Clavicle Fracture

A clavicular fracture is a common fracture usually occurring because of trauma. The trauma may be direct or indirect and is generally of high energy, but it may occur secondary to low-energy trauma in the elderly. Clinical presentation includes pain localized to the clavicle, a palpable deformity over the fracture site, and crepitus. Diagnosis is clinical and confirmed with diagnostic imaging. Management is often conservative, although an increasing number of patients with clavicular fracture now undergo surgical intervention.

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Overview

Definition

A clavicular fracture is a disruption in the integrity of the bony tissue of the clavicle (also called the collar bone). These very common fractures generally heal without incident, although complications are possible.

Epidemiology

  • Most commonly fractured bone in childhood
  • 2%–10% of all fractures
  • Incidence: 1 in 1000 people per year
  • Most commonly associated with sports injuries in younger patients
  • Most commonly associated with falls in older patients
  • The middle third of the clavicle is the most frequent location, followed by the lateral third and then the medial third.
  • 85% of clavicular fractures occur by a fall onto the lateral shoulder
  • Most common traumatic birth injury (associated with high birth weight and shoulder dystocia)

Etiology

  • High-energy trauma in children, adolescents, and adults 
    • Fall from a height
    • Motor-vehicle accident
    • Sports injury
    • Blunt force to the clavicle
  • Low-energy trauma in the elderly (e.g., simple fall)

Classification of clavicular fractures (based on location)

  • Group I: middle third
  • Group II: lateral third
  • Group III: medial third
Allman classification of fractures

Allman classification of clavicular fracture

Image by Lecturio. License: CC BY-NC-SA 4.0

Pathophysiology

The general principle behind all fractures is that the bone is subjected to a load that overcomes its bearing capacity and the bone loses its structural integrity. Any traumatic mechanism can induce a fracture if the transfer of kinetic energy is great enough.

Clinical anatomy

  • S-shaped bone
  • Only bony connection between the trunk and the arm
  • Articulates medially with the sternum and laterally with the acromion
  • With a displaced fracture, the proximal fragment is almost always displaced superiorly by the pull of the sternocleidomastoid muscle

Trauma mechanisms

  • Direct fall onto the lateral shoulder (the vast majority)
  • Fall onto an outstretched hand
  • Direct trauma to the clavicle (blunt, penetrating)

Medial third clavicle fractures (group III)

  • Least common type of clavicle fracture but most often associated with a serious injury
  • Associated with high-energy trauma and chest, head, and neck injuries

Distal third clavicle fractures (group II)

  • May be confused with acromioclavicular injuries
  • Classified based on location of the fracture and ligamentous stability
Neer's classification of distal end clavicle fracture

Neer’s classification of distal end clavicle fracture
AC: acromioclavicular

Image by Lecturio. License: CC BY-NC-SA 4.0

Clinical Presentation

The examination of a clavicular fracture depends on the clinical situation, although the majority of clavicular fractures present with a classic midshaft, group I fracture. If the fracture occurred in the context of high-energy trauma, patients may require simultaneous examination and management following the Advanced Trauma Life Support (ATLS) method (most commonly seen with group III fractures).

History

  • Patients, or first responders, will report trauma:
    • Recent
    • High-energy blunt or penetrating trauma 
      • Vehicle accident
      • Fall from height
      • High-impact sports injury
      • Attack with a blunt or sharp object
  • The clinician must assess the mechanism of trauma and injury mechanism details:
    • Vehicle accidents: types of restraints, airbags, patient position in the vehicle, status of other passengers
    • Fall mechanism
  • In elderly patients, emphasis is on comorbidities and fall risk:
    • Factors that increase risk of syncope:
      • Stroke
      • MI
      • Arrhythmia
    • Factors that increase risk of fall:
      • Arthritis in weight-bearing joints
      • Peripheral neuropathy
      • Generalized weakness
      • Visual impairment

