Clavicle Fracture

See Also

Epidemiology

Incidence: 2 to 5% of all adult Fractures
Bimodal age distribution: Age under 25 and over 55-75 years
1. Highest risk over age 70 years (esp. associated with Osteoporosis)

Pathophysiology
Mechanism of Injury

Trauma to anteromedial chest or posterolateral Shoulder
1. Fall against top or lateral Shoulder (most common)
2. Fall on Outstretched Hand
3. Direct blow to clavicle
No Trauma (in children)
1. Tumor
2. Rickets
3. Osteogenesis imperfecta
4. Physical Abuse

Symptoms

Pain and swelling localized to Fracture site
Patient unable to lift arm due to pain

Signs

Presentation: Holding the affected arm adducted and supported with the opposite hand
Gross clavicular deformity observed or palpated
1. Localized swelling, Bruising, tenderness, and crepitation
Associated lateral head rotation toward the affected side
Observe for complications
1. Neurovascular injury of affected arm
2. Pneumothorax
3. Subcutaneous Emphysema

Differential Diagnosis

Complications

Pneumothorax
Hemothorax
Brachial Plexus Injury
Subclavian artery and subclavian vein injury
Fracture nonunion (1-4%)
1. Rare, more associated with lateral Fracture (Group 2)
Sternoclavicular Joint Dislocation
1. Associated with proximal Clavicle Fractures (or confused with Clavicle Fracture in age <22 years)
2. Suspect SCJ Dislocation if Fracture displacement >50% width of clavicular head in vertical plane

Imaging
XRay

Standard Views
1. Anteroposterior clavicle view
2. Serendipity view (Cephalic tilt of 45 degrees)
Additional views
1. Shoulder Axillary View
  1. Suspected anterior-posterior displacement of Fractured fragments
2. Suspected medial Clavicle Fracture (Group 3)
  1. Zanca view with 20 degree angle
3. Weighted views
  1. Evaluate for coracoclavicular ligament disruption

Imaging
Advanced

Bedside Ultrasound
1. Efficacy in children (highly operator dependent)
Chest CT with Contrast
1. Indications
  1. Suspected occult Clavicle Fracture (may be missed on standard XRay AP Clavicle views)
  2. Proximal Clavicle Fractures or Sternoclavicular Dislocations (SCJ), especially when posterior displacement
    1. Evaluate for associated neurovascular and mediastinal injuries

Classification
Allman Grouping

Group 1: Middle third or midshaft Clavicle Fracture (75-85%)
1. Weakest, thinnest segment of the clavicle and hence most susceptible to Fracture
2. Overall clavicle shortening with medial segment raised and distal segment lowered
3. Generally stable Fracture
4. Occurs most in younger patients
5. Nonunion occurs in 15% of midshaft Clavicle Fractures
Group 2: Lateral third or distal Clavicle Fracture (15-25%)
1. Unstable if displaced Fracture
2. AC joint Osteoarthritis if articular surface involved
3. Nonunion rates as high as 28-44% for conservative, non-surgical management
  1. Attributed to Shoulder Muscle mediated displacement
4. Revised Neer Classification (based on coracoclavicular ligament integrity and nonunion risk)
  1. Type I: Intact coracoclavicular ligaments (conoid and Trapezoid ligaments)
    1. Fracture lateral to the coracoclavicular ligament and adequately counter Shoulder Muscles
    2. Treated conservatively
  2. Type 2: Coracoclavicular ligaments torn medially, only Trapezoid attached laterally
    1. Fracture medial to the coracoclavicular ligaments and unstable
    2. Medial fragment displaced superiorly and posteriorly
    3. Lateral fragment displaced inferiorly (Shoulder Muscles and arm weight)
    4. Managed with surgical repair
  3. Type 3: Clavicle Fracture involving the AC joint
    1. Coracoclavicular ligament intact and Fracture is stable
    2. Risk of acromioclavicular joint Arthritis (AC Joint Arthritis)
  4. Type 4: Periosteal sleeve disruption in children (not a bony Fracture)
    1. Distal clavicle epiphysis is not ossified until age 18 years old
    2. Risk of pseudodislocation of distal clavicle
    3. Typically treated conservatively as many remodel and heal
  5. Type 5: Coracoclavicular Ligament avulsion with small inferior cortical fragment
    1. Comminuted Fracture in which the medial fragment is unstable
    2. Treated with surgical repair
Group 3: Medial third or proximal Clavicle Fracture (5%)
1. Medial Clavicle Fractures are stable, but are associated with more significant injuries
2. Medial Clavicle Fractures may be missed on xray (typically evaluated with CT chest with contrast)
3. Associated with multi-system Trauma
4. Associated with neurovascular injury with posterior displacement of Clavicle Fracture or SCJ Dislocation
  1. Recurrent laryngeal nerve
  2. Vagus Nerves
  3. Great Vessel Laceration
  4. Mediastinal injury (trachea and lung injury)
5. Differentiate from Sternoclavicular Dislocation (SCJ Dislocation)
  1. Posterior dislocation is associated with serious neurovascular and pulmonary injuries
  2. Proximal physis does not close until age 22 years, and physis is weaker than the adjacent SCJ
    1. Suspect Salter Type 1 proximal Clavicle Fractures instead of SCJ Dislocation in age <22 years old

