Clavicle and Scapular Fractures: Clinical Guidelines

List of Abbreviations

EFA – external fixation apparatus

AO – Association for Osteosynthesis

VTE – venous thromboembolism

MVA – motor vehicle accident

CT – computed tomography

HDL – high-density lipoproteins

LDL – low-density lipoproteins

PT – physical therapy

Russian Ministry of Health – Ministry of Health of the Russian Federation

MRI – magnetic resonance imaging

LMWH – low-molecular-weight heparin from the B01AB Heparin group

NSAIDs – nonsteroidal anti-inflammatory drugs from the M01A Nonsteroidal anti-inflammatory and antirheumatic products group

UFH – unfractionated heparin from the B01AB Heparin group

PHD – proximal humeral division / proximal humerus

AAT – antitetanus serum (tetanus antitoxin**)

TIG – tetanus human immunoglobulin

WSD – wound surgical debridement / primary surgical wound debridement

TIA – transient ischemic attack

RF – risk factors

PRM – physical and rehabilitation medicine

FS – functional status

TENS – transcutaneous electrical nerve stimulation

SAB – surgical antibiotic prophylaxis

DASH – Disabilities of the Arm, Shoulder and Hand

LCP – locking compression plate

ORIF – open reduction internal fixation

SSSC – Superior Shoulder Suspensory Complex

Terms and Definitions

Absolute stability – absence of micromotion at the fracture site, provided there is anatomical reduction and interfragmentary bone compression after fixation with hardware.

EFA – external fixation apparatus: an orthopedic device containing an implant (a transosseous or extracorporeal element protruding through the skin that reaches or is embedded in the bone) and an external (non-implantable) support connecting bone fragments via transosseous elements in the treatment of fractures, pseudoarthrosis, or gradual lengthening (correction of deformity) of a segment.

Allograft - a fragment of another person's (donor's) bone tissue, typically cadaveric, that has undergone a preservation procedure.

Autograft - a fragment of the patient's own bone harvested from a donor site for transplantation to replenish a bone tissue deficit (bone defect).

Internal fixation device — an orthopedic implant placed during surgery that connects bone fragments in the treatment of fractures, deformities, or pseudarthrosis.

Fracture consolidation - the mutual joining of fragments by living bone tissue due to the successful completion of the reparative regeneration process.

Contracture – restriction of the range of motion in a joint.

Bone fragment – a part of a bone separated as a result of trauma, surgical intervention, or a destructive process.

Migration of fixation elements - the loss of the optimal position of fixation elements due to bone resorption around them, occurring when permissible cyclic loads, their number, or installation technology into the bone are exceeded (within the context of this topic).

Load – mechanical force applied to a limb, bone, and fixation system during treatment, typically recurring with constant periodicity (cyclically).

Impaired consolidation - changes in reparative bone tissue regeneration manifested by a decrease in the rate or cessation of neo-osteogenesis, leading to the inability to perform the mechanical function of the bone.

Open fracture – a disruption of bone integrity accompanied by damage to the skin in the fracture area and injury to the surrounding soft tissues.

Clavicle fracture – traumatic disruption of the integrity of the clavicle; subdivided into fractures of the shaft (diaphysis), proximal metaepiphysis, and distal metaepiphysis of the clavicle.

Scapular fracture – traumatic disruption of the integrity of the scapula.

Post-traumatic deformity - fracture consolidation with a violation of spatial, including axial and rotational, relationships between fragments.

Fixation stability – resistance of the system to external loads, allowing it to maintain the constancy of the mutual orientation of fragments and the optimal distance between them.

Fixation – a state in which relative or complete immobilization of fragments is achieved.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Clavicle and scapular fractures constitute an unclassified concept combining fractures of the shaft, proximal and distal metaepiphysis of the clavicle, as well as various scapular fractures. The term "fracture" refers to the traumatic disruption of the integrity of the specified bones and their segments. Within the framework of these clinical guidelines, only traumatic isolated open and closed fractures of the clavicle and scapula on one side are considered, excluding birth trauma.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Clavicle and scapular fractures result from direct or indirect trauma. In the direct mechanism of injury, the force is applied directly to the fracture site. The indirect mechanism is characterized by the force being applied at a distance from the fracture site. Depending on the energy of the injury, high-energy and low-energy fractures are distinguished. The former are usually the result of direct trauma and are accompanied by significant damage to surrounding soft tissues. Low-energy fractures have an indirect mechanism of injury and occur in patients with reduced bone mineral density.

Clavicle shaft and distal metaepiphysis fractures are characterized by the following injury mechanisms: fall onto the shoulder (31%), motor vehicle accidents (27%), and sports activities (23%) [1, 2]. Proximal metaepiphysis fractures of the clavicle are extremely rare in isolation; most often they result from high-energy impact and/or are a component of severe polytrauma [2]. Fractures in newborns can be singled out separately, with an average frequency of 1% – 2%. Stress fractures of the clavicle are rare and occur in athletes (wrestlers, gymnasts). Pathological fracture against the background of neoplasms is a rare occurrence.

In most cases (80–90% according to various estimates), scapular fractures result from direct high-energy trauma, including as part of severe polytrauma, such as in motor vehicle accidents [3, 4]. Glenoid injuries result from a fall on an outstretched hand and from shoulder dislocation—typically affecting the anterior rim. Posterior shoulder dislocation with posterior rim injury should be suspected in a patient with a history of seizures or after electric shock.

1.3 Epidemiology of the Disease or Condition

Among all fractures in adult patients, clavicle fractures account for about 2.6–4%, which amounts to 30 cases per 100,000 population per year [5, 6].

According to available data, up to 69% of clavicle fractures involve its diaphysis, an average of 28% involve the distal metaepiphysis, and only about 3% involve the proximal metaepiphysis [5].

Clavicle fractures are characterized by a bimodal distribution with high incidence in men under 30 years of age, as a consequence of high-energy trauma, and in the elderly. In the latter, fractures occur from low-energy falls from standing height due to osteoporosis. In young patients, fractures are most frequently localized in the middle third of the clavicle shaft, whereas elderly individuals more often injure the lateral end of the clavicle [7].

In the overall structure of bone fractures in children, clavicle fractures are among the most common—ranging from 5% to 15%. In more than half of the cases, these fractures are observed in children under 7 years of age. Fractures of the middle third of the clavicle are most commonly observed (75% to 85%). The next most frequent (10% to 20%) is injury at the level of the distal third. Injuries to the sternal end of the clavicle are quite rare [8].

Among the most common associated injuries are rib fractures, scapular fractures, and brachial plexus injuries [9].

Scapular fractures are a relatively rare type of injury (about 1% of all fracture cases). They are more common in men (64% of cases) than in women. In terms of simultaneous stratification by sex and age, the groups most susceptible to such injuries are men under 50 years and women over 64 years [10].

Fractures of the scapular body are observed most frequently (45%), followed by neck fractures (25%), articular process (glenoid) fractures (10%), acromion fractures (8%), coracoid process fractures (7%), and finally the scapular spine (5%). An extremely rare situation, especially in childhood, is scapulothoracic dissociation.

There are no reliable statistical data on mortality in isolated scapular fractures due to the rarity of this pathology. Mortality in severe polytrauma that includes a scapular fracture reaches 10–15% [10]. Scapular fractures are almost always associated with damage to other organs and fractures of various locations: chest organ injuries (80%), accompanied by hemopneumothorax (>30%), pulmonary contusion (>40%), head trauma (35–50%), rib fractures (53%), clavicle fractures (25%), other upper extremity bones (50%), spine (26–50%), and pelvic bones (15%). Due to anatomical features, scapular fractures may be accompanied by damage to the subclavian and axillary arteries (11%) and the brachial plexus (5–13%)—fortunately, 75% of patients exhibit a transient nature of changes and complete recovery. However, total-type brachial plexus injury, especially combined with Horner's syndrome, is a prognostically unfavorable situation.

Frequency of injuries accompanying scapular fractures:

• rib fractures – 53–57%;

• lung injuries (with pneumothorax and/or hemothorax and/or pulmonary contusion) – 40–47%;

• head injuries – 39%;

• spinal injuries – 25–29%;

• clavicle fracture – 18–25%;

• upper extremity bone fractures – 23%;

• abdominal injuries – 17%;

• facial bone fractures – 12%;

• upper extremity nerve injuries (e.g., brachial plexus) – 3%;

• sternal fracture – 2% [10].

1.4 Features of Coding the Disease or Condition

S42.0 – Fracture of clavicle.

S42.1 – Fracture of scapula.

S43.1 – Dislocation of acromioclavicular joint.

S43.2 – Dislocation of sternoclavicular joint

1.5 Classification of the disease or condition

Several classifications have been proposed for clavicle fractures, some of which are modifications of simpler ones:

1. According to Allman [11]:

• Type 1: fracture of the middle third of the clavicle;

• Type 2: fracture of the lateral (distal) third of the clavicle;

• Type 3: fracture of the medial (proximal) third of the clavicle.

2. According to Neer [12]:

• Type 1: fracture line lateral to the coracoclavicular ligament, both parts of the ligament (trapezoid and conoid) intact, minimal displacement;

• Type 2 (all subtypes are unstable):

o 2A: fracture line medial to the coracoclavicular ligament, both parts of the ligament intact;

o 2B1: fracture line between the two portions (parts) of the ligament, conoid ligament damaged (ruptured);

o 2B2: fracture line lateral to the coracoclavicular ligament, both parts of the ligament damaged (ruptured);

• Type 3: fracture line lateral to the coracoclavicular ligament, involves the acromioclavicular joint, the fracture itself is stable;

• Type 4: physeal fracture in children, adolescents, and adults with incomplete skeletal growth;

• Type 5: comminuted fracture, the inferior fragment remains attached to the coracoclavicular ligament.

3. According to Nordquist and Petersson [13]:

• Type 1: fracture of the shaft (middle third) of the clavicle:

o 1A: non-displaced;

o 1B: displaced;

o 1C: comminuted with one or more displaced intermediate fragments;

• Type 2: fracture of the distal third of the clavicle:

o 2A: non-displaced;

o 2B: displaced;

• Type 3: fracture of the proximal third of the clavicle:

o 3A: non-displaced;

o 3B: displaced.

4. According to Craig [7]:

• Type 1: non-displaced or minimally displaced;

• Type 2: displaced fracture, line located medial to the coracoclavicular ligament:

o 2A: conoid ligament intact;

o 2B: conoid ligament damaged (ruptured);

• Type 3: fracture line passes through the articular surface;

• Type 4: fracture in children;

• Type 5: comminuted fractures.

