Table Of Contents
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
- Birth fracture
- 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
- Sling or shoulder immobilization
- 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