Physical examination

  • Affected limb held close to body 
  • Pain at location of the clavicle fracture, exacerbated with motion or palpation 
  • Visible/palpable deformity over the fracture site:
    • Tenting of skin may occur.
    • Ecchymosis/hematoma may be present.
    • Displacement:
      • Lateral fragment may be displaced inferiorly and medially because of unopposed action of pectoralis major muscle.
      • Proximal fragment may be displaced superiorly because of unopposed action of the sternocleidomastoid muscle.
  • Assess for possible concomitant fractures/dislocations/subluxations:
    • Fractures:
      • Ribs
      • Sternum
      • Humerus
      • Acromion
      • Scapula
      • Cervical vertebra
    • Dislocations/subluxations:
      • Glenohumeral joint
      • Sternoclavicular joint
  • Assess for neurovascular injury
    • Injury to the subclavian artery → decreased pulses/pallor in affected limb
    • Injury to the brachial plexus → motor/sensory abnormalities in affected limb
  • Assess for pulmonary injury/pneumothorax:
    • Dyspnea 
    • Decreased  lung sounds and lung excursion
    • Hyperresonance to percussion

Diagnosis

Diagnosis is initially made clinically and confirmed with diagnostic imaging (X-ray).

X-ray

  • Anteroposterior (AP) view usually sufficient for diagnosis and classification
    • Should include acromioclavicular and sternoclavicular joint
    • 45-degree cephalic tilt if AP view insufficient
  • Chest X-ray is indicated if clinical suspicion of:
    • Pneumothorax
    • Sternal fracture
  • Shoulder X-rays indicated if clinical suspicion of: 
    • Glenoid or scapular fracture
    • Humeral fracture (proximal)
  • Cervical X-rays if clinical suspicion of vertebral fracture
  • Fracture description:
    • Location of fracture (Allman classification): 
      • Proximal third
      • Middle third 
      • Lateral third 
    • Complete or incomplete
    • Associated displacement or angulation
    • Secondary findings:
      • Increased opacity of soft tissues (inflammation and edema)
      • Periosteal reaction/callus formation (older fracture)

CT

  • May be needed to guide or plan definitive management in complex or uncommon cases
  • Considered in the evaluation of medial third fractures with posterior displacement 
  • Considered if concomitant cervical/thoracic vertebral fracture suspected
  • Unstable patients should not be taken to the CT scanner.

Ultrasonography

Ultrasonography is a consideration if possible arterial injury is suspected (subclavian artery).

Management

The vast majority of clavicle fractures will heal without operative intervention. However, there remain challenges secondary to the occurrence of complications and nonunion of the fracture. Definitive management depends on the type of fracture and is often done in consultation with an orthopedic surgeon. A thoracic or vascular surgery consult may be indicated in a small number of clavicle fractures with associated pneumothorax or vascular injury.

Indications for orthopedic surgical referral

  • Complete fracture displacement (displacement > 1 bone width)
  • Longitudinal shortening ≥ 2 cm, severe tenting of the skin with risk of puncture
  • Comminuted fractures
  • Open fractures
  • Displaced medial clavicular fractures
  • Type II distal clavicular fractures
  • Neurovascular compromise
  • Associated glenoid fracture (floating shoulder)
  • Symptomatic nonunion

Management by group

Group I fractures (middle third): 

  • Management depends on displacement, age, and level of activity
  • The focus remains on nonoperative management, although recently, there is more support for surgical management for some clavicle fractures
  • Nonoperative:
    • Sling versus figure 8 brace: literature shows no real difference in outcomes
    • Healing time 6–8 weeks in adults
  • Surgical intervention:
    • Increasing evidence for operative treatment of displaced clavicle fractures
    • Surgical options: 
      • Intramedullary fixation
      • Plate-and-screw fixation
    • Suggested indications:
      • Complicated fractures of the middle third
      • Fractures overlapped > 2 cm
      • Severe tenting of the skin
      • Symptomatic nonunion

Group II fractures (distal third):

  • Orthopedic referral for possible surgical intervention
  • High incidence of nonunion
  • Generally, type II fractures of the distal clavicle (level of the coracoclavicular ligaments) are treated surgically

Group III fractures (medial third):

  • Generally treated conservatively
  • Essential to assess for other associated thorax and neck injuries
  • A posterior sternoclavicular dislocation needs emergent evaluation because of the potential for great-vessel injury and other intrathoracic injuries

