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Incidence: 2 to 5% of all adult Fractures
- Bimodal age distribution: Age under 25 and over 55-75 years
- Highest risk over age 70 years (esp. associated with Osteoporosis)
- Pathophysiology
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Mechanism of Injury
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Trauma to anteromedial chest or posterolateral Shoulder
- Fall against top or lateral Shoulder (most common)
- Fall on Outstretched Hand
- Direct blow to clavicle
- No Trauma (in children)
- Tumor
- Rickets
- Osteogenesis imperfecta
- Physical Abuse
- Pain and swelling localized to Fracture site
- Patient unable to lift arm due to pain
- Presentation: Holding the affected arm adducted and supported with the opposite hand
- Gross clavicular deformity observed or palpated
- Localized swelling, Bruising, tenderness, and crepitation
- Associated lateral head rotation toward the affected side
- Observe for complications
- Neurovascular injury of affected arm
- Pneumothorax
- Subcutaneous Emphysema
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Pneumothorax
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Hemothorax
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Brachial Plexus Injury
- Subclavian artery and subclavian vein injury
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Fracture nonunion (1-4%)
- Rare, more associated with lateral Fracture (Group 2)
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Sternoclavicular Joint Dislocation
- Associated with proximal Clavicle Fractures (or confused with Clavicle Fracture in age <22 years)
- Suspect SCJ Dislocation if Fracture displacement >50% width of clavicular head in vertical plane
- Standard Views
- Anteroposterior clavicle view
- Serendipity view (Cephalic tilt of 45 degrees)
- Additional views
- Shoulder Axillary View
- Suspected anterior-posterior displacement of Fractured fragments
- Suspected medial Clavicle Fracture (Group 3)
- Zanca view with 20 degree angle
- Weighted views
- Evaluate for coracoclavicular ligament disruption
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Bedside Ultrasound
- Efficacy in children (highly operator dependent)
- Test Sensitivity: 95%
- Test Specificity: 96%
- Cross (2010) Acad Emerg Med 17(7): 687-93 [PubMed]
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Chest CT with Contrast
- Indications
- Suspected occult Clavicle Fracture (may be missed on standard XRay AP Clavicle views)
- Proximal Clavicle Fractures or Sternoclavicular Dislocations (SCJ), especially when posterior displacement
- Evaluate for associated neurovascular and mediastinal injuries
- Classification
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Allman Grouping
- Group 1: Middle third or midshaft Clavicle Fracture (75-85%)
- Weakest, thinnest segment of the clavicle and hence most susceptible to Fracture
- Overall clavicle shortening with medial segment raised and distal segment lowered
- Generally stable Fracture
- Occurs most in younger patients
- Nonunion occurs in 15% of midshaft Clavicle Fractures
- Group 2: Lateral third or distal Clavicle Fracture (15-25%)
- Unstable if displaced Fracture
- AC joint Osteoarthritis if articular surface involved
- Nonunion rates as high as 28-44% for conservative, non-surgical management
- Attributed to ShoulderMuscle mediated displacement
- Revised Neer Classification (based on coracoclavicular ligament integrity and nonunion risk)
- Type I: Intact coracoclavicular ligaments (conoid and Trapezoid ligaments)
- Fracture lateral to the coracoclavicular ligament and adequately counter ShoulderMuscles
- Treated conservatively
- Type 2: Coracoclavicular ligaments torn medially, only Trapezoid attached laterally
- Fracture medial to the coracoclavicular ligaments and unstable
- Medial fragment displaced superiorly and posteriorly
- Lateral fragment displaced inferiorly (ShoulderMuscles and arm weight)
- Managed with surgical repair
- Type 3: Clavicle Fracture involving the AC joint
- Coracoclavicular ligament intact and Fracture is stable
- Risk of acromioclavicular joint Arthritis (AC Joint Arthritis)
- Type 4: Periosteal sleeve disruption in children (not a bony Fracture)
- Distal clavicle epiphysis is not ossified until age 18 years old
- Risk of pseudodislocation of distal clavicle
- Typically treated conservatively as many remodel and heal
- Type 5: Coracoclavicular Ligament avulsion with small inferior cortical fragment
- Comminuted Fracture in which the medial fragment is unstable
- Treated with surgical repair
- Group 3: Medial third or proximal Clavicle Fracture (5%)
- Medial Clavicle Fractures are stable, but are associated with more significant injuries
- Medial Clavicle Fractures may be missed on xray (typically evaluated with CT chest with contrast)
- Associated with multi-system Trauma
- Associated with neurovascular injury with posterior displacement of Clavicle Fracture or SCJ Dislocation
