobility. Angulation of 30 to 40 degrees can be tolerated for the fifth metacarpal, 30 degrees for the fourth metacarpal, 20 degrees for the third metacarpal, and 10 degrees for the second metacarpal.
Figure 19.19 ▪ Swan-Neck Deformity.
An illustration of a swan-neck deformity that results from the improper treatment of a dorsal avulsion fracture of the distal phalanx. A hyperextension deformity will occur at the proximal interphalangeal joint, with a slight flexion of the distal interphalangeal joint. This is secondary to an imbalance between the ruptured and the unopposed distal flexor tendon. (Reproduced with permission from Simon RR, Koenigsknecht SJ: Emergency Orthopedics: The Extremities, 4th ed. McGraw-Hill, New York, 2001, p. 107.)
Bony tenderness can often be elicited by applying axial loading with the finger in the extended position.
Although degrees of angulation deformities can be tolerated, a rotational deformity of the digit, however slight, is not acceptable.
Detect rotational deformities by having the patient flex all 5 digits as in making a fist. All digits should point to the center of the palm.
Thoroughly scrutinize lacerations over any joints on the dorsum of the hand to ensure the dorsal hood is not violated, which would mean it is an open joint, necessitating emergent consultation.
Mallet fractures result from dorsal avulsion fractures in which the extensor mechanism of the DIP joint is destroyed, leaving the DIP joint in partial flexion. Mallet fractures may occur if there is forced flexion of the distal phalanx when the finger is in taut extension. This is often seen after playing basketball or baseball when the ball hits and creates axial loading of an outstretched finger. Patients present with the inability to fully extend the DIP joint.
Obtain standard x-rays of the digit. Avulsion fracture may not be apparent on x-ray. Splint the digit with the DIP in hyperextension and the PIP in 45 degrees of flexion using an aluminum splint on the dorsal aspect of the digit. This will keep the avulsed tendon in contact with its area of origin. If not properly treated, a swan-neck deformity may occur. Discharge patients with orthopedic or hand specialist follow-up in 72 to 96 hours.
The injury is relatively painless unless there is an associated phalanx fracture.
Mallet finger is a clinical diagnosis, with the inability to fully extend the DIP joint being pathognomonic.
Figure 19.21 ▪ Mallet Finger.
(A) An image of the fifth digit of an adolescent who sustained a direct blow to the tip of his finger while playing basketball. The youth was unable to extend the DIP joint. (B) A single lateral view of the left third digit from a different patient shows a fracture of the dorsal aspect of the distal third phalanx with extension into the joint space. (Photo/legend contributors: Mark Silverberg, MD/Rachelle Goldfisher, MD.)
Bennett fracture is a transverse fracture of the first metacarpal base extending into the joint and associated with metacarpal dislocation. In Rolando fracture, the metacarpal fracture is comminuted. These are usually seen with a fall on an outstretched hand and are often associated with high-impact sports such as skiing. Patients present with a significant amount of pain.
Obtain standard x-rays of the hand, thumb, and wrist and consider scaphoid x-rays. Missed fractures are associated with a significant amount of morbidity. Nonunion is a common complication if not treated in a timely and proper manner.
Consult orthopedics or hand surgery immediately; these fractures require open reduction internal fixation.
Often these injuries will require computed tomographic (CT) scan for evaluation of the carpal bones and to facilitate repair by the orthopedic surgeon.
Arthritis, limited range of motion, and decreased grip strength are fairly common complications.
Figure 19.22 ▪ Bennett and Rolando Fractures.
(A) Radiograph demonstrating fracture of base of first metacarpal bone with extension into metacarpal-carpal joint. (B) Radiograph of thumb demonstrating a Rolando fracture with an intra-articular comminuted fracture of the base of the first metacarpal. (Photo/legend contributors: Barry Hahn, MD/John Amodio, MD.)
Fracture of the fourth or the fifth metacarpal neck is called Boxer’s fracture and are the most common metacarpal fractures. Volar angulation of the distal bone is almost always present. Most commonly, this results from hitting a wall with the fist rather than from boxing injuries. Patients present with swelling and tenderness over the distal fifth metacarpal. Comminution of the anterior cortex is common, resulting in volar angulation of the metacarpal head. Often the neutral position of the pinky will be normal unless there is extreme volar angulation or any rotational component. Fractures isolated to the metacarpal neck have few complications. Because of the mobility of the fifth metacarpal-carpal joint, angulation up to 40 degrees is well tolerated. Angulation of greater than 40 degrees or any rotational deformity if not reduced will result in an inability to maintain the normal tucked-in position of a clenched hand. This will lead to further vulnerability to injury of the fifth digit.
