Clavicle Fracture

The clavicle is a long, curved bone that forms part of the shoulder girdle. It has a sternal end (rounded) and an acromial end (flat). Fractures commonly occur in the middle third of the clavicle, which is the thinnest part. They are common in children. Treatment is usually non-operative.

Accounts for 15% of paediatric upper extremity injuries.

Allman classification (divides the clavicle into thirds which correlates with mechanism, rate of complication and standards of treatment)

Classification	Location	Description
Group I (80%)	Middle third	Good prognosis with non-operative treatment
Group II (15%)	Lateral third (distal to coracoaclavicular ligaments)	More common in older osteoporotic patients. Higher rate of non-union due to pull of coracoclavicular ligaments
Group III (5%)	Medial third	Related to high-energy trauma.

Neer classification can be used to further classify the fractures

Mechanism of injury
- Birth fracture
  - Normal delivery (0.5%)
  - Breech delivery (1.6%)
- Traumatic fracture
  - Direct blow to the lateral aspect of shoulder (clavicle)
  - Fall on outstreched arm or shoulder (FOOSH)
  - Associated with sports
Associated injury
- Brachial plexus injury
- Pneumothorax
- Closed head injury
- Ipsilateral scapular fracture (floating shoulder)
- Rib fracture
Deforming forces
- Sternocleidomastoid muscle pulls the medial fragment postero-superiorly
- Pectoralis and the weight of arm pull the lateral fragment infero-medially
Patient history
- Popping or cracking of the shoulder after fall
Symptoms
- Shoulder pain
- Swelling
- Bruising
- Obvious deformity (bump or tenting of the skin)
Physical examination
- Obvious deformity
- Tenting skin (may form an open fracture)
Investigations
- X-ray (AP view of bilateral shoudlers, 45 cephalic tilt and 45 caudal tilts): to measure shortening, superior/inferior displacement and AP displacement respectively
- Chest X-ray: evaluate for pneumothorax
- CT scan: for pre-operative planning, assess vascular injury, for medial clavicle fracture and sternoclavicular dislocation
Indications for operative treatment
- Open fracture
- Tenting of the skin
- Significant displacement
- Overlap or shortening > 2cm
Indications for non-operative treatment
- Non-displaced group I fractures
- Stable group II fractures
- Non-displaced group III fractures
- Paediatric distal clavicle fractures
Indications for operative treatment
- Displaced Group I (middle third) with > 2 cm shortening
- Unstable Group II fractures
- Open fracture
- Displaced fracture with skin tenting
- Subclavian artery or vein injury
- Floating shoulder (clavicle and scapula neck fracture)
- Symptomatic non-union
- Posteriorly displaced Group III fracture
- Brachial plexus injury (controversial since 66% have spontaneous return)
- Closed head injury
- Seizure disorder
- Polytrauma patient
Non-operative treatment
- Sling or shoulder immobilization
  - Sling or figure-of-eight braces (elevates and extends the shoulder to join the distal fragment to the proximal fragment)
  - Shoulder immobilizer
- Physiotherapy
  - Return of movement exerceses at 2 – 4 weeks
  - Strengthening at 6 – 10 weeks
Operative treatment
- ORIF with plates and screws or intramedullary nail
Complications
- Supraclavicular nerve injury
- Brachial plexus injury
- Subclavian thrombosis
- Subclavian artery or vein injury
- Pneumothorax
- Non-union or malunion: rare in children. Considered if the fracture does not heal in 3 months
- Infection
- Refracture
- Anterior chest wall numbness
- Hardware prominence
- Adhesive capsulitis

