Clavicle Fracture

The clavicle, proximal humerus and the scapula together form the shoulder joint. The clavicle also
forms the bony connection between the upper limb and the thorax. It articulates with the acromion
process of the scapula laterally, at the acromioclavicular joint, and the manubrium of the sternum
medially, at the sternoclavicular joint. Ligaments connect the coracoid process of the scapula to the
mid-clavicle. The clavicle protects the brachial plexus, major underlying vessels and the lung apex.

Signs and symptoms

 Pain, particularly with upper extremity movement

 Swelling
 bruising
 Often, after the swelling has subsided, the fracture can be felt through the skin.
 Sharp pain when any movement is made.
 Referred pain: dull to extreme ache in and around clavicle area, including surrounding muscles.
 Possible nausea, dizziness, and/or spotty vision due to extreme pain

Epidemiology
 One of the most common acute shoulder injuries.
 Accounts for 2-5% of adult fractures.1,2
 More common in children.
 The most common of all paediatric fractures.3
Mechanism of injury
 Usually caused by a fall on to the lateral shoulder.
 Less commonly occurs after a direct blow to the clavicle or by falling on an outstretched arm. 2
 A common injury in contact sports, cycling and winter sports.
 In the neonate:
o Complication of breech delivery.
o One recognised third-line management of shoulder dystocia is surgical division of the
clavicle (cleidotomy).4
Presentation
 History of a fall or trauma.
 Pain, swelling and tenderness around the clavicle.
 There may be obvious deformity, including tenting of the skin and bruising.
 There may be nonuse of the arm on the affected side in neonates.
Examination
Firstly assess Airway, Breathing, Circulation (ABC) and manage as necessary.
 Diagnosis of a fractured clavicle can usually be made clinically, as the clavicle is superficial and
easily palpable. Examine the clavicle from behind the patient.
 Auscultate and percuss the lung fields to exclude a complicating pneumothorax.
 Perform a neurovascular examination of the upper limb on the affected side - examine the
upper limb pulses; look for evidence of decreased perfusion, including changes in skin colour;
assess sensation and muscle power.
 Assess and examine for any other injuries.
Investigations
 Anteroposterior view X-ray of the clavicle detects most fractures.
 Non-displaced fractures may be better seen on a 20 or 45° cephalic tilt view.
 Ensure that there is no coexisting scapular fracture which would mean a 'floating shoulder'.
 Sternoclavicular or acromioclavicular joint disruption may require CT/MRI scanning to
characterise fully.
 Chest X-ray if pneumothorax is suspected.
 Angiography if vascular damage is suspected.
Fracture classification

 Group I - Fracture of middle third

 Group II - Fracture of the distal third
o Type I - Minimally displaced/interligamentous
o Type II - Displaced due to fracture medial to the coracoclavicular ligaments
 IIA - Both the conoid and trapezoid remain attached to distal fragment
 IIB - Either the conoid is torn or both the conoid and trapezoid are torn
o Type III - Fractures involving articular surface
o Type IV - Ligaments intact to the periosteum with displacement of the proximal fragment
o Type V - Comminuted
 Group III - Fracture of the proximal third
o Type I - Minimal displacement
o Type II - Displaced
o Type III - Intraarticular
o Type IV - Epiphyseal separation (observed in patients aged 25 y and younger)
o Type V - Comminuted

Management
In a GP setting:

 Assess ABC, perform a full examination and examine for any other injury as described above.
 Ice setting
 Immobilise in a sling the arm on the affected side.
 Refer to secondary care for X-ray investigation.
After confirmed X-ray diagnosis:
 Traditionally, most clavicular fractures have been managed conservatively, even if they are
displaced.
 Open fractures obviously need orthopaedic referral.
 Management then depends on the fracture classification.
o Group 1: can be treated conservatively, whether displaced or non-displaced, with
immobilisation using a sling or a figure-of-eight bandage (clavicle strap).
o Group 2: type I and type III fractures can be treated with immobilisation. Type II
fractures may require surgery. The method of surgical treatment for clavicular fractures
is controversial. Intramedullary screws or nails and plate fixation of the clavicle are the
most usual surgical options.
o Group 3: if non-displaced, immobilisation is all that is needed. Displaced fractures may
require surgery.
 Analgesia such as paracetamol or, if the pain is severe, opiates, should be prescribed.
 Orthopaedic outpatient follow-up is usually arranged.
  Mobilisation exercises/physiotherapy should be provided.
Recent management developments
Some recent studies have shown that long-term results from conservative, or nonoperative,
management of clavicular fractures are not as favourable as previously considered:

 42% of people still had sequelae at 6 months in one study. The same study suggests the
exploration of alternative treatment options, including surgery, for certain clavicular fracture
types.7
 A recent multicentre randomised controlled trial in Canada showed that displaced clavicle
shaft fractures treated by surgical plate fixation had improved functional outcome and a lower
rate of malunion and nonunion when compared with nonoperative treatment at one year. 8
 Another study into nonoperative treatment of displaced mid-clavicular shaft fractures detected
significant residual deficits in shoulder strength and endurance. However, there was no control
group that was treated surgically.9
 Intramedullary nailing of mid-clavicular fractures was compared with nonoperative treatment
in another study. The patients who had undergone nailing showed significantly better results
concerning shoulder function, pain, personal satisfaction and cosmetic result. Return to work
time was also faster.10

Surgical
The surgery is indicated when one or more of the following conditions presents.

1. Comminution with separation (multiple piece)

2. Displacement and shortening 1.5 – 2.0 cm
3. Significant Foreshortening of the clavicle (indicated by shoulder forward).
4. Skin penetration (Open Fracture).
5. Clearly associated nervous and vascular trauma (Brachial Plexus or Supra Clavicular Nerves).
6. Non Union after several months (3–6 months, typically)
7. Distal Third Fractures which interfere with normal function of the ACJ (Acriomio Clavicular Joint).

The method of surgical treatment for clavicular fractures is controversial. Intramedullary screws or
nails and plate fixation of the clavicle are the most usual surgical options.

Elastic Nailing of the clavicle is a new technique, which seems to have less complications and is a much
less invasive procedure than plate and screw fixation. For more information 

For non union we will use plate and bone graft A very recent development is the use of an arthroscopic
procedure to stabilise clavicular fractures using a 'tightrope'. 11

Complications
Complications are uncommon.

Acute
  Pneumothorax.
 Haemothorax.
 Brachial plexus injury.
 Blood vessel injury (including subclavian vessels, internal jugular vein and axillary artery).

Late
 Nonunion and malunion (no radiographic healing at 4-6 months).
 Clavicle Nonunion (30% in distal third)
If the clavicle has not healed by 3 months it is called a 'nonunion'. These are usually painful and
require surgical fixation.
The surgery involves fixing the clavicle with a plate and screws, plus adding bone graft to aid the
healing.
 Clavicle Malunion 
If the clavicle heales in a displaced position, this is called a 'malunion'. This is accompanied by a step
(deformity) in the clavicle.
This can lead to ongoing shoulder problems, especially in athletes and manual workers. Significant
shortening of the clavicle can alter the normal alignment of the shoulder girdle leading to
dysfunction with high demand activities

 Deformity due to excessive callus formation during fracture healing.

 Thoracic outlet syndrome.
 Brachial plexus compression due to callus formation. 3
 Arthritis (more common in fractures involving the articular surface - group 2, type III).
Prognosis
 If managed promptly and correctly, this is excellent.
 Healing normally takes 6-8 weeks in an adult and 3-4 weeks in a child.
 One study showed that asymptomatic nonunion does not appear to affect the functional
outcome adversely in the medium term.13

What not to do:

 Do not apply a figure-of-eight dressing or clavicle strap if this form of splinting

increases patient discomfort.
 Do not leave an arm immobilized in a sling for more than a week. This can
result in loss of range of motion or "frozen shoulder."