Orthopaedic Surgery - Clavicle Fractures

Basics

Clavicle fractures are among the most common upper-extremity fractures encountered in the emergency department.

They occur most frequently in males younger than 20 years, while among older adults, particularly those over 65 years, women account for a greater proportion of cases.

Clavicle fractures are classified according to their location, displacement, comminution, and possible intra-articular extension.

Classification

Several classification systems are available, including the Neer, Edinburgh, and Müller AO systems.

From an anatomic perspective, fractures are divided into middle-third, lateral-third, and medial-third injuries.

Middle-third fractures are by far the most common, followed by lateral and then medial clavicle fractures.

Open Fractures

Open clavicle fractures are uncommon.

When they occur, they are often associated with substantial trauma involving the head, thorax, or major vessels.

Clavicle fractures are also frequently encountered in patients with multiple traumatic injuries.

Fracture Displacement

The characteristic displacement of a midshaft clavicle fracture is produced by opposing muscular and gravitational forces.

The sternocleidomastoid muscle pulls the medial fragment superiorly, while the pectoralis major and the weight of the arm tend to pull the lateral fragment inferiorly and medially.

These forces may create visible shortening or deformity.

Neurovascular Anatomy

The clavicle lies directly over the subclavian vein and is close to the subclavian artery and brachial plexus.

Although injury to these structures is uncommon, neurovascular damage may occur at the time of trauma or during operative fixation.

A careful neurovascular examination is therefore essential.

Lateral Clavicle Fractures

The displacement pattern of lateral clavicle fractures depends strongly on the integrity of the coracoclavicular ligaments, acromioclavicular joint, and surrounding ligamentous structures.

Disruption of these stabilizers may make the fracture unstable and increase the risk of nonunion.

General Prevention

Fall prevention is particularly important in patients with impaired balance or a history of recurrent falls.

Assistive devices, home-safety assessment, and nursing or rehabilitation evaluation may help reduce future injury.

In older adults sustaining a clavicle fracture after a low-energy fall, evaluation and treatment of possible osteoporosis may reduce the risk of subsequent fragility fractures.

Epidemiology

Clavicle fractures occur more often in men than women among patients younger than 65 years, with a reported male-to-female ratio of approximately 2.2:1.

The mean age at the time of fracture has been reported to be approximately 48 years.

Fractures occur more frequently during weekends and summer months, probably reflecting increased recreational and sporting activity.

Incidence

Reported incidence varies between populations.

One epidemiologic study found approximately 5.8 clavicle fractures per 10,000 people, while a recent U.S. study reported approximately 24.4 fractures per 100,000 person-years.

The highest incidence occurs between approximately 10 and 19 years of age.

Risk Factors

Risk factors include male sex, young age, recurrent falls, osteoporosis, participation in sports, bicycle accidents, motor vehicle collisions, and other forms of trauma.

Sports account for a substantial proportion of emergency-department presentations involving clavicle fractures.

Genetics

Genetic disorders that weaken bone may increase susceptibility to clavicle fracture.

Examples include Ehlers-Danlos syndrome and fibrous dysplasia, although most clavicle fractures occur without an underlying hereditary disorder.

Etiology

The most common mechanism is a fall, frequently directly onto the shoulder.

Other mechanisms include bicycle and motorcycle accidents, motor vehicle collisions, and contact-sport injuries.

Sports-Related Injuries

Among sporting activities, bicycling is particularly commonly associated with clavicle fracture.

Football and soccer are other frequent causes.

Age and Injury Mechanism

Men are more likely to sustain clavicle fractures through higher-energy mechanisms, whereas women, particularly older women, more often sustain fractures after falls or other relatively low-energy trauma.

Associated Conditions

Associated injuries are common, particularly after high-energy trauma.

Important associated conditions include rib fractures, pneumothorax, cervical spine injury, head injury, scapular fracture, vascular injury, and nerve injury.

Polytrauma

Patients with a clavicle fracture after major trauma require a complete trauma assessment.

Concurrent fractures may involve the spinal column, scapula, cranium, forearm, proximal humerus, or other parts of the shoulder girdle.

Spinal column fractures are among the important associated skeletal injuries.

Scapulothoracic Dissociation

A widely displaced clavicle fracture in a high-energy injury should raise concern for scapulothoracic dissociation.

This severe shoulder-girdle injury may be associated with major vascular and brachial plexus injury.

Diagnosis

Signs and Symptoms

Typical findings include pain with movement of the affected upper extremity, visible or palpable deformity over the clavicle, swelling, bruising, and ecchymosis.

Patients often support the injured arm with the opposite hand.

Skin Tenting

The displaced fracture fragment may push against the overlying skin, producing skin tenting.