5. According to Robinson [5]:

• Type 1: fracture of the medial 1/5 of the clavicle (medial metaepiphysis):

o Type 1A: non-displaced:

o Type 1A1: extra-articular;

o Type 1A2: intra-articular;

o Type 1B: displaced:

o 1B1: extra-articular;

o 1B2: intra-articular;

• Type 2: fracture of the middle 3/5 of the clavicle (shaft);

• Type 3: fractures of the lateral 1/5 of the clavicle (lateral metaepiphysis);

o 3A: non-displaced:

o 3A1: extra-articular;

o 3A2: intra-articular;

o 3B: displaced:

o 3B1: extra-articular;

o 3B2: intra-articular.

6. According to AO/OTA, the clavicle is assigned the code 15 [14]:

• 15.1 – fractures of the sternal end of the clavicle:

o A – extra-articular;

o B – partial intra-articular;

o C – complete intra-articular;

• 15.2 – clavicular shaft fractures:

o A – simple;

o B – wedge-fragment;

o C – comminuted.

• 15.3 – fractures of the acromial end of the clavicle:

o A – extra-articular;

o B – partial intra-articular;

o C – complete intra-articular;

Depending on the injury to the coracoclavicular ligaments, 15.3 fractures are further designated with lowercase Latin letters: "a" - with an intact coracoclavicular ligamentous apparatus; "b" - with injury to either the conoid or trapezoid ligament; "c" - with complete disruption of the ligamentous apparatus.

Similar to other segments, clavicular fractures in children can be subperiosteal without complete separation of fragments (greenstick fracture). As a rule, this type of injury presents only with angular displacement of the bone fragments.

For injuries in the acromioclavicular joint region, Dameron and Rockwood proposed a modification of the classification used in adult patients. It is based on the following parameters: periosteal integrity, condition of the coracoclavicular and acromioclavicular ligaments, and direction of fragment displacement. Type 1 – nondisplaced fracture; Type 2 – partial tear of the acromioclavicular ligament and periosteum with partial loss of clavicular stability; Type 3 – complete tear of the acromioclavicular ligament and periosteum, superior displacement of the clavicle within 25%-100% of its width; Type 4 – posterior displacement of the clavicle beneath the trapezius muscle; Type 5 – superior displacement of the clavicle by more than 100% of its width – effectively into the soft tissues; Type 6 – inferior displacement of the clavicle beneath the coracoid process of the scapula.

Distal clavicle fractures are classified separately: Type 1 – nondisplaced or minimally displaced; Type 2 – fracture medial to the coracoclavicular ligament; Type 3 – intra-articular fracture.

For injuries of the sternal end of the clavicle, fractures with anterior fragment displacement and posterior fragment displacement are distinguished.

Acromioclavicular joint dislocations can be classified according to Rockwood [168]:

Type 1 (Rockwood I) – acromioclavicular ligament is stretched or partially torn, coracoclavicular ligament is intact, no radiographic signs of clavicular dislocation.

Type 2 (Rockwood II) – rupture of the acromioclavicular ligament, coracoclavicular ligament is stretched or partially torn, radiographic signs of clavicular dislocation are absent or minimal.

In Types 3-6 (Rockwood III – VI), there is a complete tear of both the acromioclavicular and coracoclavicular ligaments, and the types differ based on the degree of clavicular displacement.

Rockwood III – the distance between the coracoid process and the clavicle is 200% of normal.

Rockwood IV – the clavicle is displaced posteriorly, "abutting" and/or displacing the trapezius muscle.

Rockwood V – the distance between the coracoid process and the clavicle is 200-400% of normal.

Rockwood VI – subacromial or subcoracoid displacement of the clavicle.

The classification of sternoclavicular joint dislocations distinguishes anterior and posterior subluxations and dislocations.

Like most fractures, scapular fractures are divided into: open and closed fractures; simple and multifragmentary; with and without fragment displacement.

By localization, they are distinguished into: body of the scapula fracture, articular process fracture, neck fracture, acromion fracture, coracoid process fracture.

There are 2 types of scapular neck fractures:

Type 1 – fragment displacement of less than 1.0 cm and angular deformity of less than 40 degrees – 90% of neck fractures fall into this category.

Type 2 – fragment displacement of more than 1.0 cm and angular deformity of more than 40 degrees.

Coracoid process fractures are classified by Ogawa according to the injury zone, which in turn is determined by its mechanism: Type 1 – fracture proximal to the attachment site of the coracoclavicular ligament; Type 2 – fracture of the tip of the coracoid process.

Kuhn proposed classifying acromion fractures as follows: Type 1 – nondisplaced or minimally displaced fracture; Type 2 – displaced fracture with preserved subacromial space; Type 3 – displaced fracture with a compromised subacromial space [16].

Scapular fractures are coded as 14 according to the AO/OTA classification:

• 14A – scapular process fractures:

o 14A1 – coracoid process fractures;

o 14A2 – acromion fractures;

o 14A3 – scapular spine fractures;

• 14B – scapular body fractures:

o 14B1 – fracture line exits the borders of the scapula in two or fewer places;

o 14B2 – fracture lines exit the borders of the scapula in three or more places;

• 14F – glenoid cavity fractures of the scapula:

o 14F1 – simple glenoid fracture;

o 14F2 – multifragmentary glenoid fracture [14].

A classification of scapular body fractures was proposed by J. Bartoniček et al. (2018). The authors divided the scapula into two supporting columns.

• Scapular spine fracture (spine column);

• Lateral column fracture:

o two-part;

o three-part;

o comminuted;

• Bicolumnar fracture:

o medial;

o central [15].

The classification of glenoid cavity fractures by R. Ideberg et al. (1995), as modified by K. Mayo et al. (1998):

• Type 1 – anterior rim fracture: Type 1A – fragment less than 5 mm; Type 1B – fragment greater than 5 mm;

• Type 2 – inferior glenoid fracture involving the scapular neck;

• Type 3 – superior glenoid fracture involving the base of the coracoid process;

• Type 4 – horizontal fracture involving the neck and body of the scapula, with the fracture line passing below the scapular spine;

• Type 5 – Type 4 with complete or incomplete scapular neck fracture [17, 18].

For open fractures of the clavicle and scapula, the classification by R.B. Gustilo and J.T. Anderson (1976) [19], modified by R.B. Gustilo et al. (1984) [20], is used:

• Type I – open fracture, the wound is minimally contaminated, wound size is less than 1 cm;

• Type II – open fracture, the wound is greater than 1 cm and less than 10 cm in length without significant soft tissue damage, flaps, or skin detachment;

• Type IIIA – open fracture, soft tissues cover the fragments, no periosteal stripping in the presence of extensive soft tissue damage or flaps, or in high-energy trauma regardless of wound size;

• Type IIIB – open fracture with an extensive soft tissue defect, periosteal stripping, and a comminuted fracture pattern, often with significant microbial contamination of the wound;

• Type IIIC: open fracture complicated by major vascular injury requiring surgical reconstruction, regardless of the extent of soft tissue damage.

1.6 Clinical presentation of the disease or condition

Clavicle fractures

Complaints: pain in the clavicular and/or shoulder joint region, impaired upper extremity function, clavicular deformity due to fragment displacement and soft tissue edema. In children with brachial plexus injury, motor and sensory impairments may occur. Symptoms of a clavicular fracture may include unexplained crying and restlessness, and refusal to feed. Due to age and anatomical-anthropometric features, this injury may remain undiagnosed until callus formation occurs, when the only sign will be a palpable mass in the area of the former fracture.

Anamnesis: history of trauma, the patient describes a characteristic mechanism of injury. The mechanism is most often indirect – a fall from standing height onto an adducted shoulder or abducted arm. In high-energy trauma (such as a motor vehicle accident or a fall from height), injuries are more severe and may be combined with injuries to other body segments or areas; therefore, it is necessary to thoroughly collect the patient's history and perform a physical examination. A complicated delivery process indicates a clavicular fracture in newborns: shoulder dystocia, obstetric maneuvers (vacuum extraction, maternal fundal pressure).

Objective examination: edema of the clavicular region, restriction of active movements, pain on passive movements of the upper extremity on the affected side, palpable displacement of clavicle fragments, "piano key" sign, and bone crepitus. With significant angular displacement, clavicular deformity with taut skin is observed – in such situations, there is a risk of skin perforation. In open fractures, bone fragments may be visible in the wound. The patient's characteristic appearance: the head is turned and tilted toward the injured side, the shoulder girdle is lowered and displaced anteriorly, and the medial border and inferior angle of the scapula protrude from the chest wall due to the absence of the strut-like function normally provided by the clavicle. The arm is lowered, adducted to the trunk, and internally rotated. The subclavian fossa is smoothed [21]. Examination of the injured area includes assessing the skin in the fracture zone for integrity and signs of tension. Injury to the acromial end is most noticeable when compared with the contralateral side. In older patients, ecchymosis in the injury zone may be observed. When the sternal end is injured, it is necessary to ensure the absence of airway obstruction (stridor symptoms – noisy, labored inspiration involving accessory muscles) and potential airway damage (subcutaneous emphysema), as well as dysphagia. When the neurovascular bundle is compressed by the sternal end, the patient may complain of hypoesthesia and paresthesia of the upper extremity skin, decreased muscle strength, and a diminished pulse wave may be palpated on the radial and ulnar arteries compared to the contralateral extremity. For any type of clavicular fracture, neurological status must be assessed for the presence or absence of deficits.

A rare but possible situation is the combination of clavicle and scapular fractures (the so-called "floating shoulder"), when the upper shoulder suspensory complex is ruptured—which in most cases is an indication for surgical treatment. There are also clinical reports of clavicle fractures combined with rotational dislocation at the C1-C2 segment level, which manifests as a locked subluxation around the time immobilization is discontinued.

Scapular fractures

Complaints: pain in the scapula and/or shoulder joint area, impaired function of the upper extremity, and deformity in the scapular region due to soft tissue edema and fragment displacement.

Anamnesis: history of trauma, with the patient describing a characteristic mechanism of injury. A direct mechanism of injury is most common. High-energy trauma is typical (motor vehicle accident or fall from a height). Scapular fractures may be combined with injuries to other body segments or regions; therefore, it is necessary to carefully take the patient's history and perform a physical examination. In some cases, taking the anamnesis may be difficult due to the severity of the patient's condition.

