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Clavicle Fracture

A clavicular fracture Clavicular Fracture Acute Shoulder Pain is a common fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures 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 Low-Energy Trauma Toddler’s Fractures in the elderly. Clinical presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor includes pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways localized to the clavicle, a palpable deformity Deformity Examination of the Upper Limbs over the fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures site, and crepitus Crepitus Osteoarthritis. Diagnosis is clinical and confirmed with diagnostic imaging. Management is often conservative, although an increasing number of patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with clavicular fracture Clavicular Fracture Acute Shoulder Pain now undergo surgical intervention.

Last updated: Jul 13, 2021

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Overview

Definition

A clavicular fracture Clavicular Fracture Acute Shoulder Pain is a disruption in the integrity of the bony tissue of the clavicle (also called the collar bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types). These very common fractures generally heal without incident, although complications are possible.

Epidemiology

  • Most commonly fractured bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types in childhood
  • 2%–10% of all fractures
  • Incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency: 1 in 1000 people per year
  • Most commonly associated with sports injuries in younger patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship
  • Most commonly associated with falls in older patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship
  • 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 Shoulder Dystocia Obstetric complication during obstetric delivery in which exit of the fetus is delayed due to physical obstruction involving fetal shoulder(s). Complications during Childbirth)

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 Low-Energy Trauma Toddler’s Fractures 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 Clavicular Fracture Acute Shoulder Pain

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Pathophysiology

The general principle behind all fractures is that the bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types is subjected to a load that overcomes its bearing capacity and the bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types loses its structural integrity. Any traumatic mechanism can induce a fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures if the transfer of kinetic energy is great enough.

Clinical anatomy

  • S-shaped bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types
  • Only bony connection between the trunk and the arm Arm The arm, or “upper arm” in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm: Anatomy
  • Articulates medially with the sternum Sternum A long, narrow, and flat bone commonly known as breastbone occurring in the midsection of the anterior thoracic segment or chest region, which stabilizes the rib cage and serves as the point of origin for several muscles that move the arms, head, and neck. Chest Wall: Anatomy and laterally with the acromion
  • With a displaced fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures, the proximal fragment is almost always displaced superiorly by the pull of the sternocleidomastoid Sternocleidomastoid Muscles of the Neck: Anatomy muscle

Trauma mechanisms

  • Direct fall onto the lateral shoulder (the vast majority)
  • Fall onto an outstretched hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy
  • Direct trauma Direct Trauma Toddler’s Fractures to the clavicle (blunt, penetrating)

Medial third clavicle fractures (group III)

  • Least common type of clavicle fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures but most often associated with a serious injury
  • Associated with high-energy trauma and chest, head, and neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess injuries

Distal third clavicle fractures (group II)

  • May be confused with acromioclavicular injuries
  • Classified based on location of the fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures and ligamentous stability
Neer's classification of distal end clavicle fracture

Neer’s classification of distal end clavicle fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures
AC: acromioclavicular

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Clinical Presentation

The examination of a clavicular fracture Clavicular Fracture Acute Shoulder Pain depends on the clinical situation, although the majority of clavicular fractures present with a classic midshaft, group I fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures. If the fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures occurred in the context of high-energy trauma, patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship may require simultaneous examination and management following the Advanced Trauma Life Support (ATLS) method (most commonly seen with group III fractures).

History

  • Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship, 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 Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship 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 Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship, emphasis is on comorbidities Comorbidities The presence of co-existing or additional diseases with reference to an initial diagnosis or with reference to the index condition that is the subject of study. Comorbidity may affect the ability of affected individuals to function and also their survival; it may be used as a prognostic indicator for length of hospital stay, cost factors, and outcome or survival. St. Louis Encephalitis Virus and fall risk:
    • Factors that increase risk of syncope Syncope Syncope is a short-term loss of consciousness and loss of postural stability followed by spontaneous return of consciousness to the previous neurologic baseline without the need for resuscitation. The condition is caused by transient interruption of cerebral blood flow that may be benign or related to a underlying life-threatening condition. Syncope:
      • Stroke
      • MI MI MI is ischemia and death of an area of myocardial tissue due to insufficient blood flow and oxygenation, usually from thrombus formation on a ruptured atherosclerotic plaque in the epicardial arteries. Clinical presentation is most commonly with chest pain, but women and patients with diabetes may have atypical symptoms. Myocardial Infarction
      • Arrhythmia
    • Factors that increase risk of fall:

Physical examination

  • Affected limb held close to body 
  • Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways at location of the clavicle fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures, exacerbated with motion or palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination 
  • Visible/palpable deformity Deformity Examination of the Upper Limbs over the fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures site:
    • Tenting of skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions may occur.
    • Ecchymosis Ecchymosis Extravasation of blood into the skin, resulting in a nonelevated, rounded or irregular, blue or purplish patch, larger than a petechia. Orbital Fractures/ hematoma Hematoma A collection of blood outside the blood vessels. Hematoma can be localized in an organ, space, or tissue. Intussusception may be present.
    • Displacement Displacement The process by which an emotional or behavioral response that is appropriate for one situation appears in another situation for which it is inappropriate. Defense Mechanisms:
      • 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 Sternocleidomastoid Muscles of the Neck: Anatomy muscle.
  • Assess for possible concomitant fractures/dislocations/subluxations:
    • Fractures:
      • Ribs Ribs A set of twelve curved bones which connect to the vertebral column posteriorly, and terminate anteriorly as costal cartilage. Together, they form a protective cage around the internal thoracic organs. Chest Wall: Anatomy
      • Sternum Sternum A long, narrow, and flat bone commonly known as breastbone occurring in the midsection of the anterior thoracic segment or chest region, which stabilizes the rib cage and serves as the point of origin for several muscles that move the arms, head, and neck. Chest Wall: Anatomy
      • Humerus Humerus Bone in humans and primates extending from the shoulder joint to the elbow joint. Arm: Anatomy
      • Acromion
      • Scapula
      • Cervical vertebra
    • Dislocations/subluxations:
  • Assess for neurovascular injury
    • Injury to the subclavian artery → decreased pulses/pallor in affected limb
    • Injury to the brachial plexus Brachial Plexus The large network of nerve fibers which distributes the innervation of the upper extremity. The brachial plexus extends from the neck into the axilla. In humans, the nerves of the plexus usually originate from the lower cervical and the first thoracic spinal cord segments (c5-c8 and T1), but variations are not uncommon. Peripheral Nerve Injuries in the Cervicothoracic Region motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology/ sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology abnormalities in affected limb
  • Assess for pulmonary injury/ pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax:
    • Dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea 
    • Decreased  lung sounds and lung excursion
    • Hyperresonance to percussion Percussion Act of striking a part with short, sharp blows as an aid in diagnosing the condition beneath the sound obtained. Pulmonary Examination

Diagnosis

Diagnosis is initially made clinically and confirmed with diagnostic imaging ( X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests).

X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests

  • Anteroposterior (AP) view usually sufficient for diagnosis and classification
  • Chest X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests is indicated if clinical suspicion of:
    • Pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax
    • Sternal fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures
  • Shoulder X-rays X-rays X-rays are high-energy particles of electromagnetic radiation used in the medical field for the generation of anatomical images. X-rays are projected through the body of a patient and onto a film, and this technique is called conventional or projectional radiography. X-rays indicated if clinical suspicion of: 
    • Glenoid or scapular fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures
    • Humeral fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures (proximal)
  • Cervical X-rays X-rays X-rays are high-energy particles of electromagnetic radiation used in the medical field for the generation of anatomical images. X-rays are projected through the body of a patient and onto a film, and this technique is called conventional or projectional radiography. X-rays if clinical suspicion of vertebral fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures
  • Fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures description:
    • Location of fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures (Allman classification): 
      • Proximal third
      • Middle third 
      • Lateral third 
    • Complete or incomplete
    • Associated displacement Displacement The process by which an emotional or behavioral response that is appropriate for one situation appears in another situation for which it is inappropriate. Defense Mechanisms or angulation Angulation Buckle or Torus Fracture
    • Secondary findings:
      • Increased opacity Opacity Imaging of the Lungs and Pleura of soft tissues ( inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation and edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema)
      • Periosteal reaction/callus formation (older fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures)

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 Displacement The process by which an emotional or behavioral response that is appropriate for one situation appears in another situation for which it is inappropriate. Defense Mechanisms 
  • Considered if concomitant cervical/thoracic vertebral fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures suspected
  • Unstable patients Unstable Patients Blunt Chest Trauma should not be taken to the CT scanner.

Ultrasonography

Ultrasonography is a consideration if possible arterial injury Arterial Injury Hemothorax 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 Nonunion Hip Fractures of the fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures. Definitive management depends on the type of fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures and is often done in consultation with an orthopedic surgeon. A thoracic or vascular surgery Vascular surgery Vascular surgery is the specialized field of medicine that focuses on the surgical management of the pathologies of the peripheral circulation. The main goal of most vascular procedures is to restore circulatory function to the affected vessels by relieving occlusions or by redirecting blood flow (e.g., bypass). Vascular Surgery consult may be indicated in a small number of clavicle fractures with associated pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax or vascular injury.