Obtain standard x-rays of the hand, including anteroposterior (AP) and lateral views. The lateral view is essential to determine the amount of volar angulation. Consult orthopedics for all open fractures, intra-articular fractures, fractures with a rotational component, and those associated with human bites for evaluation in the emergency department (ED). Splint closed fractures with an ulna gutter splint and discharge with instructions for orthopedic/hand specialist follow-up within a week.
Consult orthopedics for evaluation in the ED if there is angulation greater than 40 degrees for the fifth or 30 degrees for the fourth digit, or any rotational deformity.
Clinched fist-to-mouth injuries resulting in a puncture/laceration over the fourth or fifth metacarpophalangeal (MCP) joints need, at minimum, antibiotics in the ED, scrutiny for involvement of the MCP joint, and admission when associated with a fracture.
Scaphoid or navicular fractures are the most common carpal fractures and occur by falling on an outstretched hand or after seemingly minor trauma.
Perform a physical examination including snuffbox tenderness, axial loading, and forced supination to rule out a scaphoid fracture. To assess snuffbox tenderness, have the patient fully flex the thumb into the palm with the second through fifth digits flexed over it, and actively flex the wrist medially into ulnar deviation and palpate the snuffbox. Assess axial loading by keeping the thumb in the extended position while the examiner holds it by the distal phalanx and gently pushes into its origin. The proximal phalanx sits on the scaphoid and with injury this will elicit pain. To assess supination, ask the patient to shake hands with the examiner and resist attempts to force the hand into supination. If any of these tests elicit pain, scaphoid fracture should be suspected. Obtain standard x-rays of the wrist, including scaphoid or navicular views. Consult orthopedics emergently for all radiologically apparent injuries of the carpal bone or dislocations.
Nonunion is the most common complication of a scaphoid/navicular fracture, and this requires open pinning with subsequent decreased mobility.
Radiologically apparent carpal fractures or dislocations require a long arm thumb spica splint or cylindrical cast.
Blood supply to the scaphoid is paradoxical, coming from the palmar arch and the dominant ulnar artery. Therefore, distal scaphoid fractures heal better than proximal scaphoid fractures.
X-rays may not detect a scaphoid fracture for weeks.
Wrist fractures often occur from a fall on an outstretched hand, and to a much lesser extent from a crush injury and are the most common upper extremity injury. Distal radius fractures are often referred to as a “dinner fork” deformity. Colles fracture occurs when there is angulation posteriorly and Smith fracture occurs when there is angulation anteriorly. Simultaneous ulnar styloid fracture is often present. Complications are infrequent, including tendon damage and subsequent arthritis, which occurs much more frequently when the articular surface of the distal radius is involved. Injuries of the epiphysis may result in growth arrest with subsequent instability of the radioulnar joint.
Consult orthopedics emergently for displaced or angulated fractures involving the articular surface. Splint torus fractures and nondisplaced, nonangulated fractures not involving the articular surface and discharge patients with expeditious orthopedic referral.
Definitive treatment for all displaced distal radius fractures is closed reduction.
Must test for median nerve injury.
Figure 19.28 ▪ Distal Radius Fractures.
Frontal view of the wrist shows complete fracture of the distal radius and avulsion of the ulna styloid (arrow; see also Figures 19.4 and 19.10). (Photo/legend contributors: Shashdhar Rao Marneni, MD/John Amodio, MD.)
Galeazzi fracture dislocation is fracture of the distal radial shaft associated with a distal radioulnar dislocation. Monteggia fracture dislocation is fracture of the proximal third of the ulna with a radial head dislocation. The most common mechanism of injury is a fall on the arm. Tenderness on palpation is always present, but swelling and deformity may be minimal.
Obtain complete x-rays of the radius and ulna as well as the wrist. Consult orthopedics for evaluation and treatment in the ED, and immobilize, elevate, and ice the injury while awaiting consultation.
Olecranon fractures are usually due to a direct blow to the elbow. Patients present with tenderness and swelling over the posterior elbow and pain on flexion and extension.
Obtain x-rays of the elbow including AP and lateral views. Splint nondisplaced fractures with the elbow in 90 degrees of flexion and referral to orthopedics in the next several days.
Radial head fractures usually result from falls onto an outstretched hand. Type I fractures involve less than one-third of the articular surface with displacement of less than 1 mm (nondisplaced or marginal fractures). Type II have displacement of more than 1 mm or depression of more than 3 mm, with greater than one-third of the articular surface involved. Patients present with tenderness on radial head palpation and pain is worse with supination of the arm.
Evaluate for point tenderness of the lateral distal elbow over the radial head. Obtain standard x-rays of the elbow, although fractures may not be apparent on x-ray and fat pad signs are often the only evidence of a fracture. A small anterior fat pad may be normal. A “sail sign” or a large anterior fat pad is abnormal. A posterior fat pad suggests a fracture. Immobilize fractures and refer patient to follow up within several days with orthopedics. Splint nondisplaced fractures place the arm in a sling, and refer patient to follow up with orthopedics within several days. For comminuted or displaced fractures, ice, elevate, and immobilize the limb while awaiting emergent evaluation by orthopedics.
