Clavicle fractures are common injuries, occurring most often in children and young adults. Treatment is determined largely by the location of the fracture and the degree of displacement. Many clavicle fractures lend themselves to management by primary care physicians. However, it is important to note that recently published studies have led to significant changes in treatment recommendations. Fractures of the scapula occur infrequently, accounting for fewer than 1% of all fractures. This low incidence may be attributable to the protective effects of the surrounding shoulder girdle muscles as well as the scapula’s thickened edges and great mobility.
Clavicle Fractures
Clavicle fractures account for approximately 2% of all fractures and 5% of fractures seen by family physicians. Most clavicle fractures (69%) occur in the middle third of the bone, 28% involve the distal third, and 3% involve the proximal third. Diagnostic and treatment considerations vary depending on which third is fractured. Hence, discussions of clavicle fractures are typically divided into middle third, distal third, and proximal third fractures.
Anatomic Considerations
The clavicle is the only bony connection between the shoulder girdle and trunk. It acts to maintain width between the shoulders and provides some protection for the brachial plexus and great vessels. The clavicle forms an S-shaped curve—convex anterior in the proximal half and concave anterior in the distal half. The junction between these two curves is the thinnest portion of the bone and is untethered to ligamentous structures, which may explain why fractures are more common in this location. The acromioclavicular (AC) and coracoclavicular ligaments bind the clavicle to the scapula and contribute to the stability of the shoulder joint. The sternoclavicular ligaments firmly attach the clavicle to the chest. The sternocleidomastoid muscle attaches to the proximal segment of the clavicle and causes upward displacement of this portion of the bone when it is fractured. The soft tissues overlying the clavicle are quite thin. As a result, fracture hematomas and displacement are often easily seen on inspection. Open fractures of the clavicle are uncommon. However, because of the short distance between bone and skin, displaced fractures may cause tenting of the skin (taught stretching over a displaced bone end). Tenting should be addressed at the time of diagnosis to prevent skin necrosis and conversion to an open fracture.
Mechanism of Injury
Most clavicle fractures (87%) are caused by a fall onto the shoulder. Other causes include a direct blow to the clavicle (7%) and indirect trauma from falls onto an outstretched hand (6%). There is no correlation between the mechanism of injury and the site of fracture (i.e., which third is involved).
Fractures of the Middle Third of the Clavicle
Clinical Presentation
The patient with a fracture of the middle third of the clavicle usually complains of pain with any movement of the shoulder and holds the arm against the chest to protect against motion. The diagnosis of fracture is generally straightforward. A bulge is often visible at the fracture site either because of fracture hematoma or bone displacement. If displacement and shortening are present, downward and inward deformity of the shoulder is usually obvious. During examination, point tenderness over the fracture site is apparent. Crepitus or palpable motion of the fracture fragments is common given the subcutaneous position of the clavicle. Ecchymosis over the fracture or tenting of the skin may occur if the fragments are displaced. Pneumothorax, hemothorax, and neurovascular injury associated with clavicle fractures have been reported. These injuries are uncommon and are more likely to occur with fractures resulting from high-energy forces.
Imaging
An anteroposterior (AP) view is usually the only radiograph required to accurately diagnose a midshaft fracture. If the diagnosis is in question, a 45-degree cephalic tilt view can uncover the fracture ( Figure 9-1 ). In displaced fractures, the strong pull of the sternocleidomastoid muscle results in upward displacement of the medial portion of the clavicle. The lateral fragment is usually displaced downward by the weight of the arm. These features are demonstrated radiographically and schematically in Figures 9-2 and 9-3 . Comminution is frequently seen in middle third fractures ( Figure 9-2 ).
Indications for Orthopedic Referral
Emergent Referral (Within 30 to 60 Minutes)
Neurovascular compromise, open fracture, and tenting of the skin are indications for emergent referral.