Indications for orthopedic surgical referral

  • Complete fracture Complete Fracture Overview of Bone Fractures displacement Displacement The process by which an emotional or behavioral response that is appropriate for one situation appears in another situation for which it is inappropriate. Defense Mechanisms ( displacement Displacement The process by which an emotional or behavioral response that is appropriate for one situation appears in another situation for which it is inappropriate. Defense Mechanisms > 1 bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types width)
  • Longitudinal shortening ≥ 2 cm, severe tenting of the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions with risk of puncture
  • Comminuted fractures
  • Open fractures
  • Displaced medial clavicular fractures
  • Type II distal clavicular fractures
  • Neurovascular compromise
  • Associated glenoid fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures (floating shoulder)
  • Symptomatic nonunion Nonunion Hip Fractures

Management by group

Group I fractures (middle third): 

  • Management depends on displacement Displacement The process by which an emotional or behavioral response that is appropriate for one situation appears in another situation for which it is inappropriate. Defense Mechanisms, age, and level of activity
  • The focus Focus Area of enhancement measuring < 5 mm in diameter Imaging of the Breast 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 Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions
      • Symptomatic nonunion Nonunion Hip Fractures

Group II fractures (distal third):

  • Orthopedic referral for possible surgical intervention
  • High incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency of nonunion Nonunion Hip Fractures
  • 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 Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess injuries
  • A posterior sternoclavicular dislocation Sternoclavicular Dislocation Acute Shoulder Pain 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 Range of motion The distance and direction to which a bone joint can be extended. Range of motion is a function of the condition of the joints, muscles, and connective tissues involved. Joint flexibility can be improved through appropriate muscle strength exercises. Examination of the Upper Limbs (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 Malunion Hip Fractures is the most common complication:
  • Nonunion Nonunion Hip Fractures: occurs when fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures has not healed in 6 months
Conservative management of clavicle fracture

Conservative management of clavicle fractures:
A. Figure 8 bandage
B. Simple arm Arm The arm, or “upper arm” in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm: Anatomy sling

Image: “Conservative management of clavicle fractures” by Lenza M et al AL Amyloidosis. 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 Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures with either:
    • Plate fixation
    • Intramedullary pin fixation
  • Surgical complications Surgical complications Surgical complications are conditions, disorders, or adverse events that occur following surgical procedures. The most common general surgical complications include bleeding, infections, injury to the surrounding organs, venous thromboembolic events, and complications from anesthesia. Surgical Complications:
    • Infection
    • Hardware failure or migration
    • Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions breakdown
    • Brachial plexus Brachial Plexus The large network of nerve fibers which distributes the innervation of the upper extremity. The brachial plexus extends from the neck into the axilla. In humans, the nerves of the plexus usually originate from the lower cervical and the first thoracic spinal cord segments (c5-c8 and T1), but variations are not uncommon. Peripheral Nerve Injuries in the Cervicothoracic Region injury

Rehabilitation

  • As soon as tolerated, ROM exercises begin with the elbow and wrist with gentle pendulum exercise for the shoulder.
  • Physical therapy Physical Therapy Becker Muscular Dystrophy: 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 Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures

  • Direct injury to the subclavian artery or brachial plexus Brachial Plexus The large network of nerve fibers which distributes the innervation of the upper extremity. The brachial plexus extends from the neck into the axilla. In humans, the nerves of the plexus usually originate from the lower cervical and the first thoracic spinal cord segments (c5-c8 and T1), but variations are not uncommon. Peripheral Nerve Injuries in the Cervicothoracic Region
  • Compression Compression Blunt Chest Trauma of the brachial plexus Brachial Plexus The large network of nerve fibers which distributes the innervation of the upper extremity. The brachial plexus extends from the neck into the axilla. In humans, the nerves of the plexus usually originate from the lower cervical and the first thoracic spinal cord segments (c5-c8 and T1), but variations are not uncommon. Peripheral Nerve Injuries in the Cervicothoracic Region due to callus formation → compression Compression Blunt Chest Trauma neuropathy Neuropathy Leprosy
  • Pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax due to injury to the lung apex
  • Nonunion Nonunion Hip Fractures of the fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures
  • Posttraumatic arthritis Arthritis Acute or chronic inflammation of joints. Osteoarthritis (acromioclavicular (AC) or sternoclavicular (SC) joint)

Prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas

  • 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 Malunion Hip Fractures.
  • Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship return to sports/work based on:
    • Fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures location
    • Degree of healing
    • Activity requirements
  • Majority of patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship return to normal activities in 6–8 weeks.