- Recurrent laryngeal nerve
- Vagus Nerves
- Great VesselLaceration
- Mediastinal injury (trachea and lung injury)
- Differentiate from Sternoclavicular Dislocation (SCJ Dislocation)
- Posterior dislocation is associated with serious neurovascular and pulmonary injuries
- Proximal physis does not close until age 22 years, and physis is weaker than the adjacent SCJ
- Suspect Salter Type 1 proximal Clavicle Fractures instead of SCJ Dislocation in age <22 years old
- Management
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Based on Allman Group
- Group 1 (Middle third)
- Conservative therapy (see below) has been the typical treatment until ~2010
- Most mid-Clavicle Fractures are still treated with non-surgical management
- However, surgical repair has become a much more common intervention
- See Referral Indications as below
- Locking hardware, curved plates form fit the clavicle improved surgical outcomes
- Consider operative repair when displacement or overlap >2 cm
- Surgery is associated with lower risk of nonunion, faster return, but higher complication rate
- Consider operative repair in active adolescents and adults
- Clavicle shortening may cause chronic Shoulder Pain and dysfunction
- Consider a 2-4 week trial of conservative therapy prior to surgical intervention
- Athletes may elect for immediate repair to decrease time away from sport
- Consider operative repair if multiple risks for midshaft Fracture non-union
- Clavicle shortening >15mm to 20 mm
- Female gender
- Older age
- Fracture displacement or comminution
- More significant Traumatic injuries
- Skin Tenting
- Precaution: Surgical repair also risks non-union by interrupting vascular supply
- Group 2 (Lateral third)
- Displaced and possibly Neer Fracture Type II (unstable and risk of non-union): Surgery
- Nondisplaced (Neer Fracture Type I and III)
- Conservative therapy as with Allman Group 1 Fractures (see below)
- Children with Type 4 (uncommon)
- Typically treated as AC joint injury
- Group 3 (Proximal third)
- Neurovascular injury: Emergent orthopedic referral
- Nondisplaced (typical): Conservative therapy (see below)
- Displaced
- Orthopedic referral for surgery
- Suggests significant Trauma and higher risk for neurovascular injury
- Neurovascular injury present
- Emergent reduction is critical
- Towel clip can be used to grasp clavicle and apply anterior traction
- No neurovascular injury
- CT Scan of the clavicle to visualize posterior fragments
- References
- Robinson (2004) J Bone Joint Surg Am 86:1359-65 [PubMed]
- Hill (1997) J Bone Joint Surg Br 79:537-9 [PubMed]
- Management
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Conservative therapy
- Sling
- Arm sling for comfort (typically used for first 2 weeks)
- Under age 12: Sling for up to 3-4 weeks
- Over age 12: Sling for up to 4-6 weeks
- Avoid figure-of-eight (no benefit, complication risk)
- Andersen (1987) Acta Orthop Scand 58:71-4 [PubMed]
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Exercises
- Elbow range of motion Exercises as soon as able
- Shoulder Range of Motion and strength Exercises
- Passive range of motion starting once pain allows
- Start as tolerated in 2-3 weeks after injury
- Follow-up
- Re-evaluation with sports medicine or orthopedics in 1 week following injury (esp. athletes)
- Return to Play criteria
- Full and painless Shoulder Range of Motion with normal Shoulder strength
- Bony healing by exam and imaging
- Timing
- Non-Contact Sports: 6 weeks after injury
- Contact Sports: 8-16 weeks after injury
- References
- Stanley (1988) Injury 19:162-4 [PubMed]
- Management
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Referral Indications
- Emergent Consultation
- Posteriorly displaced proximal Clavicle Fracture
- Posteriorly displaced sternoclavicular Fracture
- Neurovascular injury
- Open Fracture or significant Skin Tenting
- Other referral indications
- Painful nonunion after 4 months
- Extreme proximal displaced Clavicle Fracture (Allman Group 3)
- Distal displaced Clavicle Fracture (Allman Group 2)
- Midshaft displaced Clavicle Fracture (Allman Group 1) indications
- Displaced or overlapping >2 cm (controversial) or
- Multiple nonunion risks or
- Persistent pain or
- Active teens, athletes and adults (esp. if dysfunction)
- Adult: Clavicle Fracture site remains prominent
- Child: Site remodels and disappears in months
- Short-term
- Pneumothorax
- Neurovascular injury
- Long-term
- Physeal Injury in adolescents (Allman Group 3 medial Fractures)
- Thoracic Outlet Syndrome
- Weakness or Paresthesias
- Deformity of cosmetic significance (or palpable Fracture callus site)
- Post-Traumatic Arthritis
- Medial Fractures that extend into sternoclavicular joint
- Malunion or nonunion (non-healing after 4-6 months after 10-20% of midshaft Clavicle Fractures)
- Advanced age
- Female patients
- Displaced or comminuted Fractures
- Tobacco Abuse
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