Clavicle fracture

Clavicle fractures are common, especially in children and adolescents, and often result from a direct fall onto the shoulder. They are classified by location using the Allman classification system, with two-thirds of fractures located in the midshaft. Patients typically present with signs of fracture such as swelling, focal tenderness, and reduced arm mobility, or more specific signs such as shoulder drooping or skin tenting around the clavicle. Diagnosis is confirmed with x-ray, although additional imaging studies such as CTA may be needed for suspected vascular injury. Treatment is based on fracture location and may include conservative fracture management and/or surgical fracture care.

• Common (accounts for ∼ 2.6% of all fractures) ^[1]
• Most commonly occurs in children and adolescents ^[2]
• Most common birth trauma in newborns ^[3]

Epidemiological data refers to the US, unless otherwise specified.

• Direct trauma (∼ 95% of cases) ^[4]
  • Fall onto the shoulder (most common cause), e.g., from bicycle accident
  • Direct blow to the clavicle, e.g., from a football tackle
• Indirect trauma (∼ 5% of cases): mainly falls onto an outstretched hand ^[4]
• Birth trauma (see “Birth-related clavicle fracture”)

A midshaft fracture is the most common clavicle fracture because it is the thinnest segment of bone and lacks ligamentous and muscular support. ^[5]

Allman classification system ^[6]

The Allman classification system categorizes fractures of the clavicle according to fracture location.

• Signs of fracture, e.g., pain, ecchymosis, swelling
• Sagging of the shoulder due to downward distracting force of the weight of the upper limb on the lateral fracture fragment
• Skin tenting over the clavicle due to the upward distracting force of the sternocleidomastoid on the medial fracture fragment
• Shortening of the clavicle due to the medial distracting force (adduction) of the pectoralis major on the lateral fracture fragment

Clinical evaluation ^[5][7]

Any findings that suggest neurovascular injury or an open fracture should prompt urgent orthopedic consultation.

• Neurovascular examination
  • Evaluate for brachial plexus injury, e.g., upper extremity paresthesias or weakness. ^[8][9]
  • Assess for subclavian artery injury, e.g., weak or absent upper extremity pulses. ^[9][10]
• Skin examination: Evaluate for laceration, tearing, and skin tenting.
• Lung examination: Assess for signs of pneumothorax.

Posteriorly displaced fracture fragments may result in injuries to the brachial plexus, subclavian vessels, and lung apex. ^[5]

Imaging ^[5][7]

X-ray

• Indication: best initial test for suspected clavicle fracture
• Views: anterior-posterior and 45° cephalic tilt
• Findings: radiographic fracture signs, fracture fragments, displacement, angulation, and/or shortening

Additional imaging ^[5][7]

• CT upper extremity or chest: for assessing associated injuries, intraarticular fractures, preoperative planning for complicated fractures, and inconclusive x-ray findings
• CT angiography upper extremity or chest: for suspected vascular injury ^[10]
• MRI upper extremity: to assess intraarticular or ligamentous injury and soft tissue structures in high-grade acromioclavicular separations to guide management decisions ^[11]
• Ultrasound: may be used for suspected pediatric clavicle fractures ^[12]

• Acromioclavicular joint injury
• Sternoclavicular joint injury
• Rib fracture
• Scapular fracture
• Shoulder dislocation
• Rotator cuff injury

The differential diagnoses listed here are not exhaustive.

General principles ^[13][14][15]

• Most clavicle fractures are managed conservatively, regardless of their Allman classification. ^[13]
• Surgical fracture management is increasing, e.g., in patients with:
  • Young age
  • Few comorbidities
  • High-energy injury mechanisms
  • Midshaft (group I) fractures ^[13]
  • Medial (group III) fractures ^[13]
  • Concerns about professional impact (e.g., in athletes) or cosmesis

Initial management ^[7]

• Provide general fracture care, including analgesia for fractures.
• Immobilize with an arm sling for comfort as soon as a clavicle fracture is suspected.
• Identify indications to consult orthopedics for fractures.
• Consult surgery if there is suspicion of an intrathoracic injury (e.g., pneumothorax, subclavian artery injury)
• Arrange prompt follow-up with orthopedics for all patients.

Rule out concomitant intrathoracic injuries in patients with medial (group III) clavicle fractures.

Conservative management ^[7][15]

Recommended for nondisplaced, closed fractures

• Immobilize in an arm sling for 4–8 weeks.
• Perform early passive range of motion exercises.
• Avoid noncontact sports for 6 weeks and contact sports for 2–4 months. ^[5]
• See also “Conservative fracture management.”

Surgical fracture management ^[13][14][15]

Indications

• High risk for malunion or nonunion
  • Significant displacement
  • Shortening > 2 cm
  • Severely comminuted
• Open fractures
• Neurovascular injury
• Skin tenting

Operative techniques

Depend on fracture location and type and include:

• Intramedullary nailing
• Plate fixation
• Ligament repair: typically for lateral (group II) fractures

• Fracture complications: e.g., nonunion, malunion ^[7]
• Neurovascular injuries: e.g., brachial plexus injury, subclavian artery injury
• Lung injuries: e.g., pneumothorax, hemothorax ^[7]
• Thoracic outlet syndrome

We list the most important complications. The selection is not exhaustive.