Fracture, Clavicle

By admin On Dec 5, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Fracture, Clavicle

Christopher C. Trigger

Tanya J. Hagen

Basics

The clavicle is a subcutaneous S-shaped bone.
1st bone to ossify in the human body (5th wk of gestation)
Functionally acts as a strut that connects the shoulder girdle to the axial skeleton

Description

Allman classification based on fracture site (1,2)
Craig further subdivided group II and III fractures:
- Group I: Fracture of the middle third
- Group II: Fracture of the lateral (distal) third:
  - Type I: Lateral to coracoclavicular (CC) ligament (typically nondisplaced)
  - Type II: Medial to the CC ligaments; causes superior displacement of the medial fragment relative to the lateral fragment
  - Type III: Fracture extends into the acromioclavicular (AC) joint.
  - Type IV: Proximal fragment displacement out of periosteal tube (only in children)
  - Type V: Comminuted where CC ligaments remain attached to an inferior bone fragment only
- Group III: Fracture of the medial (proximal) third:
  - Type I: Nondisplaced
  - Type II: Displaced with ligamentous rupture
  - Type III: Fractures extend into the sternoclavicular (SC) joint.
  - Type IV: Fracture causes epiphyseal separation (children and adolescents).
  - Type V: Comminuted

Epidemiology

Incidence

Most commonly fractured bone in children and adolescents
Bimodal age distribution with peaks in children/adolescents and the elderly
Predominant gender: Male > Female (2.5:1)
80% are group I; 15% group II; 5% group III.

Risk Factors

Direct trauma and fall onto the shoulder are the most common mechanisms of injury.
Highest-risk sports in the U.S. are football, lacrosse, and hockey.

Commonly Associated Conditions

AC joint injury
Labral tears
Rotator cuff injuries
Proximal humeral fractures
Rib fractures
Pneumothorax/hemothorax
SC joint dislocation
Brachial plexus, vascular injuries (uncommon)

Diagnosis

Diagnosis is easily made by history, physical exam, and appropriate imaging.

History

Direct trauma or a fall
Middle-third fractures are frequently seen with fall on an outstretched arm.
Distal-third fractures most often are associated with loads transmitted to the lateral aspect of the shoulder.

Physical Exam

With or without ecchymosis or tenting of the skin over the fracture
Tenderness to palpation at fracture site
Pressure along the clavicle may reveal fracture motion or crepitus.
Careful pulmonary and neurovascular exam must be performed to identify possible associated injury.

Diagnostic Tests & Interpretation

Imaging

Radiographs:
- An anteroposterior (AP) view of the clavicle including the AC and SC joints and the shoulder girdle
- A 30–45-degree cephalic-tilt (Zanca) view is recommended to delineate displacement and comminution in all fracture types.
- A 40-degree cephalic-tilt view of the SC joint (serendipity view) can rule out SC dislocations.
- An axillary view can be useful in distal clavicle fractures.
CT scan:
- Articular fractures of the medial or lateral clavicle may require a CT scan.
- A CT angiogram or standard angriogram can be used if distal vascular deficit is suspected (1,2).

Diagnostic Procedures/Surgery

Special considerations: The proximal clavicular epiphysis is the last growth plate in the body to fuse (approximately age 20 yrs). Therefore, many injures involving the SC joint in athletes probably are physeal injuries and should be evaluated by thin-cut CT scan.

Differential Diagnosis

AC joint injury
Glenohumeral dislocation
Rotator cuff contusion/tear
Labral injury
Rib fracture
Humeral head fracture
SC joint injury

P.179

Treatment

The primary goal in treating clavicular fractures is to obtain bony union and restore shoulder function to preinjury level with little or no residual pain, dysfunction, or cosmetic deformity (2,3,4).
Most fractures can be treated nonoperatively (80–90%).
Most clavicle fractures (when treated nonsurgically) will heal clinically in 3–6 wks; radiographic healing usually takes longer.
Arm sling and sling-and-swathe are the most common forms of immobilization (2,3,4)[B].
Figure-of-eight harness is used less frequently because of discomfort, noncompliance, and worse complication rates.
Range of motion (ROM) and active shoulder flexion (up to 40°) as well as isometric deltoid and rotator cuff strengthening can begin once pain is improved.
Avoid ROM >45° of forward flexion until clinical evidence of healing is seen.
As union progresses, increase ROM and resistive exercises.
When radiographic union is present, full active use of the arm is allowed.

Surgery/Other Procedures

Surgery is rarely required.
Indications for early operative treatment include (1,2,3):
- Displaced or shortened (>1.5 cm) and comminuted middle-third fractures of the clavicle
- Type II distal clavicle fractures are typically managed surgically owing to the high rate of nonunion; also, operative treatment is recommended in type IV and V fractures.
- Neurovascular compromise
- Any open fractures
- Tenting of skin over an irreducible fracture
- Concomitant glenoid neck fracture, also known as floating shoulder
- Posterior fracture dislocations of the medial clavicle should be reduced in the presence of a thoracic surgeon owing to risk of vascular injury.
Surgical techniques used include open reduction with rigid fixation (ORIF) with plates and screws or intramedullary fixation.
Primary operative fixation is becoming much more common in healthy, young athletes, as well as professional athletes with a goal of possibly expediting return to play.
Secondary operative treatment is considered for
- Persistent (>6 wks) displacement and shortening despite immobilization
- Malunion

Ongoing Care

Follow-up should be scheduled 1–2 wks after injury to assess clinical symptoms and then every 2–4 wks until clinical and radiographic union occur (2).
Radiographic union progresses more slowly than clinical union.
Radiographs should be performed at intervals of 4–6 wks to assess healing.
A final radiograph to assess callus formation and clinical union can be useful.
Athletes should not be allowed to return to play until the fracture is clinically and radiographically healed (typically 6–8 wks) (2,4)[C].
Noncontact and throwing athletes should have full, painless ROM and at least 90% strength compared with the uninjured arm (usually requires ∼6 wks).
Return to contact/collision sports may take up to 8–12 wks.

Complications

Posttraumatic arthritis
Nonunion:
- Degree of displacement and comminution most important factors
- More common in women and the elderly
- Recent studies show a 2% rate of nonunion in patients managed surgically and a 4.5% rate of nonunion in nonoperative patients.
- Historically, 0.1–1% of nonunions occurred for nonoperative treatment and 3.5–5% for operative treatment. Improved surgical technique and better reporting presumably are the reasons for the change.
Malunion resulting in angulation, shortening, and a poor cosmetic appearance
Neurovascular injury (uncommon): Medial branch (ulnar nerve) of the brachial plexus most commonly affected

References

1. Kim W, McKee MD. Management of acute clavicle fractures. Orthop Clin North Am. 2008;39:491–505, vii.

2. Pujalte GG, Housner JA. Management of clavicle fractures. Curr Sports Med Rep. 2008;7:275–280.

3. Jeray KJ. Acute midshaft clavicular fracture. J Am Acad Orthop Surg. 2007;15:239–248.

4. Pecci M, Kreher JB. Clavicle fractures. Am Fam Physician. 2008;77:65–70.

Additional Reading

Smekal V, Oberladstaetter J, Struve P, et al. Shaft fractures of the clavicle: current concepts. Arch Orthop Trauma Surg. 2008.

Codes

ICD9

810.00 Closed fracture of clavicle, unspecified part
810.01 Closed fracture of sternal end of clavicle
810.02 Closed fracture of shaft of clavicle