Management
Based on Allman Group

Group 1 (Middle third)
1. Conservative therapy (see below) has been the typical treatment until ~2010
  1. Most mid-Clavicle Fractures are still treated with non-surgical management
  2. However, surgical repair has become a much more common intervention
    1. See Referral Indications as below
    2. Locking hardware, curved plates form fit the clavicle improved surgical outcomes
    3. Consider operative repair when displacement or overlap >2 cm
    4. Surgery is associated with lower risk of nonunion, faster return, but higher complication rate
2. Consider operative repair in active adolescents and adults
  1. Clavicle shortening may cause chronic Shoulder Pain and dysfunction
  2. Consider a 2-4 week trial of conservative therapy prior to surgical intervention
  3. Athletes may elect for immediate repair to decrease time away from sport
3. Consider operative repair if multiple risks for midshaft Fracture non-union
  1. Clavicle shortening >15mm to 20 mm
  2. Female gender
  3. Older age
  4. Fracture displacement or comminution
  5. More significant Traumatic injuries
  6. Skin Tenting
  7. Precaution: Surgical repair also risks non-union by interrupting vascular supply
Group 2 (Lateral third)
1. Displaced and possibly Neer Fracture Type II (unstable and risk of non-union): Surgery
2. Nondisplaced (Neer Fracture Type I and III)
  1. Conservative therapy as with Allman Group 1 Fractures (see below)
3. Children with Type 4 (uncommon)
  1. Typically treated as AC joint injury
Group 3 (Proximal third)
1. Neurovascular injury: Emergent orthopedic referral
2. Nondisplaced (typical): Conservative therapy (see below)
3. Displaced
  1. Orthopedic referral for surgery
  2. Suggests significant Trauma and higher risk for neurovascular injury
  3. Neurovascular injury present
    1. Emergent reduction is critical
    2. Towel clip can be used to grasp clavicle and apply anterior traction
  4. No neurovascular injury
    1. CT Scan of the clavicle to visualize posterior fragments
References
1. Robinson (2004) J Bone Joint Surg Am 86:1359-65 [PubMed]
2. Hill (1997) J Bone Joint Surg Br 79:537-9 [PubMed]

Management
Conservative therapy

Sling
1. Arm sling for comfort (typically used for first 2 weeks)
  1. Under age 12: Sling for up to 3-4 weeks
  2. Over age 12: Sling for up to 4-6 weeks
2. Avoid figure-of-eight (no benefit, complication risk)
  1. Andersen (1987) Acta Orthop Scand 58:71-4 [PubMed]
Exercises
1. Elbow range of motion Exercises as soon as able
2. Shoulder Range of Motion and strength Exercises
  1. Passive range of motion starting once pain allows
  2. Start as tolerated in 2-3 weeks after injury
Follow-up
1. Re-evaluation with sports medicine or orthopedics in 1 week following injury (esp. athletes)
Return to Play criteria
1. Full and painless Shoulder Range of Motion with normal Shoulder strength
2. Bony healing by exam and imaging
3. Timing
  1. Non-Contact Sports: 6 weeks after injury
  2. Contact Sports: 8-16 weeks after injury
References
1. Stanley (1988) Injury 19:162-4 [PubMed]

Management
Referral Indications

Emergent Consultation
1. Posteriorly displaced proximal Clavicle Fracture
2. Posteriorly displaced sternoclavicular Fracture
3. Neurovascular injury
4. Open Fracture or significant Skin Tenting
Other referral indications
1. Painful nonunion after 4 months
2. Extreme proximal displaced Clavicle Fracture (Allman Group 3)
3. Distal displaced Clavicle Fracture (Allman Group 2)
4. Midshaft displaced Clavicle Fracture (Allman Group 1) indications
  1. Displaced or overlapping >2 cm (controversial) or
  2. Multiple nonunion risks or
  3. Persistent pain or
  4. Active teens, athletes and adults (esp. if dysfunction)

Course

Adult: Clavicle Fracture site remains prominent
Child: Site remodels and disappears in months

Complications

Short-term
1. Pneumothorax
2. Neurovascular injury
Long-term
1. Physeal Injury in adolescents (Allman Group 3 medial Fractures)
2. Thoracic Outlet Syndrome
3. Weakness or Paresthesias
4. Deformity of cosmetic significance (or palpable Fracture callus site)
5. Post-Traumatic Arthritis
  1. Medial Fractures that extend into sternoclavicular joint
6. Malunion or nonunion (non-healing after 4-6 months after 10-20% of midshaft Clavicle Fractures)
  1. Advanced age
  2. Female patients
  3. Displaced or comminuted Fractures
  4. Tobacco Abuse

References

Dreis (2020) Crit Dec Emerg Med 34(7):3-21
Kiel (2024) Crit Dec Emerg Med 38(6): 22-3
Wirth in Greene (2001) Musculoskeletal Care, p. 127-8
Housner (2003) Phys Sports Med 31:30-6 [PubMed]
Monica (2016) Am Fam Physician 94(2): 119-27 [PubMed]
Pecci (2008) Am Fam Physician 77: 65-71 [PubMed]
Quillen (2004) Am Fam Physician 70:1947-54 [PubMed]