Objective examination: edema of the scapular region, subcutaneous hemorrhage in the scapula, shoulder joint, and upper back area, limitation of active movements, pain during passive movements of the upper extremity on the affected side, and fragment crepitus (rare). In open fractures, bone fragments may be visualized in the wound. Since scapular injuries are not life-threatening conditions and are often merely a component of polytrauma, the priority is to identify and treat injuries that pose the primary threat. The ABC examination protocol should be followed, with serial examinations and correction of developing abnormalities. Thus, labored breathing, distended neck veins, tracheal deviation, absence of chest wall excursion, and breath sounds on the injured side may indicate the presence of a hemato-/pneumothorax or developing cardiac tamponade. In such a situation, a more detailed examination takes a back seat. Local examination may reveal ecchymosis in the injury zone, pain on palpation, and assessment of the range of motion.

2. Diagnostics, medical indications and contraindications for diagnostic methods

Criteria for establishing the diagnosis/condition:

• history data;

• physical examination data;

• instrumental examination data.

2.1 Complaints and Anamnesis

In most cases, patients present with the complaints described in section 1.6 "Clinical Presentation".

2.2 Physical Examination

Physical examination findings are described in section 1.6 "Clinical Presentation".

-In patients with suspected clavicle and/or scapular fractures, it is recommended to assess the following parameters for diagnostic purposes no later than 1 hour after admission to a medical facility, with mandatory recording of the results in the medical documentation:

-assessment of somatic status;

-visual and palpation assessment of local status [23];

-blood pressure measurement;

-body temperature measurement;

-assessment of the risk of venous thromboembolic events [24, 146].

Level of Evidence 5Grade of Recommendation C (Level of Evidence – 5).

Comment: Due to the fact that the risk of thromboembolic complications in pediatric patients is significantly lower than in adults, being less than 17 per 10,000 [25], assessment of the risk of thrombosis and PE in children with isolated clavicle or scapular injury is generally not required.

• In patients of all age groups with suspected clavicle and/or scapular fractures, it is recommended to assess the state of innervation and blood circulation in the peripheral parts of the extremity to rule out neurovascular bundle injury at the fracture level [26, 27, 145, 146, 158, 159].

For adults – recommendation grade C (level of evidence – 4).

For children – recommendation grade C (level of evidence – 5).

• When deciding on surgical treatment for adult patients with clavicle and/or scapular fractures, it is recommended to collect anamnesis and perform a physical examination to identify risk factors and cardiovascular diseases [28, 29].

LE AQOE 3Level of Evidence A (reliability of evidence level – 3).

Comment: Risk factors for the development of cardiovascular diseases include: arterial hypertension, smoking, dyslipidemia (elevated total cholesterol >4.9 mmol/L and/or LDL cholesterol >3 mmol/L and/or HDL cholesterol in men <1.0 mmol/L, in women <1.2 mmol/L, and/or triglycerides >1.7 mmol/L), diabetes mellitus, and a family history of cardiovascular disease at a young age (<55 years for men and <65 years for women) [28]. Established cardiovascular disease is understood to mean: coronary artery disease, cerebrovascular disease, peripheral atherosclerosis, chronic heart failure, pulmonary hypertension, valvular heart disease, and cardiomyopathies [30, 29].

• All adult patients referred for elective surgical treatment of a clavicle and/or scapular fracture are recommended to undergo an assessment of the risk of perioperative cardiovascular complications, taking into account the type of planned surgical treatment for the clavicle and/or scapular fracture, regardless of the presence of comorbid pathology, in order to prevent life-threatening complications of surgical treatment [28, 31].

LE AQOE 3Level of Evidence A (reliability of evidence level – 3).

Comments: When surgical treatment is performed for emergency (<6 hours) and urgent (6–24 hours) indications, preoperative risk assessment is not performed.

Minor orthopedic surgeries are accompanied by a low risk of cardiovascular complications (30-day risk of myocardial infarction or cardiovascular death after surgery is less than 1%). Major orthopedic surgeries are accompanied by an intermediate (moderate) risk of cardiovascular complications (30-day risk of myocardial infarction or cardiovascular death after surgery is 1–5%) [32].

• To assess the risk of perioperative cardiovascular complications in adult patients with clavicle and/or scapular fractures, it is recommended to use a special algorithm (Appendix B4) [32, 33].

RG CLoE 5Recommendation grade C (level of evidence – 5).

• Elective surgical treatment to create conditions for bone union is recommended without additional workup for adult patients with clavicle and/or scapular fractures whose risk of cardiovascular complications is determined to be low. In patients with an intermediate or high perioperative risk of cardiovascular complications, it is recommended to assess the patient's functional status [32, 34].

GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).

2.3 Laboratory Diagnostics

All patients diagnosed with a clavicle and/or scapular fracture for whom surgical treatment is planned are recommended to undergo the following laboratory tests for diagnostic purposes:

- complete blood count;

- urinalysis;

- general general-medical biochemical blood test: total bilirubin, alanine aminotransferase (ALT), aspartate aminotransferase (AST), urea, creatinine, total protein, glucose;

- determination of main blood groups by the ABO system and determination of the D antigen of the Rhesus system (Rh factor);

- determination of antibodies to hepatitis A virus (Hepatitis A virus) in the blood;

- determination of hepatitis B virus surface antigen (HBsAg) in the blood;

- determination of hepatitis C virus class G antibodies (anti-HCV IgG) in the blood;

- determination of antibodies to Treponema pallidum in the blood;

- coagulogram (screening hemostasis test);

- determination of the international normalized ratio (INR) [35, 36].

Level of Evidence 5Grade of Recommendation C (Level of Evidence – 5).

• When deciding on surgical treatment for adult patients with clavicle and/or scapular fractures, it is recommended to test the blood level of N-terminal pro-B-type natriuretic peptide (NT-proBNP) for diagnostic purposes in cases of intermediate or high risk of cardiovascular complications and low functional status of the patient (see Appendix G2) [28, 30, 32].

LEL 5Grade of Recommendation C (Level of Evidence – 5).

2.4 Instrumental Diagnostics

Comments: Comparative radiographs of the contralateral clavicle and shoulder joint can assist in diagnosing injuries of the acromioclavicular joint region. Radiography of the clavicle in the anteroposterior projection with a 20° cephalic beam tilt makes it possible to assess the presence of shortening due to the fracture [8, 37, 44]. In some cases (depending on the patient's age and pain intensity), comparative radiography of both acromioclavicular joints can be performed with weight (from 2.0 kg to 5.0 kg) attached to the healthy and injured extremities to assess vertical stability.

In injuries of the sternal end of the clavicle, radiography in the anteroposterior projection has low diagnostic value. A special view with the beam directed 40 degrees cranially (Rockwood view) allows for clearer visualization of the position of the sternal end of the clavicle; however, computed tomography remains the method of choice in this situation—in addition to clear visualization of bone structures, CT allows assessment of the mediastinal organs for concomitant injuries.

After confirmation of a clavicle fracture by diagnostic imaging methods, the patient should be hospitalized in an inpatient facility according to indications; in the absence of indications for hospitalization, the patient may be discharged for outpatient treatment at their place of residence.

If a patient refuses inpatient treatment, the reason for refusal must be documented in the medical chart with the personal signature of the patient or their legal guardians (in case of legally established incapacity of the patient).

Comments: The Zanca view is an anteroposterior view with a 10-15 degree cephalic tilt of the X-ray tube.

Comments: Computed tomography is most frequently (service code: A06.03.062 Computed tomography of bone and/or A06.09.005 Computed tomography of thoracic organs) required for fractures of the proximal end of the clavicle. This is due to the fact that it is difficult to differentiate between a fracture and a dislocation in the sternoclavicular joint region using plain radiographs. Computed tomography also allows visualization of the underlying structures of the chest wall, mediastinum, and neurovascular bundle (when performed with intravenous contrast enhancement) [37].

Comments: Scapular fractures are among the most difficult injuries to diagnose in the shoulder joint region. The transcapsular Y-view is the most informative radiographic projection for diagnosing scapular fractures when computed tomography cannot be performed [39].

2.5 Other Procedures

• When treating patients with clavicle and/or scapula fractures, it is recommended to consider the following indications for consultations with related specialists in clinical practice in order to rule out life- or health-threatening conditions for the patient:

- neurosurgeon consultation: in case of nerve injury or suspected nerve injury and concomitant traumatic brain injury;

- general surgeon / pediatric surgeon consultation: in case of suspected or objectively diagnosed concomitant abdominal trauma;

- cardiovascular surgeon consultation: in case of concomitant vascular injury or suspected vascular injury;

- general practitioner / pediatrician consultation: in the presence of comorbid conditions of a therapeutic profile (according to medical history) [21, 23, 146].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

• Before surgical treatment, adult patients with clavicle and/or scapula fractures are recommended a consultation with a general practitioner / cardiologist or anesthesiologist-resuscitologist in order to rule out acute or unstable cardiovascular conditions and perform perioperative cardiovascular risk assessment [32].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

• Before surgical treatment, adult patients with clavicle and/or scapula fractures are recommended a cardiologist consultation for patients with pathological ECG changes and/or elevated NT-proBNP levels in order to rule out acute or unstable cardiovascular conditions, if they are determined to be at high perioperative risk and have low functional status [32].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

• Upon detection of acute or unstable clinical conditions in adult patients with clavicle and/or scapula fractures, it is recommended to postpone elective surgical treatment, and the patient should be transferred to a regional vascular center or a specialized cardiology department in order to improve cardiac status and stabilize the patient's condition [32].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1 Conservative Treatment

• For patients with clavicle and/or scapula fractures upon admission to the hospital, it is recommended to provide the following minimum scope of care in the admission department in order to stabilize the general condition:

- ensuring thermal comfort for the patient;

- adequate pain management;

- immobilization of the injured upper extremity;

- correction of fluid and electrolyte imbalances [37, 44, 146].

GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).

Comment: For middle third clavicle fractures in children, in the absence of the threat of skin perforation and compression of the neurovascular bundle, conservative treatment consisting of immobilization is effective – successful fracture healing is observed in 95-98% of patients, and comparison with the group of operated patients reveals no advantages in treatment outcomes [33].

After birth, the clavicle continues to grow at a constant rate until 12 years of age. During the first 5 years of life, bone growth occurs from the central part of the clavicle—the length increases by approximately 8.4 mm per year. After 12 years, the clavicle grows by about 2.6 mm per year in girls and 5.4 mm per year in boys, and approximately 80% of clavicle growth occurs from the sternal end. Thus, 80% of its final length is reached by the clavicle at 9 years of age in girls and 12 years of age in boys. This must be taken into account to predict the remodeling of traumatic deformity.