Nonemergent Referral (Within A Few Days of Injury)
Historically, it was widely believed that these fractures almost always healed well, even if displaced. However, studies have shown that when complete displacement is present (i.e., displacement greater than one bone width; see Figure 9-2 ), conservative treatment produced unsatisfactory outcomes in more than 30% of patients. It is unclear whether surgery provides better outcomes. Some meta-analyses suggest that surgery is superior to sling immobilization, while others do not. Referral should therefore be considered for all patients with complete displacement, especially if there is comminution or significant shortening (>18 mm in men or >14 mm in women) because these factors are associated with even worse outcomes. Surgery may also be more appealing if the patient is an athlete or is concerned about the prospect of a permanent visible lump at the fracture site, which is a common outcome. Surgery carries a risk of complications, including wound infections and hardware failure, and the benefits of surgery must be weighed against these risks. For patients who are poor operative risks or prefer to avoid surgery, conservative treatment (described below) is a very reasonable alternative. Referral is also indicated for malunion and nonunion that is symptomatic. Asymptomatic malunion and nonunion do not require treatment. If a glenoid neck fracture is present on the same side as the clavicle fracture (“floating shoulder”), referral is also indicated. This is an unstable injury and surgery appears to be the best treatment option.
Initial Treatment
Table 9-1 summarizes management guidelines for middle third clavicle fractures.
| initial treatment | |
| Splint type and position | Figure-of-eight clavicle strap with shoulders in “position of attention” or arm sling |
| Sling preferable for nondisplaced fractures or plastic bowing in children | |
| Initial follow-up visit | 1 to 2 weeks to assess pain level and healing |
| Patient instruction | If using figure-of-eight, keep strap tight to hold shoulders in position |
| follow – up care | |
| Cast or splint type and position | Figure-of-eight clavicle strap or arm sling |
| Length of immobilization | 4 to 8 weeks or until fracture site is nontender |
| 3 to 6 weeks in children | |
| Healing time | 6 to 12 weeks in adults |
| 3 to 6 weeks in children | |
| Follow-up visit interval | Every 2 to 3 weeks |
| Repeat radiography interval | At 6 weeks to assess callus and when clinical healing achieved |
| Patient instruction | Use of the arm as pain permits |
| Avoid contact sports or activities with potential for falling for 1 to 2 months after clinical and radiographic healing | |
| Bony deformity possible | |
| Indications for orthopedic consult | Tenting of skin |
| Open fracture | |
| Consider referral for all patients with displacement greater than one bone width, especially if comminution or significant shortening is present or if the patient is concerned about cosmetic result | |
| Symptomatic malunion and nonunion (after 12 weeks) |
The goal of conservative treatment for midshaft fractures is reduction of motion at the fracture site. The fracture site is best stabilized by restricting shoulder motion to less than 30 degrees of abduction, forward flexion, or extension. This can be achieved with a sling or a figure-of-eight bandage that keeps the shoulders back (“position of attention”) ( Figure 9-4 ). Treatment outcomes are nearly identical for the figure-of-eight bandage and sling support. Figure-of-eight treatment has the advantage of leaving the elbow and hand free for daily activities, but it is more uncomfortable than a sling. It is not a good choice for patients who live alone because the bandage must be tightened regularly to maintain tension, and this requires assistance. Figure-of-eight treatment has the potential to minimize displacement and may be the preferred option for nonoperative treatment of completely displaced fractures, especially if shortening is present. An arm sling can be used with a figure-of-eight bandage for additional comfort and support.
Follow-up Care
Immobilization in the figure-of-eight bandage or arm sling should be continued until crepitus resolves and tenderness at the fracture site is minimal or absent. Follow-up visits should occur 1 to 2 weeks after injury to assess clinical symptoms and then every 2 to 3 weeks until the patient is asymptomatic. Clinical union has occurred when the fracture site is painless and the patient can move the arm fully without discomfort. Radiographic union progresses more slowly than clinical union and may not be present for 12 weeks. The usual healing time for this fracture is 3 to 6 weeks in children and 6 to 12 weeks in adults. Repeat radiographs of these fractures are not necessary at each return visit, but a final radiograph when clinical union is achieved is helpful to assess callus formation. During the period of immobilization, the patient may use the extremity as symptoms allow, but strenuous activities should be avoided. Patients who have sling immobilization should be instructed to perform elbow range of motion (ROM) exercises to maintain normal function. After immobilization, shoulder ROM and strengthening exercises speed recovery. Within several weeks, a visible “bump” (healing callus) may occur at the fracture site. This usually completely remodels and disappears in children but persists to some extent in adults because of relatively less remodeling. In adults, a permanent visible prominence over the fracture site is common, and they should be apprised of this likely outcome.