Reference Intervals ›

Biochemistry

ACTH	P: <80 ng/L
ALT	P: 5–35 U/L
Albumin	P: 35–50 g/L
Aldosterone	P: 100–500 pmol/L
Alk. phosphatase	P: 30–130 U/L
α-Amylase	P: 0–180 IU/dL
α-Fetoprotein	S: <10 kU/L
Angiotensin II	P: 5–35 pmol/L
ADH	P: 0.9–4.6 pmol/L
AST	P: 5–35 U/L
Bicarbonate	P: 24–30 mmol/L
Bilirubin	P: 3–17 μmol/L
BNP	P: <50 ng/L
CRP	P: <10 mg/L
Calcitonin	P: <0.1 mcg/L
Calcium (ionized)	P: 1.0–1.25 mmol/L
Calcium (total)	P: 2.12–2.60 mmol/L
Chloride	P: 95–105 mmol/L
Cholesterol	P: <5.0 mmol/L
VLDL	P: 0.128–0.645 mmol/L
LDL	P: <2.0 mmol/L
HDL	P: 0.9–1.93 mmol/L
Cortisol AM	P: 450–700 nmol/L
Cortisol Midnight	P: 80–280 nmol/L
CK ♂	P: 25–195 U/L
CK ♀	P: 25–170 U/L
Creatinine	P: 70–100 μmol/L
Ferritin	P: 12–200 mcg/L
Folate	S: 2.1 mcg/L
FSH	P: 2–8 U/L ♂; >25 menopause
GGT ♂	P: 11–51 U/L
GGT ♀	P: 7–33 U/L
Glucose (fasting)	P: 3.5–5.5 mmol/L
Growth hormone	P: <20 mu/L
HbA1C (DCCT)	B: 4–6%
HbA1C (IFCC)	B: 20–42 mmol/mol
Iron ♂	S: 14–31 μmol/L
Iron ♀	S: 11–30 μmol/L
Lactate (venous)	P: 0.6–2.4 mmol/L
Lactate (arterial)	P: 0.6–1.8 mmol/L
LDH	P: 70–250 U/L
LH	P: 3–16 U/L
Magnesium	P: 0.75–1.05 mmol/L
Osmolality	P: 278–305 mosmol/kg
PTH	P: 0.8–8.5 pmol/L
Potassium	P: 3.5–5.3 mmol/L
Prolactin ♂	P: <450 U/L
Prolactin ♀	P: <600 U/L
PSA	P: 0–4 mcg/mL
Protein (total)	P: 60–80 g/L
Red cell folate	B: 0.36–1.44 μmol/L
Renin (erect)	P: 2.8–4.5 pmol/mL/h
Renin (recumbent)	P: 1.1–2.7 pmol/mL/h
Sodium	P: 135–145 mmol/L
TBG	P: 7–17 mg/L
TSH	P: 0.5–4.2 mU/L
T4	P: 70–140 nmol/L
Free T4	P: 9–22 pmol/L
TIBC	S: 54–75 μmol/L
Triglycerides	P: 0.50–2.3 mmol/L
T3	P: 1.2–3.0 nmol/L
Troponin T	P: <0.1 mcg/L
Urate ♂	P: 210–480 μmol/L
Urate ♀	P: 150–390 μmol/L
Urea	P: 2.5–6.7 mmol/L
Vitamin B12	S: 0.13–0.68 nmol/L
Vitamin D	S: 50 nmol/L

Arterial Blood Gases

pH	7.35–7.45
PaCO₂	4.7–6.0 kPa
PaO₂	>10.6 kPa
Base excess	±2 mmol/L

Urine

Cortisol (free)	<280 nmol/24h
Hydroxyindole acetic acid	16–73 μmol/24h
Hydroxymethylmandelic acid	16–48 μmol/24h
Metanephrines	0.03–0.69 μmol/mmol cr.
Osmolality	350–1000 mosmol/kg
17-Oxogenic steroids ♂	28–30 μmol/24h
17-Oxogenic steroids ♀	21–66 μmol/24h
17-Oxosteroids ♂	17–76 μmol/24h
17-Oxosteroids ♀	14–59 μmol/24h
Phosphate (inorganic)	15–50 mmol/24h
Potassium	14–120 mmol/24h
Protein	<150 mg/24h
Protein/creatinine ratio	<3 mg/mmol
Sodium	100–250 mmol/24h

Haematology

WCC	4.0–11.0 ×10⁹/L
RBC ♂	4.5–6.5 ×10¹²/L
RBC ♀	3.9–5.6 ×10¹²/L
Hb ♂	130–180 g/L
Hb ♀	115–160 g/L
PCV ♂	0.4–0.54 L/L
PCV ♀	0.37–0.47 L/L
MCV	76–96 fL
MCH	27–32 pg
MCHC	300–360 g/L
RDW	11.6–14.6%
Neutrophils	2.0–7.5 ×10⁹/L (40–75%)
Lymphocytes	1.0–4.5 ×10⁹/L (20–45%)
Eosinophils	0.04–0.44 ×10⁹/L (1–6%)
Basophils	0–0.10 ×10⁹/L (0–1%)
Monocytes	0.2–0.8 ×10⁹/L (2–10%)
Platelets	150–400 ×10⁹/L
Reticulocytes	0.8–2.0% / 25–100 ×10⁹/L
Prothrombin time	10–14 s
APTT	35–45 s

Paediatric

Pulse Rate (bpm)
Neonate	140–160
Infant <1yr	120–140
1–5 years	110–130
5–12 years	80–120
>12 years	70–100
Respiratory Rate (tachypnoea)
0–2 months	≥60/min
2–12 months	≥50/min
1–5 years	≥40/min
>5 years	≥30/min
Blood Pressure (mmHg)
Term	65/45
1 year	75/50
4 years	85/60
8 years	95/65
10 years	100/70
Weight Formulas
3–12 months	(a + 9)/2 kg
1–6 years	2a + 8 kg
>6 years	(7a − 5)/2 kg
Haemoglobin (g/dL)
Term newborn	13–20
1 month	11–18
2 months	10–15
1–2 years	10–13
>2 years	11–14
MUAC (6 months–5 years)
Obese	>17.5 cm
Normal	13.5–17.4 cm
At risk	12.5–13.4 cm
Moderate malnutrition	11.5–12.4 cm
Severe malnutrition	<11.5 cm
Developmental Milestones
Social smile	1.5 months
Head control	4 months
Sits unsupported	7 months
Crawls	10 months
Stands unsupported	10–12 months
Walks	12–13 months
Talks	18 months
CSF WBC (/mm³)
Term newborn	0–25
>2 weeks	0–5

Calculator ›

Clavicle Fracture

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