Comments: The figure-eight bandage does not provide better functional results compared to the sling and causes more inconvenience to patients, especially in the early stages of treatment [6, 45]. In pediatric patients, the duration of immobilization is 3-4 weeks. A palpable callus usually appears by days 7-12, and as a rule, the severity of the pain syndrome significantly decreases during this period. Follow-up radiography is performed every 4 weeks until radiological signs of complete healing appear, which may take up to 10 weeks in case of significant fragment displacement.

Comments: Immobilization of the injured upper extremity is carried out using a sling bandage for a period of 3 weeks until the pain subsides and fracture consolidation begins [46].

Most scapular fractures (>80%) can be managed conservatively with good functional outcomes [47]. In a systematic review of 520 scapular fractures, M. Zlowodzki et al. (2006) found that 99% of isolated body fractures and 83% of scapular neck fractures are treated without surgery, with excellent and good functional outcomes in 86% and 77% of cases, respectively. In contrast, 80% of glenoid cavity fractures require surgical treatment, with excellent and good outcomes in 82% of cases [10].

• In patients with clavicle and/or scapular fractures, it is recommended as part of conservative treatment to perform follow-up radiographs of the injured segment in two projections every 4 weeks to monitor the fracture consolidation process and the position of bone fragments [23].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comment: Clavicle and scapular fractures may be accompanied by acromioclavicular joint dislocation. However, in the absence of a complete simultaneous rupture of the acromioclavicular and coracoclavicular ligaments, radiological signs of dislocation are minimal or absent, corresponding to Rockwood types I-II dislocation. Such dislocations, if present, require conservative treatment only. At the same time, this recommendation does not preclude surgical treatment of clavicle fractures for other indications.

Comment: Sternoclavicular joint dislocation may occur in injuries involving fractures of the clavicle and/or scapula. Conservative treatment (including closed reduction of the dislocation) does not preclude subsequent surgical treatment. The risk of recurrent dislocation is considered to range from 21% to 100% [171-173]; however, such a condition is well compensated functionally and affects upper extremity function only to a minor degree.

Comments: Posterior sternoclavicular dislocations may be accompanied by injury to the mediastinal and chest anatomical structures. Therefore, during closed or open reduction of the dislocation, a surgeon proficient in thoracic surgery and a critical care physician must be present at the clinic. Treatment should begin with an attempt at closed reduction of the dislocation. If closed reduction fails, open reduction of the sternal end of the clavicle must be performed followed by reconstruction of the ligamentous apparatus using one of the accepted methods.

Analgesia

To provide adequate analgesia for patients with clavicle and/or scapula fractures, it is recommended to use multimodal analgesia for adults and children, taking into account age restrictions, which may include non-steroidal anti-inflammatory and antirheumatic drugs (NSAIDs) from the M01A group, paracetamol**, gabapentinoids, and immediate-release opioids, or monomodal analgesia if multimodal administration is not feasible [48-55, 147, 148].

GoR ALoE 2Grade of Recommendation A (Level of Evidence – 2).

Comments: Multimodal anesthesia (MMA) involves the use of multiple analgesic drugs (opioid and non-opioid) with different mechanisms of action, along with non-pharmacological interventions aimed at targeting peripheral and/or central sites of the nervous system [43]. This combination allows for more effective pain management by enhancing the effects of various drugs, which in most cases leads to a reduction in the frequency of prescriptions and/or doses of opioid analgesics. Thus, MMA improves the risk profile of each drug while providing synergistic pain control using different classes of medications. Postoperative MMA may include psychotherapy, physical therapy, NSAIDs, paracetamol**, gabapentinoids, regional anesthesia (single-shot injection or peripheral nerve catheter placement), local injections, and opioids [50, 51].

In modern literature, authors emphasize the use of the lowest effective doses of opioids for the shortest possible duration, avoiding extended-release opioids. As an adjuvant during MMA in adult patients, a single intravenous dose of #dexamethasone** 1.25–20 mg can be administered before surgery (60 minutes prior to incision), which significantly reduces pain [54].

It must be kept in mind that parenteral administration of most NSAIDs (ketorolac**, diclofenac**) is limited to a maximum of two days, which requires timely switching the patient to oral administration, changing the drug, or approving further use with a medical committee. The specific choice of local anesthesia technique and medications is made by the attending physician individually, in accordance with the patient's characteristics, local protocols, and the medical organization's equipment.

When prescribing analgesic therapy for children, a single dose should be chosen taking into account the child's weight and age. Preference should be given to analgesics with oral or rectal administration routes, avoiding intramuscular injections.

Recommended analgesic medications are listed in Appendices A3.1-A3.3

• Adult patients with clavicle and/or scapula fractures are recommended to undergo local blockade or regional anesthesia as part of a postoperative multimodal regimen for pain relief [54, 56, 157].

GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).

Prevention of venous thromboembolic complications

• In patients with clavicle and/or scapula fractures, it is recommended to consider perioperative VTE prophylaxis to reduce the risk of their development if general anesthesia lasts longer than 90 minutes, if the surgery may significantly impair the patient's mobility, or in the presence of a history of VTE [57].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comments: In patients with upper extremity fractures (scapula, clavicle, humerus, forearm, and hand), the incidence of VTE is 2.72%, developing within 90 days after hospital discharge. Risk factors for this complication include age over 40 years, anemia, chronic pulmonary disease, coagulopathy, heart failure, oncological diseases, obesity, renal failure, head trauma, chest trauma, abdominal trauma, rib fractures, humerus fractures, elbow region fractures, and closed reduction [58].

Taking into account the increasing population prevalence of genetically determined thrombophilias (antithrombin III, protein C, or S deficiency, factor V Leiden mutation, prothrombin G20210A mutation, etc.), the widespread and often uncontrolled use of estrogens, population aging, and the rising incidence of diabetes and other metabolic disorders that increase the risk of VTE, pharmacological thromboprophylaxis may be advisable when treating patients with additional VTE risk factors for clavicle and scapula fractures, as well as extensive soft tissue trauma of the upper extremities. The final decision is made by the attending physician, taking into account the extent of injury, the nature of the planned procedure, and additional patient-related VTE risk factors. Perioperative administration of LMWH to this category of patients may be carried out according to the regimens and dosages provided in Appendix A3.4 for a duration of 7-10 days (until hospital discharge) or for several days until normal/expected mobility is restored.

Recommended medications and thromboprophylaxis regimens are given in Appendix A3.4.

The issues of VTE prevention in trauma and orthopedic patients are discussed in detail in the 2022 methodological guidelines [59] and the 2023 Russian expert recommendations [60].

Features of thromboprophylaxis in pediatric patients

Hospitalized patients older than 6 months are recommended to undergo bleeding and VTE risk assessment within 24 hours of admission [61] and periodically during their hospital stay [62–64].

LoR CLoE 5Level of Recommendation C (Level of Evidence 5).

Comment: There are no validated VTE risk assessment scales developed for pediatric patients, nor are there validated bleeding risk assessment scales for anticoagulant therapy. Therefore, when deciding on VTE prophylaxis, individual bleeding risk factors (Appendix A3.5), VTE risk factors (Appendix A3.6), and the risk-benefit ratio should be considered [65, 67].

For VTE prophylaxis in children, mechanical and pharmacological methods are used.

• In pediatric patients at high risk for VTE, it is recommended to consider prescribing prophylactic doses of UFH or LMWH from the B01AB group [70].

GPP CLEL 5Level of Evidence C (Level of Likelihood of Evidence 5).

Comment: LMWHs are preferred for pediatric patients [69, 70], but in Russia, the use of all LMWHs is currently contraindicated in children; therefore, their prescription is possible only by decision of the medical commission (off-label use). Some foreign guidelines mention the use of direct oral anticoagulants (rivaroxaban**) for VTE prophylaxis in children [67], however, there is currently insufficient clinical evidence regarding their efficacy and safety in this patient population [66, 68].

To decide on pharmacological VTE prophylaxis, a consultation with a pediatrician or a hematologist experienced in treating thrombosis in children is recommended. When prescribing anticoagulants to children, it is advisable to monitor general blood count parameters within 48 hours after starting treatment with enoxaparin or heparin [64]. According to indications, anti-Xa levels should be determined 4-6 hours after the administration of sodium enoxaparin** (target anti-Xa level 0.1-0.3 IU/ml). Routine monitoring of anti-Xa levels is not recommended [71]. Re-evaluation of anti-Xa may be considered if active bleeding develops or signs of renal dysfunction appear during sodium enoxaparin** therapy [80]. When prescribing anticoagulants to children, the glomerular filtration rate is calculated using the modified Schwartz formula (http://nephron.com/peds_nic.cgi).

Surgical antimicrobial prophylaxis

• In the surgical treatment of patients with closed clavicle and/or scapula fractures, it is recommended to perform surgical antibiotic prophylaxis (SAP) of surgical site infections by a single preoperative administration of an antibacterial drug to reduce the risk of infectious complications [22, 73].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: In accordance with international clinical guidelines for the prevention of surgical site infections [73, 74], the objective of SAP is to achieve bactericidal concentrations of the antibacterial drug in tissues exposed to microbial contamination during surgery to prevent surgical site infections. The necessity of SAP is determined by the surgical wound class of the upcoming operation: SAP is not required for "clean" surgical wounds not involving the implantation of orthopedic implants and metal hardware. SAP should be performed for: clean-contaminated and contaminated surgical wounds; "clean" surgical wounds involving the placement of orthopedic implants and metal hardware. For infected ("dirty") wounds, SAP is not indicated; antibiotic therapy is performed instead.

• In patients with clavicle and/or scapula fractures, it is recommended to use 1st and 2nd generation cephalosporins (cefazolin**, cefuroxime**) as first-line agents for surgical antibiotic prophylaxis during surgical interventions in traumatology and orthopedics, and glycopeptide antibiotics (vancomycin**), lincosamides (#clindamycin**) as alternatives in case of beta-lactam antibiotic intolerance [73].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: For patients with an unburdened allergic history and no significant risk factors for methicillin-resistant Staphylococcus carriage, 1st and 2nd generation cephalosporins (cefazolin**, cefuroxime**) are used for SAP, administered intravenously 30 to 60 minutes before skin incision. In case of beta-lactam intolerance, a combination of vancomycin** with one of the fluoroquinolones (ciprofloxacin**, #levofloxacin**) administered for at least 60 minutes with the intravenous infusion starting 2 hours before the incision, or #clindamycin**, should be prescribed. In patients with significant risk factors for methicillin-resistant Staphylococcus carriage (MRS), the SAP regimen must include an antibiotic with anti-MRS activity (vancomycin**). In most cases, a single preoperative dose of the antibiotic is sufficient for effective prophylaxis. For prolonged procedures or massive blood loss, an additional intraoperative dose of the antibiotic should be administered (the estimated time for intraoperative administration is two half-lives after the preoperative dose). Administering an antibiotic after wound closure in the operating room is inappropriate, even in the presence of placed drains.

