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Three Part Question

[In children with a fractured clavicle] is [orthopaedic review in fracture clinic better than following the instructions on the advice sheet] at [decreasing time to return of normal activities]?

Clinical Scenario

A 9 year old girl attends the Emergency Department following a fall from her horse on her right (dominant)side. Examination and x-rays confirm an isolated, uncomplicated fracture of the clavicle. Overlying skin is not in jeopardy and there is no neurovascular impairment. You wonder whether broad arm sling, adequate analgesia and parental advice sheet would be enough or would the orthopaedic follow up improve the outcome.

Search Strategy

- Medline 1966-06/09 using NHS Evidence Search 2 interface
- PubMed 1966-06/09, U.S. National library of Medicine and the National Institues of Health
{[clavicle] and [fractur*]} OR {[MESH clavicle] and
[MESH fracture]} AND ["fracture clinic" OR orthopaedic OR orthopedic]. LIMIT 1966-06/09, human, child (0-18), english
Medline: 17 articles found and reviwed, 1 found relevant to the question

PubMed: 122 articles found and reviwed, 1 found relevant to the question (Same article which was found on Medline)

Search Outcome

One article found relevant to the question

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
JDF Calder, M Solan, S Gidwani, S Allen, DM Ricketts September 2002 United Kingdom	Children aged 2-16	a- Retrospective analysis (286 patients) b- Prospective analysis (60 patients) (After change in practice based upon findings in the retrospective analysis)	a- Fracture clinic follow up	17% discharged after first visit, 68% after second visit, 12% after third visit, 3% had four or more visits (These additional clinic appointments did not alter the subsequent management of the patients).
			b- Fracture clinic follow up	All discharged after first visit. Only 1 patient reattended the clinic who was reassured, advised and discharged. All patients were interviwed at a mean of 7.3 months after injury, no patient reported shoulder pain and all were back to normal activities.

Comment(s)

As the incidence of complications following isolated childhood clavicle fractures looks to be very low, when the integrity of the overlying skin is not in jeopardy and there is no neurovascular impairment, with a thorough conselling and a patient information sheet, patients may be safely discharged home from the Emergency Department, being given advice to see their GP in case of severity of symptoms.

Clinical Bottom Line

Children with an isolated, uncomplicated fractured clavicle may be safely discharged from the Emergency Department with an advice sheet and no initial orthopaedic follow up.

References

1. JDF Calder, M Solan, S Gidwani, S Allen, DM Ricketts Management of paediatric clavicle fractures, is follow-up necessary? An audit of 346 cases Annals of the Royal College of Surgeons of England September 2002, vol./is. 84/5(331-3), 0035-8843