Clinical Relevance

Other common diagnoses related to shoulder trauma

  • Rotator cuff tendon tear Rotator Cuff Tendon Tear Chronic Shoulder Pain: injury to the tendons of the muscles that make up the rotator cuff. Rotator cuff tendon tear Rotator Cuff Tendon Tear Chronic Shoulder Pain 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 Glenohumeral Dislocation Acute Shoulder Pain: dislocation of the humeral head Humeral head The upper rounded extremity of the humerus fitting into the glenoid cavity of the scapula. Arm: Anatomy from the glenoid fossa. The glenohumeral joint is the most commonly dislocated joint, and > 90% of shoulder dislocations are anterior–inferior.
  • Acromioclavicular joint Acromioclavicular joint The gliding joint formed by the outer extremity of the clavicle and the inner margin of the acromion process of the scapula. Examination of the Upper Limbs injury: common injury in adults. Acromioclavicular joint Acromioclavicular joint The gliding joint formed by the outer extremity of the clavicle and the inner margin of the acromion process of the scapula. Examination of the Upper Limbs injury is caused by a fall on the lateral shoulder with the arm Arm The arm, or “upper arm” in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm: Anatomy adducted.
  • Sternoclavicular joint Sternoclavicular Joint Examination of the Upper Limbs 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 Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax: accumulation of air within the pleural space Pleural space The thin serous membrane enveloping the lungs (lung) and lining the thoracic cavity. Pleura consist of two layers, the inner visceral pleura lying next to the pulmonary parenchyma and the outer parietal pleura. Between the two layers is the pleural cavity which contains a thin film of liquid. Pleuritis (between the parietal Parietal One of a pair of irregularly shaped quadrilateral bones situated between the frontal bone and occipital bone, which together form the sides of the cranium. Skull: Anatomy and visceral pleura Visceral pleura Pleura: Anatomy), which can be open (in communication Communication The exchange or transmission of ideas, attitudes, or beliefs between individuals or groups. Decision-making Capacity and Legal Competence with the atmosphere) or under tension (without an opening in the chest wall Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. Chest Wall: Anatomy). Pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax can occur in clavicular fractures because of injury to the lung apex.
  • Syncope Syncope Syncope is a short-term loss of consciousness and loss of postural stability followed by spontaneous return of consciousness to the previous neurologic baseline without the need for resuscitation. The condition is caused by transient interruption of cerebral blood flow that may be benign or related to a underlying life-threatening condition. Syncope: self-limited, transient loss of consciousness caused by inadequate cerebral perfusion Cerebral Perfusion Syncope, 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 Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification tissue after interruption of blood flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure ( ischemic stroke Ischemic Stroke An ischemic stroke (also known as cerebrovascular accident) is an acute neurologic injury that occurs as a result of brain ischemia; this condition may be due to cerebral blood vessel occlusion by thrombosis or embolism, or rarely due to systemic hypoperfusion. Ischemic Stroke) or active hemorrhage ( hemorrhagic stroke Hemorrhagic stroke Stroke due to rupture of a weakened blood vessel in the brain (e.g., cerebral hemispheres; cerebellum; subarachnoid space). Subarachnoid Hemorrhage), which has characteristic neurologic clinical features.
  • MI MI MI is ischemia and death of an area of myocardial tissue due to insufficient blood flow and oxygenation, usually from thrombus formation on a ruptured atherosclerotic plaque in the epicardial arteries. Clinical presentation is most commonly with chest pain, but women and patients with diabetes may have atypical symptoms. Myocardial Infarction: injury to the myocardium Myocardium The muscle tissue of the heart. It is composed of striated, involuntary muscle cells connected to form the contractile pump to generate blood flow. Heart: Anatomy due to ischemia Ischemia A hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation. Ischemic Cell Damage. MI MI MI is ischemia and death of an area of myocardial tissue due to insufficient blood flow and oxygenation, usually from thrombus formation on a ruptured atherosclerotic plaque in the epicardial arteries. Clinical presentation is most commonly with chest pain, but women and patients with diabetes may have atypical symptoms. Myocardial Infarction is characterized by an increase in cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) enzymes Enzymes Enzymes are complex protein biocatalysts that accelerate chemical reactions without being consumed by them. Due to the body’s constant metabolic needs, the absence of enzymes would make life unsustainable, as reactions would occur too slowly without these molecules. Basics of Enzymes (especially troponin T), ECG ECG An electrocardiogram (ECG) is a graphic representation of the electrical activity of the heart plotted against time. Adhesive electrodes are affixed to the skin surface allowing measurement of cardiac impulses from many angles. The ECG provides 3-dimensional information about the conduction system of the heart, the myocardium, and other cardiac structures. Electrocardiogram (ECG) changes suggestive of ischemia Ischemia A hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation. Ischemic Cell Damage in 2 contiguous leads, and chest pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways.

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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