Single doses of core antibacterial drugs for SAP during surgical interventions in adult traumatology and orthopedics: cefazolin** 2 g (if patient weight ≥120 kg — 3 g), cefuroxime** 1.5 g, #clindamycin** 900 mg, vancomycin** 15 mg/kg as a slow IV infusion, ciprofloxacin** 400 mg, #levofloxacin** 500 mg [73]. Single doses for children should be calculated based on actual weight: cefazolin** 30 mg/kg, cefuroxime** 50 mg/kg, #clindamycin 10 mg/kg, vancomycin** 15 mg/kg; the use of fluoroquinolones (ATC: J01MA) during the period of bone and joint system development is contraindicated due to the risk of arthropathy [73, 147, 148].

Comments: In cases of open fractures, prophylactic antibiotic administration is effective in preventing early infection, and the drug should be administered as soon as possible after trauma. Cefazolin** is the antibiotic of choice, but in patients with open high-energy fractures with displacement and segmental loss; major vessel damage; and heavily contaminated wounds, it is advisable to broaden the spectrum of prescribed antibiotics to cover gram-negative pathogens. In such cases, adding #gentamicin** (at a dose of 6 mg/kg once daily) to cefazolin** may be considered [76, 77]. An alternative to this combination can be #ampicillin+sulbactam** (at a dose of 3.0 g every 8 hours for 3 days) [78]; the latter is particularly relevant in case of risk of clostridial infection. According to the majority of researchers, in Gustilo and Anderson type III open fractures, antibiotics should not be continued for more than 72 hours after soft tissue wound closure [79].

Blood-saving technologies

Comments: Tranexamic acid** effectively reduces blood loss and leads to a smaller decrease in hemoglobin levels in the postoperative period. Randomized clinical trials demonstrate the efficacy of local subfascial administration of #tranexamic acid** to adult patients into the postoperative wound area, comparable to intravenous administration of an equivalent dose of the drug [163, 164]. In children, tranexamic acid is prescribed in accordance with the instructions for use in patients older than 1 year undergoing surgeries with expected blood loss of at least 10% of the circulating blood volume [166].

Comments: Systematic reviews and meta-analyses demonstrate that perioperative use of intravenous iron preparations, in particular ferric carboxymaltose**, in adult trauma and orthopedic patients, especially in the postoperative period, is an effective alternative to blood transfusion, as it reduces the proportion of patients who underwent blood transfusion, decreases the volume of packed red blood cells transfused, leads to a lower incidence of infectious complications, but does not alter mortality rates [81, 82].

Evidence of the efficacy of intravenous iron preparations for correcting preoperative iron deficiency anemia in elective orthopedic procedures has been obtained in the pediatric population [149, 150]. Data on the use of these drugs in children in the postoperative period following trauma surgeries are lacking.

3.2 Surgical Treatment

Comment: When performing plate osteosynthesis for clavicular dislocations in the acromioclavicular joint, the following implants are used: non-absorbable sterile bone fracture fixation plate with screws***, non-absorbable non-sterile bone fracture fixation plate with screws***, non-absorbable sterile orthopedic bone screw***, non-absorbable non-sterile orthopedic bone screw***.

Acromioclavicular joint dislocations with corresponding radiological findings (discrepancy of articular surfaces) correspond to types III–VI according to the Rockwood classification, in which both the acromioclavicular and coracoclavicular ligaments are ruptured. Surgical treatment is indicated for these types of dislocations. A wide range of reconstructive interventions has been described in the literature, such as ligamentoplasty, hook plate osteosynthesis, and surgeries using arthroscopic techniques and implants. However, no clear one-to-one correspondence between Rockwood types III–VI and a specific type of surgical intervention has been established. It is advisable for the orthopedic trauma surgeon or surgeon to choose the type of intervention based on the nature of the injury, their skills, and the available equipment and hardware.

- open clavicular fractures;

- clavicular fractures with a threat of skin perforation by bone fragments;

- clavicular fractures with concomitant neurovascular disorders;

- pathological clavicular fractures;

- clavicular fracture as part of polytrauma;

- floating shoulder [6, 22].

GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).

Comments: Indications for surgical treatment may include complications of conservative treatment: nonunion, malunion of fractures, and neurological disorders. Isolated displaced clavicular fractures are a relative indication for surgery. The rate of clavicular fracture nonunion with conservative treatment is 10–23%, whereas with surgical treatment this complication occurs in 1–2% of cases [6, 83, 84]. Retrospective studies also indicate that a 1.5–2 cm shortening of the clavicle during conservative treatment leads to worse functional outcomes due to decreased muscle strength in the shoulder girdle area [7].

Comments: When performing plate osteosynthesis, the following implants are used: non-absorbable sterile bone fracture fixation plate with screws***, non-absorbable non-sterile bone fracture fixation plate with screws***, non-absorbable sterile orthopedic bone screw***, non-absorbable non-sterile orthopedic bone screw***.

Reconstructive plates and anatomically pre-contoured locking compression plates are used for osteosynthesis. The former have lower strength, and their use is therefore associated with a higher rate of fixation failure or hardware breakage [84].

Clavicular osteosynthesis can be performed open or minimally invasively. In the first case, the surgeon makes a longitudinal or oblique incision in the projection of the injured clavicle. A longitudinal incision provides good visualization of the fracture site, but may damage the supraclavicular nerve. In addition, it is not cosmetic, which may be important for patients, especially women [6].

When performing minimally invasive osteosynthesis, the surgical incision is made away from the fracture site. The plate is inserted subcutaneously through an incision, after which closed fracture reduction is performed and the implant is fixed. Screws in the end of the plate opposite to the primary incision are inserted through percutaneous punctures or through an additional incision [22]. At least three cortical screws or two locking screws should be inserted into each fragment [6].

The plate can be positioned on either the superior surface of the clavicle or the anteroinferior surface [6, 85]. In a study by Sohn et al., comparing the two plate positioning options on the clavicle during minimally invasive fixation revealed no significant difference in the clinical outcomes of both patient groups [86].

Comments: When performing plate osteosynthesis, the following implants are used: non-absorbable sterile bone fracture fixation plate with screws***, non-absorbable non-sterile bone fracture fixation plate with screws***, non-absorbable sterile orthopedic bone screw***, non-absorbable non-sterile orthopedic bone screw***.

A high rate of fracture union (93–100%) of the distal clavicle, as well as excellent functional outcomes, are observed with both hook plate fixation and LCP fixation. However, hook plate placement more frequently leads to complications and always requires removal after fracture union. Complications associated with this implant occur in 40–70% of cases. Such complications include subacromial impingement, rotator cuff injuries, acromion fractures, fixation failure, and discomfort associated with the subcutaneous location of the plate [88, 89].

Comment: In children, plate removal is usually possible at 5–6 weeks from the date of surgical treatment of the injury, but the key factor for removing or retaining the hardware is the presence or absence of fracture consolidation, respectively.

• For patients with fractures of the proximal third of the clavicular shaft, to create conditions for bone union and prevent complications, plate osteosynthesis, tension band wiring, and transosseous suture are recommended [6, 90].

GPP CLOE 4Grade of Recommendation C (Level of Evidence – 4).

Comments: When performing plate osteosynthesis, the following implants are used: non-absorbable sterile bone fracture fixation plate with screws***, non-absorbable non-sterile bone fracture fixation plate with screws***, non-absorbable sterile orthopedic bone screw***, non-absorbable non-sterile orthopedic bone screw***.

Most proximal clavicle fractures do not require surgical treatment. However, it must be borne in mind that displaced medial clavicular fractures result in nonunion in 14–20% of cases [6, 91]. Open reduction and internal fixation of a proximal clavicle fracture are performed via an anterior surgical approach. Depending on the fracture architectonics, the plate can be positioned slightly superiorly or inferiorly to achieve the optimal screw trajectory for stable fragment fixation [6].

• For patients with fractures of the middle third of the clavicular shaft, to create conditions for bone union and prevent complications, external fixation with an apparatus is recommended [92, 93].

GPP CLOE 4Grade of Recommendation C (Level of Evidence – 4).

Comments: When applying an external fixation apparatus to fix fractures of the middle third of the clavicular shaft, the following implants are used: Schanz pins, Kirschner wires, olive wires.

Functional outcomes of treatment for patients with clavicle fractures treated via extramedullary fixation are similar to those after plate osteosynthesis. However, extramedullary osteosynthesis statistically significantly provides better functional scores compared to conservative treatment [92].

• For patients with middle-third shaft clavicle fractures, intramedullary osteosynthesis is recommended to create conditions for bone healing and prevent complications [6, 94, 95].

GoR ALoE 2Grade of Recommendation A (Level of Evidence – 2).

Comments: The following implants are used for intramedullary osteosynthesis of middle-third clavicle shaft fractures: elastic intramedullary nails, clavicular intramedullary nails, Kirschner wires, threaded pins.

Studies comparing functional outcomes between the two options of osteosynthesis for middle-third clavicle fractures report that at 1 year post-intervention, DASH (Disabilities of the Arm, Shoulder and Hand) scores for both techniques were 0.5–3 [94, 96, 97]. In the early postoperative period, some authors noted better function of the operated extremity in patients who underwent plate osteosynthesis [96, 97]. The rate of nonunion is identical for both techniques at 1–2% [6, 94, 96, 97].

Among the advantages of clavicle intramedullary osteosynthesis are a smaller surgical incision, shorter operative time, and fewer infectious complications [96, 98]. R. Houwert et al. (2012) noted that intramedullary osteosynthesis less frequently requires reoperation, and the risk of refracture after removal of the intramedullary implant is lower. However, these same authors noted that infection after intramedullary osteosynthesis occurs with the same frequency as after plate fixation [99]. The degree of fragment comminution is a predictor of delayed rehabilitation, lower functional outcome, and implant-related discomfort. No such correlation was observed with plate osteosynthesis. Therefore, some researchers recommend using intramedullary osteosynthesis only for simple middle-third clavicle fractures [96, 99, 100].