Marked tenting or blanching indicates threatened skin integrity and may represent an indication for urgent operative treatment.

Physical Examination

The clavicular region and the entire upper extremity should be inspected carefully.

The examiner should look for open wounds, abrasions, skin tenting, expanding hematoma, abnormal alignment, or evidence of additional injury.

Neurovascular Examination

A careful neurovascular examination is essential.

Motor function and sensation throughout the upper extremity should be evaluated and compared with the opposite side.

Vascular Examination

Although vascular injury is rare, the examiner should confirm symmetric distal pulses and brisk capillary refill.

An expanding hematoma, diminished pulse, cool extremity, or other evidence of vascular compromise requires urgent assessment.

Examination for Associated Injuries

The remainder of the injured extremity should be palpated and the major joints examined.

Additional fractures, shoulder dislocation, or other injuries may coexist and should not be overlooked.

Trauma Examination

Patients injured through high-energy mechanisms require a complete trauma examination to identify associated thoracic, spinal, abdominal, cranial, or extremity injuries.

Elderly Patients After Falls

Older adults who sustain a clavicle fracture after a fall should also be evaluated for head and cervical spine injury.

This is particularly important in patients with recurrent falls or those taking anticoagulant medication.

Imaging

Dedicated Clavicle Radiographs

Standard evaluation includes dedicated radiographs of the clavicle.

An anteroposterior view and approximately 20° cephalad view are commonly obtained.

Chest Radiograph

An AP chest radiograph can help assess fracture displacement and compare the injured clavicle with the opposite side.

It may also reveal associated injuries such as rib fractures or pneumothorax.

Shoulder Radiographs

Dedicated shoulder radiographs can help exclude associated injuries involving the scapula, acromioclavicular joint, or proximal humerus.

CT

CT is not routinely required for uncomplicated midshaft fractures.

It may be helpful for medial clavicle fractures, complex fracture patterns, or when the relationship to adjacent thoracic structures is unclear.

Vascular Imaging

If vascular injury is suspected, angiographic imaging may be required to evaluate the subclavian or other nearby vessels.

Additional Imaging

Additional radiographs or advanced imaging should be obtained according to the mechanism of injury and clinical suspicion for associated trauma.

Pathologic Fracture Evaluation

Pathologic testing is not routinely necessary.

A pathologic fracture should be considered when the injury occurs after an unusually minor mechanism, when there is a personal or strong family history of malignancy, or when radiographs demonstrate a suspicious underlying bony lesion.

Differential Diagnosis

The differential diagnosis includes acromioclavicular joint separation, rib fracture, scapular fracture, shoulder dislocation, sternoclavicular joint dislocation, and proximal humerus fracture.

Treatment

General Principles

Treatment depends on both patient factors and fracture characteristics.

Most clavicle fractures can be managed nonoperatively, although operative fixation has become more common in selected displaced fractures.

Nondisplaced Fractures

Nondisplaced or minimally displaced fractures usually heal successfully with nonoperative care.

A sling, pain control, and gradual restoration of shoulder motion are typically sufficient.

Medial and Lateral Fractures

Many medial and lateral clavicle fractures can also be managed without surgery when alignment and stability are acceptable.

However, unstable lateral fractures require closer assessment because the risk of nonunion is higher.

Children Versus Adults

Children have greater remodeling potential and a higher likelihood of healing displaced fractures than adults.

Consequently, substantial displacement that might prompt surgery in an adult may still be treated successfully without surgery in a younger child.

Monitoring Displaced Fractures

Displaced fractures treated nonoperatively should undergo repeat radiographs during the first several weeks to ensure that alignment has not worsened.

Sleeping Position

During the painful acute phase, patients may find it more comfortable to sleep in a chair or recliner rather than lying flat.

Activity

Sling Immobilization

A sling is commonly used for approximately 2–4 weeks.

During the early period, the involved upper extremity is generally kept non-weight-bearing.

Early Joint Motion

The sling should be removed several times each day for gentle elbow, wrist, and hand range-of-motion exercises.

This helps prevent stiffness in uninvolved joints.

Shoulder Motion

Gentle shoulder range of motion can usually begin after approximately 2–4 weeks, depending on pain, fracture stability, and clinical progress.

More strenuous motion and strengthening are delayed until healing has progressed.

Figure-of-Eight Brace

A figure-of-eight clavicle brace may be used, but it has not shown a clear advantage over a simple sling.

It may also produce greater discomfort during the early treatment period.

Axillary Care

When using a sling, the axillary fold should be kept clean and dry to prevent irritation, moisture accumulation, and skin breakdown.

Preoperative Activity

Patients awaiting surgery should generally remain non-weight-bearing in a sling.