Neurovascular complications are rare in minimally displaced radial head fractures.
Myositis ossificans in this area can occur when radial head or neck fractures are accompanied by elbow dislocation.
Radial neck fractures, which are also common in children, are usually buckle fractures that can easily be overlooked on x-rays.
Figure 19.32 ▪ Radial Head Fracture.
(A) Lateral view of the elbow shows a fracture of the radial head (arrow). Note anterior displacement of the anterior fat pad and visualization of the posterior fat pad, indicative of intra-articular effusion. (B) Angulated lateral view shows anterior displacement of fractured radial head. (Photo/legend contributors: Mark Silverberg, MD/John Amodio, MD.)
Supracondylar fractures are caused by falls onto an outstretched hand, typically in children from 3 to 15 years of age. Patients present with a swollen elbow and tenderness over both the lateral and medial epicondyles.
Obtain 4 views of the elbow, including AP and lateral views of both the forearm and humerus. X-rays may show the fracture line, an anterior fat pad sign (displaced anterior fat pad), a posterior fat pad, or an abnormal anterior humeral line. The anterior humeral line is drawn down the anterior cortex of the humerus on the lateral x-ray of the elbow and should pass through the center of the ossification center of the capitellum. Consult orthopedics while the patient is in the ED, with degree of displacement, the reliability of outpatient observation, and the availability of urgent follow-up determining the urgency of the consultation. Splint nondisplaced fractures discharge patient, if and only if at-home neurovascular observation and early orthopedic referral is possible. Admit patients with displaced fractures for early reduction.
Figure 19.33 ▪ Supracondylar Fracture.
(A) Clinical picture of a supracondylar fracture with marked soft tissue swelling in a child with a history of falling on an outstretched arm (B) Lateral projection of the right elbow shows a supracondylar fracture of the humerus with severe anterior displacement of humerus. The capitellum is in normal anatomic alignment with the radial head. (Photo contributors: Binita R. Shah, MD and John Amodio, MD.)
Nerve injury occurs in 7% of supracondylar fractures. The median nerve and the radial nerve are most often injured.
A positive “OK” sign indicates injury to anterior interosseous nerve. There is loss of strength of the thumb interphalangeal joint in flexion as well as the index DIP joint in flexion. This injury renders the patient unable to perform the “OK sign,” with the thumb and index finger apposed against resistance.
Brachial artery compromise can lead to Volkmann contracture (compartment syndrome of the forearm), which will lead to muscle and nerve fibrosis and drastic loss of function.
Humerus fractures may be due to a fall or a direct blow, the latter of which should alert the clinician to the possibility of abuse. Patients present with decreased movement of the extremity and localized swelling.
Obtain perpendicular AP and lateral views of the entire humerus and consult orthopedics for evaluation in the ED for anything greater than one-part fractures or fractures with significant displacement. Immobilize the shoulder and refer urgently to orthopedics.
Figure 19.36 ▪ Proximal Humerus Fracture.
(A) Frontal view of the humerus demonstrates a buckle fracture of the diametaphysis of the humerus (see also Figure 19.2). (Photo/legend contributors: Miriam Krinsky, MD/John Amodio, MD.)
Adhesive capsulitis (frozen shoulder) can occur with proximal fracture, and raises the possibility of neglect.
Brachial plexus injuries and axillary nerve and artery injuries are associated.
Avascular necrosis can occur with medical conditions that cause decreased perfusion, such as sickle cell anemia, or circulatory compromise.
Humeral shaft fractures typically involve the middle third, and 10% to 20% have radial nerve injury. The brachial artery can also be injured.
Myositis ossificans can be avoided by active routine exercise rather than just simple passive stretching in the recuperatory phase.
Young children have open epiphyses and usually suffer epiphyseal separation rather than fractures.
Displacement is significant if there is separation of greater than 1 cm or angulation of greater than 45 degrees.
Figure 19.38 ▪ Myositis Ossificans.
Lateral view of the elbow demonstrates a dense calcification/ossification of the posterior aspect of the elbow joint extending from the distal humeral shaft to the olecranon process. The posttraumatic myositis ossificans was related to a subperiosteal hematoma sustained from a stab wound, which occurred 3 months previously. This 16-year-old presented with a frozen elbow after months of immobilization. (Photo contributor: Michael Lucchesi, MD.)
Clavicle fractures are the most common fracture in children and are commonly caused by a direct blow or fall on the shoulder. Patients present with pain on clavicular palpation. Swelling is usually minor and usually occurs directly over the fracture. If there is significant distraction of the clavicle, injury to the subclavicular artery or vein may occur.
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