• When treating patients with scapular fractures, it is recommended to consider the following relative indications for surgical treatment in order to select the optimal management strategy:

- displacement of intra-articular fragments by more than 4 mm;

- presence of a bone fragment involving more than 25% of the articular surface;

- medialization of the glenoid fossa by more than 20 mm;

- glenopolar angle of less than 22°;

- displacement across the full width or angulation of scapular body fragments by more than 45°;

- pronounced retroversion or anteversion of the scapular neck;

- scapular fracture as part of polytrauma in a young patient;

- disruption of the superior shoulder suspensory complex (SSSC) in more than two locations [22, 47].

GPP CLOE 4Grade of Recommendation C (Level of Evidence – 4).

Comments: Isolated extra-articular scapular fractures generally do not require surgical intervention, whereas the majority of intra-articular injuries necessitate open reduction and internal fixation [10, 22].

The glenopolar angle is the angle formed by two lines: one connecting the uppermost and lowermost points of the glenoid fossa, and the other connecting the uppermost point of the glenoid fossa to the inferior angle of the scapula. Normally, the glenopolar angle ranges from 30° to 45°. The value of this angle following a fracture indicates the degree of displacement of the scapular articular process and can be an important factor in determining the treatment strategy [101].

The SSSC includes the glenoid process, coracoid process, coracoclavicular ligaments, distal clavicle, acromioclavicular joint, and acromion.

Comments: The following implants are used when performing scapular plate osteosynthesis: non-absorbable sterile bone-fixation plate with screws***, non-absorbable non-sterile bone-fixation plate with screws***, non-absorbable sterile orthopedic bone screw***, non-absorbable non-sterile orthopedic bone screw***.

For osteosynthesis of the scapular body and/or neck, the posterior approach and Judet's approach are most widely used. The posterior approach is performed along the lateral border of the scapular body and superiorly runs in the projection of the glenohumeral joint space. Judet's approach is more extensive. The incision starts from the acromion, runs along the scapular spine, and, curving downward, continues along the medial border of the scapular body. For the surgeon's convenience, the infraspinatus and teres minor muscles can be detached from the infraspinatous fossa. An alternative option is muscle splitting with the formation of intermuscular windows [22, 46, 47].

Comments: The following implants are used when performing scapular plate osteosynthesis: non-absorbable sterile bone-fixation plate with screws***, non-absorbable non-sterile bone-fixation plate with screws***, non-absorbable sterile orthopedic bone screw***, non-absorbable non-sterile orthopedic bone screw***.

Intra-articular scapular fractures require open reduction of fragment displacement and fixation under conditions of absolute stability. To this end, anatomical reduction and interfragmentary compression must be achieved [22].

The deltopectoral surgical approach is used for fractures of the anterior or inferior margin of the glenoid fossa. The posterior approach allows visualization of its posterior margin [22, 46, 47].

For fractures of the superior pole of the glenoid, the superior approach is convenient. In this case, the incision is made in the frontal plane midway between the clavicle and the scapular spine, and laterally it is positioned immediately posterior to the acromioclavicular joint. The fibers of the trapezius muscle are split, and the supraspinatus muscle is retracted either anteriorly or posteriorly. The scapular notch must be visualized to avoid injury to the suprascapular nerve. Isolated acromial fractures can be stabilized using the described approach [22, 46, 47].

For inferior pole fractures, a lateral approach can be used, performed via an incision along the midaxillary line starting from the axillary fossa. This approach also allows osteosynthesis of the scapular neck [46].

3.3 Other Treatment

Comments: In accordance with clauses 4156-4157 of the Sanitary Rules and Norms on the Prevention of Infectious Diseases (SanPiN 3.3686-21), emergency tetanus prophylaxis is carried out for any injuries involving compromised integrity of the skin and mucous membranes. Emergency tetanus prophylaxis is performed up to the 20th calendar day from the moment of injury [160]. The prescription of drugs for emergency tetanus immunoprophylaxis is carried out differentially depending on the availability of documentary confirmation of prophylactic vaccination or immunological monitoring data on anti-tetanus immunity titers, as well as taking into account the nature of the injuries.

Emergency tetanus immunoprophylaxis is carried out in the form of taking into account age restrictions:

- passive immunization or seroprophylaxis with human tetanus immunoglobulin** (HTIG), and in its absence - tetanus antitoxin** (TAT), taking into account age restrictions;

- active-passive prophylaxis consisting of the simultaneous administration of human tetanus immunoglobulin (and in its absence - TAT) and tetanus toxoid** (TT) into different anatomical sites;

- emergency revaccination with tetanus toxoid** (or reduced antigen content diphtheria-tetanus toxoid** - dT-adsorbed) to stimulate immunity in previously vaccinated individuals [103, 104, 160].

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Comments: The method of limb immobilization is determined by the attending trauma surgeon. Following limb fixation, a consultation with a PRM (Physical and Rehabilitation Medicine) physician / exercise therapy doctor is performed to establish a rehabilitation program. This includes dynamic exercises for the fingers and wrist, isometric exercises for the muscles of the arm, forearm, and scapula, alternated with breathing exercises and exercises for the healthy limbs.

One week after the injury, assisted exercises are permitted, followed by active movements in the elbow joint. The arm is temporarily released from the fixation bandage, and from a standing forward-bent position, swinging movements are performed with the freely hanging arm at the shoulder joint [94,89,95,91,93]. Ice packs are used to reduce pain [109, 113-115].

A follow-up consultation with the PRM physician / exercise therapy doctor is conducted after two weeks to adjust the rehabilitation program. During weeks 2–4 post-injury, flexion and abduction up to 90 degrees in the shoulder joint assisted by the healthy arm, as well as isometric exercises for the shoulder and rotator cuff muscles, are permitted [105, 115].

All exercises are repeated up to 10 times and performed 4–5 times a day. Movements should not cause pain [115].

In pediatric patients, after the discontinuation of immobilization, to prevent re-fracture (~ 2%), it is recommended to maintain a restricted activity regimen for at least 1 month, followed by a gradual increase in physical activity based on subjective sensations. Full participation in sports is recommended no earlier than 3 months from the date of injury [116].

Comments: Consultation with a PM&R/exercise therapy physician and prescription of a rehabilitation program are carried out immediately after removing the immobilizing bandage. The program (weeks 4–8 post-injury) includes assisted dynamic exercises, free dynamic exercises, exercises with light objects, simple mechanotherapy, exercises in water for shoulder flexion and abduction with increasing amplitude up to the pain threshold, and isometric exercises.

Starting from week 8, resistive exercises (dynamic exercises with resistance and additional load), mechanotherapy, and exercises on training equipment for scapular stabilization and strengthening of the shoulder and rotator cuff muscle groups are included.

After 12 weeks (3 months) following a repeat consultation with the PRM physician / exercise therapy doctor, exercises are prescribed to stabilize the shoulder joint and scapula, and to increase arm muscle endurance (exercises with weights, movement resistance, concentric and eccentric exercises, sessions on mechanical apparatuses and training equipment [109, 115].

Participation in non-contact sports (swimming, cycling) is permitted 3 months after the injury, and in contact sports (wrestling, boxing) after 4 months [111].

Comments: In the post-immobilization period, following a consultation with a PRM / physical therapy physician, manual and/or underwater massage of the shoulder joint and scapula region, electroanalgesia (TENS, interferential currents, pulsed currents), magnetotherapy-laser therapy, and thermotherapy are prescribed [109]. The choice of physiotherapeutic treatment type and procedure methodology is determined individually depending on clinical symptoms, age, and the absence of contraindications.

Comments: Following surgery, regardless of the method of clavicle fracture osteosynthesis, the arm is fixed in an orthosis for a period of 2 to 3 weeks according to various authors [107, 112, 114-118].

The rehabilitation program is designed by a PRM physician / exercise therapy doctor during patient consultation in the inpatient facility after surgery [119]. To reduce pain and edema, local cryotherapy and magnetotherapy are prescribed [114], which can be continued at home. Recommended physical exercises consist of isometric contractions of the shoulder and forearm muscles, active movements of the fingers and hand, facilitated exercises for the elbow joint, and swinging movements of the freely lowered arm in the shoulder joint. After 5 days, the bandage is temporarily removed, and assisted exercises using the healthy arm are prescribed (flexion and abduction up to 90 degrees in the shoulder joint), as well as external and internal rotation within a pain-free range of motion. It has been proven that early mobilization of the shoulder joint does not lead to an increase in complications, but improves treatment outcomes [117, 119, 120]. As a rule, this stage of rehabilitation is carried out at home.

Comments: At 2–6 weeks post-surgery, following a follow-up consultation with the PRM physician / exercise therapy doctor, the fixation bandage is removed. Active dynamic exercises for the shoulder joint are prescribed with an increased range of motion in flexion, abduction, and rotation directions. The exercises are performed with the help of the healthy arm, objects, and basic mechanotherapy [107, 113, 118].

At 6 weeks post-surgery, following consultation with the PRM physician / exercise therapy doctor, the program is complicated by adding exercises with additional load, movement resistance, and active mechanotherapy to strengthen the rotator cuff and shoulder muscles. Physical exercises in water and manual massage of the shoulder and scapula region are prescribed [110].

In an uncomplicated course of the recovery process, restoration of limb function and its working capacity is observed after 3–4 months. Return to sports is permitted during this timeframe [118, 120].

Comments: Immediately after surgery, following consultation with the PRM physician / exercise therapy doctor, cryotherapy is prescribed, which can be continued at home using ice packs for a week. After 2–3 weeks, heat packs and TENS can be used [106, 109].

The implementation of physiotherapeutic procedures is generally limited to home-based rehabilitation. In cases of complicated recovery or delayed restoration of limb function, outpatient (day hospital) rehabilitation is performed, where physiotherapeutic techniques may include thermotherapy, magnetotherapy-laser therapy, electrotherapy, and ultrasound therapy.

SCAPULA

Comments: The immobilizing bandage fixes the shoulder joint and arm for a period of 4–6 weeks. Following a consultation with the PRM physician / exercise therapy doctor, an individual rehabilitation program is created and performed at home [120]. During the first 1–2 weeks after the injury, the program includes dynamic exercises for the fingers, hand, and elbow joint, isometric exercises for the forearm and shoulder muscles combined with movements of the healthy limb.