Return to Work or Sports
Return to work or sport activity can progress steadily as permitted by the patient’s comfort level. Most patients are back to pre-injury levels of activity within 6 to 8 weeks. Those with occupations requiring heavy lifting, pushing or pulling, or overhead activity may need an additional 2 to 3 weeks to regain adequate strength for these tasks. Patients should refrain from contact sports or activities that put them at risk of falling for 8 to 10 weeks after the injury.
Complications
Serious complications resulting from fractures of the middle third of the clavicle, such as pulmonary, arterial, or nerve injury, are rare. Malunion resulting in angulation, shortening, and a poor cosmetic result is the most common complication. Malunion may lead to ongoing tenderness and reduction in shoulder function. Nonunion occurs less frequently. Predisposing factors include marked displacement, severe trauma, fracture comminution, and inadequate immobilization. A late complication associated with nonunion is brachial plexus compression neuropathy resulting from hypertrophic callus formation. The onset of symptoms of this condition may be early or quite late. Ulnar or median nerve symptoms are the most common.
Pediatric Considerations
Middle third clavicle fractures in children and adolescents are treated the same as in the adult patient. In the younger child, plastic bowing of the clavicle may occur, and these injuries should be treated just like other fractures to prevent an overt fracture. The healing time is much shorter than in adults, with most children back to full activity within 4 weeks after injury. Protection from contact or collision sports is advisable for an additional 2 to 3 weeks after adequate clinical and radiographic healing.
Birth Injuries
The clavicle may be fractured during childbirth trauma. These fractures usually involve the midshaft. Clavicle fractures in the newborn period are easily detected if the physician has a heightened awareness of the possibility of this lesion after difficult deliveries, especially those complicated by shoulder dystocia. Palpation of the clavicles should be part of every newborn examination. An infant with a clavicle fracture has decreased use of the arm on the injured side and reacts with pain to movement of the arm. Manipulation of the clavicle usually produces crepitus or palpable motion at the fracture site. Little treatment is needed for clavicle fractures in newborns because they almost always heal well within 2 weeks. Avoiding pressure on the clavicle and minimizing movement of the affected arm during feeding, dressing, and handling ensure greater comfort for the infant. Pinning the sleeve of the affected side to the chest with the elbow at 90 degrees is another treatment option. After symptoms resolve, the infant will begin to use the arm normally.
Fractures of the Distal Third of the Clavicle
Clinical Presentation
Fractures of the distal clavicle often produce no deformity and can easily be overlooked. These fractures can be difficult to distinguish from an AC separation. During examination, tenderness is apparent over the AC joint and in surrounding tissues. Pain increases with adduction of the arm across the chest. Ecchymosis and swelling over the AC joint may occur.
Imaging
Fractures of the distal third of the clavicle are classified into three types ( Figure 9-5 ). In type I fractures, which are the most common, the supporting ligaments remain intact, and no significant displacement of the fracture fragments occurs ( Figure 9-6 ). In type II distal fractures, a tear of the coracoclavicular ligament results in upward displacement of the proximal fragment ( Figure 9-7 ). Type II fractures are particularly difficult to diagnose on standard clavicle views. Anterior and posterior 45-degree oblique views or a stress view of both shoulders with a 10-lb weight strapped to each wrist more clearly demonstrates the extent of separation of the fracture fragments. Type III fractures are intraarticular fractures through the AC joint. These fractures may be subtle and overlooked initially because there is often no displacement.