Conservative management

  • The most widely used devices are the sling, sling and swathe, and figure 8 brace
  • Range of motion (ROM) exercises of the elbow and wrist are started within 2–3 days of injury.
  • Fewer complications and a faster recovery in nondisplaced midshaft fractures
  • Clinical union: 
    • 6–12 weeks in adults
    • 3–6 weeks in children
  • Malunion is the most common complication:
    • Incomplete healing
    • Shortening
    • Angulation
  • Nonunion: occurs when fracture has not healed in 6 months
Conservative management of clavicle fracture

Conservative management of clavicle fractures:
A. Figure 8 bandage
B. Simple arm sling

Image: “Conservative management of clavicle fractures” by Lenza M et al. License: CC BY 4.0

Surgical management

Recent literature has challenged the belief that all midshaft fractures heal without difficulty.

  • Open reduction and internal fixation of the fracture with either:
    • Plate fixation
    • Intramedullary pin fixation
  • Surgical complications:
    • Infection
    • Hardware failure or migration
    • Skin breakdown
    • Brachial plexus injury

Rehabilitation

  • As soon as tolerated, ROM exercises begin with the elbow and wrist with gentle pendulum exercise for the shoulder.
  • Physical therapy: ROM and strengthening exercises are based on clinical and radiographic findings of healing.
  • 2–4 months required for athletes in contact sports and evidence of radiologic healing

Complications related to a clavicle fracture

  • Direct injury to the subclavian artery or brachial plexus
  • Compression of the brachial plexus due to callus formation → compression neuropathy
  • Pneumothorax due to injury to the lung apex
  • Nonunion of the fracture
  • Posttraumatic arthritis (acromioclavicular (AC) or sternoclavicular (SC) joint)

Prognosis

  • Most clavicular fractures are managed conservatively with good results.
  • Support for surgical treatment of middle third fractures is increasing.
  • Serious complications are uncommon; most common complication is a malunion.
  • Patients return to sports/work based on:
    • Fracture location
    • Degree of healing
    • Activity requirements
  • Majority of patients return to normal activities in 6–8 weeks.

Clinical Relevance

Other common diagnoses related to shoulder trauma

  • Rotator cuff tendon tear: injury to the tendons of the muscles that make up the rotator cuff. Rotator cuff tendon tear can occur as a result of acute trauma, falls, repetitive motion, or tendon degeneration. The tendon of the supraspinatus muscle is the most commonly torn. 
  • Glenohumeral dislocation: dislocation of the humeral head from the glenoid fossa. The glenohumeral joint is the most commonly dislocated joint, and > 90% of shoulder dislocations are anterior–inferior.
  • Acromioclavicular joint injury: common injury in adults. Acromioclavicular joint injury is caused by a fall on the lateral shoulder with the arm adducted.
  • Sternoclavicular joint injury: This type of joint injury may take the form of sprains or dislocations, and dislocations can be anterior or posterior. Posterior dislocations require emergent care because of the potential for injury to mediastinal structures.

Clinically relevant topics related to clavicle fractures and falls

  • Pneumothorax: accumulation of air within the pleural space (between the parietal and visceral pleura), which can be open (in communication with the atmosphere) or under tension (without an opening in the chest wall). Pneumothorax can occur in clavicular fractures because of injury to the lung apex.
  • Syncope: self-limited, transient loss of consciousness caused by inadequate cerebral perfusion, most often the result of an abrupt drop of systemic BP. Syncopal episodes are brief (8–10 seconds) and are classified as cardiogenic, orthostatic, or neurally mediated.
  • Stroke: Stroke is an injury to brain tissue after interruption of blood flow (ischemic stroke) or active hemorrhage (hemorrhagic stroke), which has characteristic neurologic clinical features.
  • MI: injury to the myocardium due to ischemia. MI is characterized by an increase in cardiac enzymes (especially troponin T), ECG changes suggestive of ischemia in 2 contiguous leads, and chest pain.

References

  1. Browner, B., Jupiter, J., Krettek, C., Anderson, P. (2020). Skeletal Trauma: Basic Science, Management, and Reconstruction. Philadelphia: Elsevier.
  2. Bentley, T. P., Hosseinzadeh, S. (2021). Clavicle fractures. StatPearls. Retrieved June 27, 2021, from http://www.ncbi.nlm.nih.gov/books/NBK507892/

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