Following a repeat consultation with the PRM physician / exercise therapy doctor two weeks after the fracture, dynamic movements in the shoulder joint are prescribed under facilitated conditions: swinging movements with the freely lowered arm, active flexion, abduction, and external rotation in the shoulder joint with the assistance of the healthy arm. Light housework is permitted [122, 124].

Comments: After the removal of immobilization, a follow-up consultation with a physical and rehabilitation medicine (PRM) physician/exercise therapy specialist is performed. An individualized rehabilitation program is developed in accordance with the fracture location, degree of consolidation, and functional impairments. The program consists of dynamic exercises to increase the range of motion in the shoulder joint (flexion, abduction, rotation), resistance and weighted exercises (resistance training) to strengthen the muscles of the shoulder region, scapula, and rotator cuff, basic and pulley-based mechanotherapy, and exercise machine training.

Rehabilitation continues until full recovery of limb function, up to 3–4 months [122-124]. Sports activities may be resumed once limb function is restored, after 4 months [121].

Comments: Following surgery, the arm is immobilized in a shoulder-supporting orthosis. After a consultation with a PRM physician/exercise therapy specialist, a rehabilitation program is prescribed, including local cryotherapy, free dynamic exercises for the fingers, hand, and elbow joint of the operated arm, assisted self-help movements in the shoulder joint up to 90 degrees of flexion and abduction, isometric muscle exercises combined with general conditioning exercises for the healthy limbs, and breathing exercises [111, 120, 123].

The program is carried out until discharge from the inpatient facility and continued at home for 2–3 weeks. Wearing a fixing orthosis is optional and it is removed to perform therapeutic exercises [111].

Comments: Starting from the 3rd week post-operatively, the outpatient rehabilitation program includes assisted dynamic exercises for the shoulder joint, pulley-based and basic mechanotherapy, water exercises, passive mechanotherapy as indicated, and manual and/or underwater massage [120, 122, 125].

The rehabilitation program during 8–12 weeks after surgery is supplemented with exercises to restore muscle strength and endurance: static exercises, dynamic resistance and weighted exercises, mechanotherapy, and training on exercise machines.

Sports activities and heavy physical labor can be resumed 3–4 months after surgery [111].

Due to the low incidence of these injuries, treatment outcomes in pediatric patients are scarcely covered in the literature; based on data presented for adult patients, it can be concluded that in most cases, upper extremity function is restored to a normal level.

Comments: The rehabilitation program is designed by a PRM physician/exercise therapy specialist to prevent complications associated with hypokinesia, joint stiffness, and muscle hypotonia. Depending on the activity regimen, immobilization period, or postoperative period, the program consists of physical exercises, physical therapy, massage, and mechanotherapy.

5. Prevention and Dispensary Observation

Prevention of clavicle and/or scapula fractures consists in adherence by citizens to social safety rules during household chores, sports activities, presence in vehicle traffic zones, walking on poor surfaces, and during icy conditions.

A significant share of responsibility in fracture prevention also belongs to state structures, which are obliged to ensure safety to prevent road traffic injuries, as well as ensure compliance with safety regulations in industries with increased risk of trauma.

Comments: Upon discharge from the hospital, the patient must be referred to a trauma center or outpatient traumatology department, indicating the treatment provided and detailed recommendations for the continuation of treatment and rehabilitation. This will ensure continuity between the inpatient and outpatient stages of treatment.

Follow-up examinations with radiographs and assessment of functional recovery dynamics are performed at 6–8 weeks post-surgery (assessment of fracture consolidation degree and the feasibility of full limb load for extra-articular fractures), 12 weeks post-surgery (assessment of fracture consolidation degree and the feasibility of limb load for intra-articular fractures), 24 weeks post-surgery (assessment of functional recovery dynamics), and 1 year post-surgery (assessment of the functional outcome of treatment and deciding on the need and timing for implant removal).

6. Organization of Medical Care

Clinical application of recommendations: Traumatology and Orthopedics, Anesthesiology and Intensive Care, Medical Rehabilitation, Health Organization and Public Health.

Objective of clinical guidelines: These clinical guidelines have been developed to improve the quality of medical care and standardize diagnostic and treatment algorithms for patients with clavicle and/or scapula fractures.

Indications for planned hospitalization:

unsatisfactory result of conservative treatment – absence of signs of clavicle and/or scapula fracture consolidation following conservative treatment or osteosynthesis surgery within 2.5 to 3.5 months after trauma or surgery [21-23].

Indications for emergency hospitalization:

Patients with suspected or confirmed clavicle and/or scapula fractures must be referred to an inpatient facility to determine the need for emergency hospitalization. Indications for emergency hospitalization include:

- open clavicular fractures;

- clavicle fractures with a risk of skin perforation by bone fragments;

- clavicular fractures with concomitant neurovascular disorders;

- pathological clavicle fractures;

- clavicle fracture as part of polytrauma;

- floating shoulder [6, 22];

- displacement of intra-articular fragments of the glenoid cavity by more than 4 mm;

- presence of a glenoid cavity bone fragment involving more than 25% of the articular surface;

- medialization of the glenoid cavity by more than 20 mm;

- glenopolar angle less than 22°;

- displacement across the full width or angulation of scapular body fragments by more than 45°;

- pronounced retroversion or anteversion of the scapular neck;

- scapular fracture as part of polytrauma in a young patient;

- disruption of the SSSQ (superior shoulder suspensory complex) in more than two sites [22, 47].

Indications for patient discharge from the hospital:

1. Internal fixation of the fracture with hardware, shoulder arthroplasty, or adequate plaster immobilization for conservative treatment has been performed.

2. The first stage of rehabilitation has been completed.

3. There is no acute infectious process.

4. Refusal of the patient or their legal guardians (in case of legally established patient incapacity) to continue inpatient treatment (the reason for refusal must be documented in the medical history with the personal signature of the patient or their guardians).

7. Additional Information

To assess treatment outcomes in patients with fractures at the shoulder girdle and arm level, questionnaires have been developed to evaluate the functional result of treatment.

1) Disabilities of the Arm, Shoulder, and Hand questionnaire (Disabilities of the Arm, Shoulder, and Hand, DASH) was developed jointly by the American Academy of Orthopaedic Surgeons, the Council of Musculoskeletal Specialty Societies, and the Institute for Work and Health of Canada. It belongs to patient-reported outcome measures (patient-reported outcome measures) and was introduced in 1996 for the standardized assessment of the impact of various musculoskeletal injuries and diseases on upper extremity function [126]. DASH is a 30-item questionnaire with response options presented on a 5-point Likert scale. Scores range from 0 (no functional limitations) to 100 (most severe functional limitations). The questionnaire is intended for patients with any musculoskeletal disorders of the upper extremities [127]. DASH has two optional modules (four items each) intended for athletes, musicians, and workers whose activities require specific physical conditioning and whose functional limitations may arise only under high loads exceeding the scope of the 30 DASH items. Approved translation versions of DASH in 56 languages and dialects, including Russian, are available on the website of the Institute for Work and Health of Canada, which holds the copyright for the questionnaire (https://dash.iwh.on.ca/available-translations).

2) Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH) is a shortened 11-question version of the DASH questionnaire with the same response options [128, 129]. Like DASH, it is intended for patient self-assessment of the degree of upper extremity functional impairment in various diseases and injuries. QuickDASH also features two optional modules (four items each) intended for athletes, musicians, and workers whose activities require specific physical conditioning and whose functional limitations may occur only under high loads exceeding the scope of the 11 QuickDASH items. The optional modules are scored separately. In a number of studies, comparison of the DASH and QuickDASH questionnaires showed that both instruments have approximately equal sensitivity, specificity [130-134], and minimal clinically important difference values (12-14 points for DASH and 12-15 points for QuickDASH) [135]. In a systematic review of 23 patient self-assessment instruments for various upper extremity pathologies, the QuickDASH questionnaire demonstrated the highest content and construct validity, reliability, and responsiveness [136]. There are reports of successful application of QuickDASH in children aged 8–18 years [137, 138]. Approved translation versions of QuickDASH in 56 languages and dialects, including Russian, are available on the website of the Institute for Work and Health, which holds the copyright (https://dash.iwh.on.ca/available-translations).

The Russian translation of the QuickDASH in its original version is provided in Appendix G1.

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Belenky I.G., MD, Associate Professor, Saint Petersburg I.I. Джанелидзе Research Institute of Emergency Medicine, St. Petersburg, member of ATOR.

2. Bozhkova S.A., Doctor of Medical Sciences, Vreden National Medical Research Center of Traumatology and Orthopedics of the Ministry of Health of the Russian Federation, St. Petersburg, member of ATOR

3. Geroyeva I.B., MD, Professor, Federal State Budgetary Institution "N.N. Priorov National Medical Research Center of Traumatology and Orthopedics" of the Russian Ministry of Health, Moscow.

4. Gorbatyuk D.S., Candidate of Medical Sciences, Priorov National Medical Research Center of Traumatology and Orthopedics of the Ministry of Health of the Russian Federation, Moscow

5. Kleymenova E.B., Doctor of Medical Sciences, Professor, Priorov National Medical Research Center of Traumatology and Orthopedics of the Ministry of Health of the Russian Federation, Moscow.

6. Mayorov B.A., Candidate of Medical Sciences, Dzhanelidze St. Petersburg Research Institute of Emergency Medicine, Pavlov First Saint Petersburg State Medical University, St. Petersburg, member of ATOR.

7. Nazarenko A.G., MD, DSc, Professor of the RAS, National Medical Research Center of Traumatology and Orthopedics named after N.N. Priorov of the Russian Ministry of Health, Moscow, Vice President of ATOR.

8. Otdelenov V.A., Candidate of Medical Sciences, Priorov National Medical Research Center of Traumatology and Orthopedics of the Ministry of Health of the Russian Federation, Moscow.

9. Ryzhikov D.V., Candidate of Medical Sciences, Turner National Medical Research Center for Children's Orthopedics and Trauma of the Russian Ministry of Health, St. Petersburg.

10. Sergeev G.D., PhD, Saint Petersburg I.I. Dzhanelidze Research Institute of Emergency Medicine, St. Petersburg, member of ATOR.

11. Khusainov N.O., Candidate of Medical Sciences, Turner National Medical Research Center for Children's Orthopedics and Trauma of the Russian Ministry of Health, St. Petersburg.

Conflict of interest.