After fixation, activity restrictions depend on the surgical construct, implant, and surgeon’s postoperative protocol.

Physical Therapy

Nonoperative Rehabilitation

Formal physical therapy is not necessary for every patient.

For nonoperatively treated fractures, gentle motion can begin after approximately 2–4 weeks.

Early Exercises

Rehabilitation may begin with pendulum and pulley exercises.

These are gradually advanced toward full shoulder range of motion as pain decreases and healing progresses.

Postoperative Therapy

The timing of physical therapy after surgery varies according to fixation stability, patient factors, and surgeon preference.

Stable fixation often allows earlier controlled motion.

Medication

First-Line Treatment

Pain management may include ice, acetaminophen, and NSAIDs when appropriate.

Some surgeons limit NSAID use because of theoretical concerns regarding bone healing, although practice varies.

Additional Analgesics

Tramadol may be considered for selected patients.

Short courses of opioid analgesics are sometimes required during the acute painful period.

Opioid Considerations

Before prescribing opioids, factors such as patient age, comorbidities, concurrent medications, fall risk, and overall health should be considered.

Surgery

Indications

Operative treatment may be considered for an open fracture, threatened skin, floating shoulder, severe displacement, significant shortening, or other unstable fracture patterns.

Shortening greater than approximately 2 cm may contribute to the decision for surgery in selected displaced midshaft fractures.

Floating Shoulder

A floating shoulder refers to major disruption of the shoulder suspensory complex, often involving an ipsilateral scapular neck fracture together with clavicular injury.

This pattern may warrant operative stabilization depending on displacement and overall injury severity.

Open Reduction and Internal Fixation

Surgery commonly involves open reduction and internal fixation (ORIF) with plates, screws, or other internal fixation devices.

The goals are restoration of length and alignment, stable fixation, and facilitation of earlier functional rehabilitation.

Follow-Up

Prognosis

Most clavicle fractures heal successfully.

Outcome depends on fracture location, displacement, age, soft-tissue condition, and whether the fracture is treated surgically or nonoperatively.

Operative Treatment of Displaced Midshaft Fractures

Surgical fixation of appropriately selected displaced midshaft fractures can reduce the rates of nonunion and symptomatic malunion compared with nonoperative treatment.

It may also permit a quicker early return to work and improved short-term functional recovery.

Hardware Removal

One disadvantage of operative fixation is the relatively high rate of subsequent procedures.

Many patients request hardware removal because the clavicle is subcutaneous and plates can be prominent or irritating.

Nonunion

Some displaced midshaft fractures treated nonoperatively progress to nonunion.

Not all nonunions are sufficiently symptomatic to require further treatment.

Lateral Clavicle Nonunion

Nonunion is relatively common after certain lateral clavicle fractures.

However, some radiographic nonunions remain minimally symptomatic and do not require surgery.

Complications

Infection

Surgical fixation carries a risk of wound infection and deep implant-related infection.

Hardware Failure

Internal fixation devices may loosen, break, or fail, especially if union is delayed or excessive loading occurs too early.

Nonunion

Failure of the fracture to unite is more likely with marked displacement, shortening, comminution, smoking, and certain unstable lateral fracture patterns.

Symptomatic Malunion

A clavicle fracture that heals with substantial shortening or deformity may produce pain, weakness, altered shoulder mechanics, or cosmetic dissatisfaction.

Symptomatic malunion is more commonly encountered after markedly displaced fractures treated nonoperatively.

Shoulder Stiffness

Prolonged immobilization or associated shoulder injury may result in post-traumatic stiffness.

Early controlled motion after an appropriate period of fracture protection can reduce this risk.

Supraclavicular Nerve Symptoms

Numbness over the clavicle or upper chest may occur because the cutaneous supraclavicular nerve branches can be stretched or injured during the initial trauma.

They may also be cut or stretched during surgical exposure.

Neurovascular Injury

Although rare, injury to the brachial plexus or subclavian vessels can occur because of their close relationship to the clavicle.

These complications can occur from the initial fracture or during operative treatment.

Patient Monitoring

Early Radiographic Monitoring

Radiographs should be obtained every few weeks during the early post-injury or postoperative period to confirm maintenance of alignment.

This is especially important for displaced fractures treated without surgery.

Healing Surveillance

After the acute period, imaging may be repeated approximately every 4–6 weeks until satisfactory clinical and radiographic union is demonstrated.

Clinical Monitoring

Follow-up should assess pain, skin condition, neurovascular status, shoulder range of motion, tenderness at the fracture site, and functional recovery.

Increasing pain, new neurologic symptoms, skin compromise, or progressive deformity should prompt earlier reassessment.