High Yield Topics

Clavicle Fractures

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Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.
Title: 5-Minute Orthopaedic Consult, 2nd Edition
> Table of Contents > Clavicle Fractures

Clavicle Fractures
Henry Boateng MD
James W. Wenz Sr MD
Basics
Description
  • The clavicle serves as the primary bony connection between the thorax and upper limb.
  • A fracture of the clavicle also is known as a “broken collarbone.”
  • Classification:
    • By location in the clavicle: proximal, middle, or distal 1/3 (1)
  • Fracture displacement and comminution are important factors.
  • Clavicle fractures from high-energy
    trauma may be associated with ipsilateral scapula fractures and
    represent an unstable “floating shoulder.”
General Prevention
Avoidance of direct trauma to shoulder
Epidemiology
  • Distribution is trimodal:
    • Injury occurs in newborns secondary to birth trauma.
    • Fractures in adolescents and young adults is secondary to trauma.
    • Elderly patients sustain fractures secondary to osteoporosis and falls.
Incidence
  • 1 of the most common fractures (2,3)
    • 5% involve the proximal 1/3 of the clavicle.
    • 70% the middle 1/3
    • 25% the distal 1/3
Risk Factors
  • Male gender
  • Contact sports
  • Large birth size (<4 kg) and older maternal age among newborns (4)
  • High-energy trauma
  • Falls among the elderly
Etiology
  • Primarily direct trauma to shoulder girdle
  • In the adult, clavicle fractures
    typically result from sports or motor vehicle accidents and are caused
    by a direct blow to the shoulder.
  • Clavicle fractures also can result from
    severe chest injuries with lung trauma or a dissociation of the
    shoulder complex from the rib cage.
  • In the infant, these injuries frequently are related to difficult deliveries and can occur with brachial plexus palsy.
Associated Conditions
  • Subclavian vascular injury
  • Brachial plexus injury
  • Scapular fractures
  • Shoulder fracture or dislocation
  • Lung or rib injury
  • Floating shoulder
  • Ligamentous injury and disruption
Diagnosis
Signs and Symptoms
History
The patient has a history of shoulder trauma, high-energy trauma, or a difficult birth.
Physical Exam
  • Pain over the shoulder or clavicle
  • Pain in ROM of the shoulder
  • Deformity and swelling over the clavicle
  • In children, refusal to move the extremity
Tests
Imaging
  • If vascular injury is considered, obtain an arteriogram.
  • Order a standard AP view of the clavicle and a view with the beam tilted 45° cephalad.
  • If a shoulder disorder is suspected, then specific shoulder views, including an axillary view, are needed.
  • If posterior displacement of proximal 1/3 fractures is suspected, obtain a CT scan.
Pathological Findings
  • This fracture typically occurs in the middle 1/3 of the clavicle because of the bone’s biomechanics and structure.
  • The middle 1/3 of the clavicle
    experiences the largest bending moment with applied load to the
    shoulder and has the smallest cross-sectional area.
Differential Diagnosis
  • Clavicle fractures can be associated with other injuries, including pneumothorax, rib fractures, and humerus fractures.
  • Posterior fracture displacement of medial fractures
  • Shoulder–proximal humerus fracture or dislocation
  • AC separation (tearing of the ligaments without fracture)
  • AC joint arthrosis
  • Rotator cuff disorders
  • Pneumothorax or hemothorax
  • Injury to the brachial plexus
  • Injury to the great vessels
  • Head injury
  • Scapulothoracic dissociation
  • Floating shoulder (fracture of the clavicle and scapula)
Treatment
Initial Stabilization
  • Analgesics and sling immobilization
  • Physical therapy for early ROM of the shoulder (Codman exercise)
  • Most of these injuries can be managed nonoperatively.
  • Most clavicle fractures do not require reduction maneuvers.
  • Immobilization for 1 week in a sling and then gentle ROM of the shoulder are treatments of choice for most of these fractures.
  • The patient should be referred to an orthopaedic surgeon if any question about treatment arises.
  • Midclavicular fractures without large displacements or shortening can be treated with a sling.
  • Posterior medial clavicle fractures must be evaluated for the possibility of airway compromise or concurrent injury.
    • May need immediate reduction by an orthopaedic surgeon.
  • Because the medial growth physis does not
    close for the clavicle until the patient is ~21 years old, medial
    fractures in the young adult are typically Salter-Harris type II
    fractures and eventually remodel (5).
Activity
  • The shoulder should be immobilized until comfortable, and then increasing ROM exercises should begin.
  • Until tenderness resolves, limit lifting or overhead work.
Nursing
  • With any shoulder injury, care should be taken that appropriate personal care of the armpit is taken.
    • Because of pain with abducting the shoulder, this area may be difficult to keep clean.