The working group for drafting clinical guidelines for the treatment of patients with clavicle and/or scapula fractures has no conflicts of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. Orthopedic trauma surgeons

2. Surgeons

3. Pediatric surgeons

4. Ambulance physicians

5. General practitioners / district internists

6. District pediatricians

7. General practitioners (family physicians)

8. Feldshers

Stages of evaluating the levels of evidence and grades of recommendation:

1. Definition of search criteria and selection of publications on clinical trials (CTs) regarding the efficacy and/or safety of the medical intervention described in the recommendation statement.

2. Systematic search and selection of CT publications in accordance with the previously established criteria.

Systematic search and selection of clinical trial publications:

The evidence base for the recommendations consisted of publications retrieved via information retrieval in the following databases: Central Scientific Medical Library (CSML) "Russian Medicine", MEDLINE (US NLM), and COCHRANE Library; scientific electronic libraries eLibrary.ru and "CyberLeninka"; as well as on the Internet using Yandex, Google, and Google Scholar search engines, by reviewing leading specialized peer-reviewed domestic medical journals on the subject and treatment guidelines for fractures from the international Association for Osteosynthesis AO/ASIF.

Table 1.Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

Table 2.Levels of Evidence (LoE) grading scale for prevention, treatment and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

Table 3.Grades of Recommendation (GoR) for prevention, diagnostic, treatment and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines.

The update mechanism for clinical guidelines provides for their systematic revision—at least once every three years, as well as upon the emergence of new evidence-based data regarding the diagnosis, treatment, prevention, and rehabilitation of specific conditions, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

Appendix A3.1 Pain management recommendations for major musculoskeletal trauma (surgical fixation of long bone fractures or complex joint fractures, extensive soft tissue trauma, extensive surgery, etc.) in adults

Appendix A3.2 Pain management recommendations for non-surgical musculoskeletal trauma (closed fractures, superficial wounds, etc.) in adults

Appendix A3.3 Analgesic dosage regimen for children

¹ In children under 12 years of age, it is preferable to use morphine** if opioid analgesics need to be prescribed, as the use of tramadol** is associated with a higher risk of adverse reactions [151, 152].

² Not recommended for use in children because its metabolite accumulates in the body and provokes seizures upon repeated administration [153].

Appendix A3.4 Recommended dosing regimens of low molecular weight heparins for the prophylaxis of high-risk VTE in conservative treatment and orthopedic surgery in adult patients at high risk for VTE

Appendix A3.5. Bleeding Risk Factors in Children Aged 6 Months to 18 Years

Notes:

1. If the patient meets at least one of the "NOT recommended" criteria, avoid pharmacological prophylaxis, as the risk outweighs the benefit.

2. If the patient has at least one relative contraindication criterion, consider withholding pharmacological prophylaxis.

3. Consider consulting a hematologist if the patient is at high risk for VTE with a high bleeding risk [60].

4. Uncontrolled hypertension is defined as systolic or diastolic blood pressure above the 95th percentile for age, height, and sex [61].

5. Coagulopathy is defined as INR > 1.5, aPTT > 44 s, fibrinogen < 100 g/L, or platelets < 50,000/µL.

Appendix A3.6. Risk factors for VTE in children aged 6 months to 18 years

Notes:

− Reduced mobility is defined as a decrease in mobility compared to baseline or the inability to participate in physical therapy.

− A central venous access device is defined as a non-tunneled catheter, tunneled catheter, or central venous catheter.

− A major burn is defined as a burn involving more than 50% of the body surface area.

− Major surgical procedures include operations lasting longer than 45 minutes.

− Critically ill patients are defined as those admitted to an intensive care unit (requiring inotropic support or mechanical ventilation).

− Thrombophilic states include antithrombin deficiency, protein C or S deficiency, factor V Leiden, or prothrombin gene mutation.

− Active malignancy is defined as receiving chemotherapy/radiation therapy within the preceding 6 months.

− Active inflammatory disease includes Kawasaki disease, inflammatory bowel disease, systemic lupus erythematosus, or nephrotic syndrome.

− Estrogen therapy includes oral contraceptives, estrogen replacement therapy, or use within the past 2 weeks.

− Obesity is defined as a BMI above the 95th percentile for age.

Key:

Low VTE risk:

• No altered mobility and 0-1 risk factor

Moderate VTE risk:

• No mobility impairment and 2-3 risk factors

• Altered mobility and 0-1 other risk factors

High VTE risk:

• No mobility impairment and ≥4 risk factors

• Altered mobility and ≥2 other risk factors

Thromboprophylaxis recommendation

Appendix B. Physician Action Algorithms

Appendix B1. Management algorithm for clavicle fracture treatment [121]

Appendix B2. Algorithm of physician actions in the treatment of a clavicle fracture in a pediatric patient

Appendix B3. Management algorithm for scapular fracture treatment [122]

Appendix B4. Algorithm for assessing cardiovascular risk of surgery

CVRF – cardiovascular risk factors (arterial hypertension, smoking, dyslipidemia (elevated total cholesterol >4.9 mmol/L and/or LDL cholesterol >3 mmol/L and/or HDL cholesterol <1.0 mmol/L in men, <1.2 mmol/L in women, and/or triglycerides >1.7 mmol/L), diabetes mellitus, family history of premature cardiovascular disease (<55 years for men and <65 years for women);

CVD – cardiovascular disease (coronary artery disease, cerebrovascular disease, peripheral artery disease, chronic heart failure, pulmonary hypertension, valvular heart disease, cardiomyopathies);

rRCRI - reconstructed RCRI index (See Appendix 15.3);

FS – functional status (the patient's ability to climb 2 flights of stairs independently without stopping before the injury).

*- regional vascular center or specialized cardiological department.

Appendix C. Patient Information

A clavicle fracture is an injury to the upper extremity bone that connects the scapula to the bones of the trunk. This trauma most commonly occurs from falling on the shoulder in everyday life or during sports, as well as in motor vehicle accidents. In clavicle fractures, the patient may experience pain in the injury area, as well as when attempting to move the arm. In addition, deformation in the clavicle region due to edema can be observed, or a crunching sound (bone fragment crepitus) can be felt during upper extremity movements.

A scapular fracture is a rare injury that occurs most commonly as a result of a motor vehicle accident, a fall from a height, or physical assault (a direct blow to the back in the scapular region). With this injury, the patient experiences pain in the upper back, which worsens with arm movements. Pronounced swelling or ecchymosis may also appear in the injury area.

Patients with these injuries require treatment in an emergency department or in an inpatient surgical or traumatological unit. Medical care consists of analgesia, immobilization of the injured arm using a sling or bandage, and, if necessary, osteosynthesis surgery of the clavicle and/or scapula. Osteosynthesis is a surgical intervention during which a surgeon or traumatologist uses special implants to fix bone fragments to create conditions for fracture healing.

The duration of wearing an immobilizing (fixation) bandage is determined by the attending physician. The bandage may be either plaster or soft, depending on the characteristics of the fracture. Immobilizing bandages may be prescribed by the attending physician both in cases of non-operative treatment and following surgical intervention.

The patient should regularly attend follow-up examinations as prescribed by the attending physician of the trauma center or hospital to assess the position of the fragments and implants (if present).

Rehabilitation may begin in the first few days after the injury or osteosynthesis surgery. The goal of rehabilitation is the prompt restoration of the range of motion in the joints of the injured limb. The timing and intensity of rehabilitation exercises are determined by the attending physician, physical therapist, or exercise therapy physician.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1. QuickDASH upper extremity disability questionnaire

Russian title: The shortened disabilities of the arm, shoulder and hand questionnaire.

Original title: The shortened disabilities of the arm, shoulder and hand questionnaire (Quick DASH)

Source: QuickDASH Outcome Measures: Russian translation. Institute for Work & Health, 2006. https://dash.iwh.on.ca/available-translations

Type: questionnaire

Purpose: assessment of the impact of musculoskeletal injuries and diseases on upper extremity function.

Content:

INSTRUCTIONS: This questionnaire concerns your condition as well as your ability to perform certain activities. Please answer each question, referring to your condition over the past week, by circling the appropriate number. If you did not have the opportunity to perform a specific activity last week, please choose the most appropriate response. It does not matter which hand you use to perform a given activity; please answer based on your ability, regardless of how you independently accomplish the task.

QuickDASH disability/symptom score = ([sum of n responses] / n - 1) × 25, where n is the number of completed responses.

The QuickDASH score cannot be calculated if more than 1 item is missed.

OPTIONAL MODULE SCALING. All 4 questions must be answered. Simply add the assigned values for each response and divide by 4 (number of items); subtract 1 and multiply by 25.

Appendix G2. Revised Cardiac Risk Index (rRCRI)

Russian title: Reconstructed Revised Cardiac Risk Index for noncardiac surgical procedures

Original title: Reconstructed Revised Cardiac Risk Index (rRCRI)

Source: Davis C., Tait G., Carroll J. et al. The Revised Cardiac Risk Index in the new millennium: a single-centre prospective cohort re-evaluation of the original variables in 9,519 consecutive elective surgical patients. Can. J. Anaesth. 2013; 60(9): 855-863.

Type: scale

Purpose: prediction of the risk of perioperative cardiac complications in noncardiac surgery: myocardial infarction, pulmonary edema, ventricular fibrillation or cardiac arrest, development of complete AV block.

Content:

1. High-risk surgery (intrathoracic or intra-abdominal surgery, or vascular surgery above the groin) - 1 point

2. Coronary artery disease (history of myocardial infarction, positive stress test, angina pectoris, use of nitroglycerin, ** pathological Q wave on ECG) - 1 point.

3. Heart failure (history of heart failure, pulmonary edema, paroxysmal nocturnal dyspnea, bilateral lung rales, gallop rhythm, pulmonary congestion on chest X-ray) - 1 point.

4. TIA/Stroke - 1 point

5. Creatinine clearance <30 mL/min - 1 point

Scoring:

• total score of 0 – low risk of cardiovascular complications;

• a total score of 1 – moderate risk of cardiovascular complications;

• a total score of 2 or more – high risk of cardiovascular complications.

Notes:

The RCRI index was developed in 1977 [139] to predict the risk of perioperative cardiac complications in noncardiac surgery. It was validated in the Lee study [140], revised in 2013 [141], and re-validated based on clinical risk factors (instead of the criterion "creatinine level >176.8 µmol/L", the scale uses the criterion "creatinine clearance <30 mL/min"; the clinical criterion "insulin-requiring diabetes mellitus" was removed), which is why it is called the revised index. It includes 5 parameters, each assigned 1 point. This exact version of the index is recommended by the Russian Society of Cardiology [30].