Outline:
The clavicular fracture is often caused by indirect force. In a fall, if the lateral side of shoulder or the palm first touches the ground, the force may be transmitted through acromioclavicular joint to the clavicle, leading to clavicular fracture. Most cases of the fracture are shortly oblique or transverse. Besides overlapping displacement, the proximal end of fracture may displace backward and upward because of traction of sternocleidomastoid muscle, and the distal end may displace forward and downward because of traction of both arm weight and greater pectoral muscle. Greenstick fracture mostly occurs in children.

Major points for diagnosis:
1. There is a definite history of trauma.

2. The patient has too severe a painful swelling over the clavicular region to move the injured arm.

3. The diseased shoulder drops and leans forward and inward with the patient’s head leaning to the injured side, and chin toward the healthy side. There is local tenderness, abnormal motility or bony crepitus. A childhood patient has no remarkable manifestation clinically. But moving the patient’s arm such as putting on clothes, lifting the hand or holding up beneath the axillary fossa, may lead to cry.

4. Roentgenogram may determine site, type and displacement of fracture.

Treatment:
The children fracture without displacement or green-stick fracture can be treated by suspending fixation with a triangular bandage for the diseased arm. The fracture with slight displacement can be treated by fixation of 8 shaped bandage for 1 to 3 weeks. The fracture with displacement should be treated by reduction and fixation.

Reduction:  
The patient sits with chest stuck out, head raised and arms akimbo. The operator genuflects against the patient’s midpoint of back with one of his knees, holds the patient’s lateral surface of the shoulders with his hands, applies traction slowly toward the back, making the patient’s chest stuck out and shoulder shrugged. In this way the displacement can be improved. If there is still lateral displacement, correct it by pressing manipulation (see Fig. 5). For this kind of fracture, anatomical reduction is generally not needed, slight displacement does little harm to the function of arm.

Fixation:  
Apply co-shaped bandage fixation. A cotton-pad is put under each axilla. Next, a bandage is used to wrap from the back of diseased side, passing superoanterior part of the shoulder and under the axilla up to the back of shoulder, then, transversely passing the back to the opposite shoulder, whirling around its superoanterior part and under the axilla, transversely passing the back to return to the superoanterior part of the diseased shoulder again. Do the same until at least 8 to 12 rounds have been made. Hang the forearm in front of chest with a triangular sling after wrapping. Generally, the duration of fixation is 2 to 3 weeks for children’s displaced fracture, 4 weeks for adults’ fracture, and 6 weeks for comminuted fracture.

Functional exercise:
In the early stage, the patient is advised to practice flexion and extension of his wrist and elbow joints and clenching his hands. In the middle and late stages, he should do functional exercise of the shoulder with attention to abduction and rotation for fear that he get periarthritis of shoulder due to too long fixation of the shoulder.  For old patients, functional exercise should be especially emphasized.

Herbal therapy:
Internal treatment based on syndrome differentiation In the early stage

1. In the early stage:
Main symptoms and signs: Swelling, distension and pain in the fracture region, impaired functional activity.
 
Therapeutic methods:
Promoting blood flow to remove the stasis, removing swelling to alleviate pain.

Recipe and herbs:
Modified Fuyuan Huoxue Decoction. Specifically, Chaihu (Radix Bupleuri) 12 g, Tianhuafen (Radix Trichosanthis) 12 g, Zhidahuang (Radixet Rhizoma RheiPraeparata) 6 g, Taoren (Semen Persicae) 6g, Dangguiwei (Extremitas Radix Angeicae Sinensis) 15 g, Chishaoyao (Radix PaeniaeRubrae ) 10 g, Honghua (Flos Carthmi) 10 g, Chuanshanjia (Squama Manitis ) 10 g and Gancao (Radix Glycrrhizae) 3g.

2. In the middle stage
Main symptoms and signs:
Subdued swelling and relieved pain, disunited bones.

Therapeutic method:
Reuniting the bones, muscles and ligaments.

Recipe and herbs:
Modified Xugu Huoxue Decoction. Specifically, Dangguiwei (ExtremitasRadix Angelicae Sinensis) 10 g, Chishaoyao (Radix Paeniae Rubrae) 10 g, Baishaoyao (Radix Paeoniae Alba) 10 g, Shengdihuang (Radix Rehmanniae) 15 g, Honghua (Flos Carthmi) 6 g, Zhechong ( Eupolyphaga seu Steleophaga) 10 g, Gusuibu (Rhizoma Drynarii) 12 g, Duanzirantong ( Pyritum Carcinatum ) ( to be decocted first) 10 g, Xuduan (Radix Dipsaci ) 10 g, Luodeda (Herba Centellae) 10 g, Ruxiang ( Gummi Olibanum) 6 g, Moyao (Myrrha) 6 g and Gancao (Radix Glycyrrhizae ) 5 g.

3. In the late stage
Main symptoms and signs:
Partially diminished movement of the shoulder joint, rigidity of muscles and tendons.
Therapeutic methods:
Relaxing tendons and activating collaterals, and freeing joint movement.

Recipe and herbs:
Modified Huoxue Shujin Decoction. Specifically, Danggui (Radix Angelicae Sinensis) 15 g, Jixueteng (Caulis Spatholobi ) 18 g, Danshen (Radix Salviae Miltiorrhizae) 15 g, Sangzhi (Ramulus MoriAlbae) 12 g, Honghua (Flos Carthmi) 6 g, Chuanxiong (Rhizoma Ligustici Chuanxiong) 10 g, Qinjiao (Radix Gentianae Macrophyllae) 10 g, Weilingxian (Radix Clematidis ) 10 g, Jianghuang (Rhizoma Curcumae longae) 10 g, Qianghuo (Rhizoma seu Radix Notopterycjii) 10 g, Niuxi (Radix Achyranthis Bidentatae) 10 g and Gancao (Radix Glycyrrhizae) 5 g.

External therapy:
In the early stage, Sanse Application may be used externally; in the middle stage, Herbal Plaster for Jiegu Xujin is externally applied; and in the late stage, Herbal Plaster for Jiangu Zhuangjin may be externally applied.