P.75


Special Therapy
Physical Therapy
  • Codman exercises should be instituted
    early in the course, using a pendulum-type movement of the shoulder
    with the trunk bent and supported.
  • Passive ROM to the overhead position increases as the pain diminishes in several weeks.
  • Strengthening exercises are used when pain resolves.
Medication (Drugs)
  • Analgesics should be prescribed as appropriate to the level of pain experienced.
  • Narcotics may be required for pain relief.
Surgery
  • Surgery may be needed for:
    • Displaced fractures in patients who are highly active or have jobs with overhead activity:
      • These patients may be unsatisfied with the deformity that will result from nonoperative treatment (6).
    • Comminuted or displaced midshaft fractures
    • Displaced fractures of the lateral 1/5 of the clavicle: Controversy exists as to the effectiveness of surgery (3)
    • Open fractures over the clavicle
    • Substantially displaced fractures with skin tenting
    • Nonunion of previous fractures
    • Floating shoulder
  • The exact determinants for surgical intervention and the type of surgery are controversial (7).
  • The most common treatment is open reduction and internal fixation with a plate and screws.
    • The plate may be placed superiorly, anteriorly, or anteroinferiorly.
    • Hardware irritation is common after surgery, requiring plate removal.
  • Pin fixation is a less invasive alternative.
    • Threaded screws or titanium flexible nails may be used.
    • A serious complication of pin fixation is migration of the pin into the intrathoracic region.
    • Usually the pin must be removed after fracture healing.
Prognosis
  • The prognosis is good for patients with minimally displaced fractures.
  • Patients with displaced fractures develop a generally asymptomatic deformity from the fracture.
  • Functional deficits are unusual but can occur with markedly displaced fractures.
  • Return to full function should occur by 6–12 weeks.
  • If the fracture has caused shortening or
    if a displaced distal clavicle fracture is present, problems with AC
    arthrosis or function may occur.
Complications
  • Skin breakdown over the fracture site
  • Nonunion or malunion (may require future procedures to realign the bone and permit healing)
  • Vascular injury
  • Nerve injury
  • Pneumothorax
  • Residual pain
Patient Monitoring
  • Order serial radiographs at intervals of 3–4 weeks to monitor healing.
  • Assess the skin carefully to ensure that it has not been compromised.
  • Evaluate nerve and vascular function acutely and at follow-up intervals.
References
1. Robinson CM. Fractures of the clavicle in the adult. Epidemiology and classification. J Bone Joint Surg 1998;80B:476–484.
2. Robinson
CM, Court-Brown CM, McQueen MM, et al. Estimating the risk of nonunion
following nonoperative treatment of a clavicular fracture. J Bone Joint Surg 2004;86A:1359–1365.
3. Robinson CM, Cairns DA. Primary nonoperative treatment of displaced lateral fractures of the clavicle. J Bone Joint Surg 2004;86A:778–782.
4. Beall MH, Ross MG. Clavicle fracture in labor: risk factors and associated morbidities. J Perinatol 2001;21:513–515.
5. Salter RB, Harris WR. Injuries involving the epiphyseal plate. J Bone Joint Surg 1963;45A:587–622.
6. Nowak J, Holgersson M, Larsson S. Sequelae from clavicular fractures are common: a prospective study of 222 patients. Acta Orthop 2005;76: 496–502.
7. Zlowodzki
M, Zelle BA, Cole PA, et al. Treatment of acute midshaft clavicle
fractures: systematic review of 2144 fractures: on behalf of the
Evidence-Based Orthopaedic Trauma Working Group. J Orthop Trauma 2005;19:504–507.
Additional Reading
Schmidt AH. Shoulder trauma. In: Baumgaertner MR, Tornetta P, III, eds. Orthopaedic Knowledge Update: Trauma 3. Rosemont, IL: American Academy of Orthopaedic Surgeons, 2005:151–161.
Miscellaneous
Codes
ICD9-CM
  • 767.2 Clavicle fracture due to birth trauma
  • 810.00 Interligamentous part clavicle fracture
  • 810.01 Sternal end clavicle fracture
  • 810.02 Mid shaft clavicle fracture
  • 810.03 Acromial end clavicle fracture
Patient Teaching
  • The physician should stress that residual bony deformity may occur after closed treatment.
  • Functional limitation is unusual but may occur.
Activity
Patients generally begin immediate pendulum exercises and gradually progress with ROM as tolerated.
FAQ
Q: How long does recovery take?
A: The average recovery is 4 months after injury. Some patients require >6 months to recover fully.

Q: What factor increases the risk of late deformity or pain?
A: The amount of initial displacement corresponds best to ultimate outcome of closed treatment.

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