Fractures of the Clavicle

Ovid: Manual of Orthopaedics

Editors: Swiontkowski, Marc F.; Stovitz, Steven D.
Title: Manual of Orthopaedics, 6th Edition
> Table of Contents > 13 – Fractures of the Clavicle

Fractures of the Clavicle
I. General Information
  • Anatomy and mechanism.
    The clavicle, otherwise known as the collarbone, is the main stabilizer
    between the axial (via the sternoclavicular joint) and the appendicular
    (via the acromioclavicular joint) skeleton. Any force absorbed by the
    upper extremity transmits to the thorax through the clavicle. This
    fact, in addition to its superficial location, explains why it is
    vulnerable to injury. In fact, it has been estimated to be the most
    commonly fractured bone (1,2).
    Most frequently, clavicle fractures result from a blow
    to the shoulder region such as during a fall to the turf, though they
    also may result from a direct hit to the collarbone. These fractures
    are most commonly seen in children and young adults (1),
    although they are diagnosed with increasing frequency in later decades
    where more active lifestyles are taking place in the context of
    epidemic osteoporosis.
  • Classification.
    Allman classified these fractures according to whether they were
    proximal, middle, or distal one third injuries and noted that the
    middle one-third fracture was by far the most common (3).
    The distal one-third clavicle fracture should be distinguished further
    as to whether it is intraarticular or extraarticular and whether or not
    it is displaced, which would imply disruption of the coracoclavicular
    ligaments (4).
II. Diagnosis
  • History and physical exam.
    Pain and deformity localized to the clavicle provide the most typical
    presentation. Frequently, ecchymosis and tenting of the skin are
    recognized. The typical deformity in the common middle third fracture
    is caused by the proximal (medial) fragment bone spike being pulled by
    the sternocleidomastoid muscle, which inserts on the proximal clavicle.
    The deformity is accentuated by the weight of gravity on the upper
    extremity pulling downward on the distal (lateral) fragment.
    Physical exam will frequently detect bony crepitance and
    should include inspection of the skin for punctures or lacerations
    consistent with an open fracture. As the clavicle is directly anterior
    to the brachial plexus and the subclavian artery, exam should also
    include neurovascular assessment, particularly in injuries associated
    with high-energy mechanisms.
  • Radiographs.
    A standard anteroposterior view of the clavicle usually confirms the
    diagnosis of a fracture. Comminution and displacement should be
    described. The degree of overriding of the fracture fragments should be
    noted as well since impaction forces to the lateral forequarter can
    cause medialization of the shoulder. This is an important variable in
    deciding on treatment. Oftentimes, in the setting of polytrauma, a
    chest x-ray provides the initial radiographic diagnosis. Surrounding
    structures such as the scapula and ribs should be inspected for injury
    as well.
III. Treatment
  • Nonoperative.
    The vast majority of clavicle fractures should be treated
    nonoperativley. Extraarticular fractures displaced less than 1 cm are
    treated with a simple sling or sling-and-swathe immobilizer for
    comfort. A figure-of-8 strap may be used to maintain the shoulder in a
    retracted position to theoretically improve alignment. This technique
    may be most useful for children, in which case care must be


    not to snug it too tightly, which can compromise skin and compress the
    brachial plexus. Studies do not seem to suggest, however, that there is
    any difference in shoulder function, range of motion, or residual
    deformity between the use of a sling or a figure-of-8 strap (5).

    Intraarticular distal clavicle fractures most often also
    warrant nonoperative treatment if the coracoclavicular ligaments are
    intact and there is not much displacement of the proximal clavicular
    shaft. In the case of intraarticular clavicle fractures, the patient
    should be warned of the possibility of arthritic symptoms if there is
    stepoff or comminution at the acromioclavicular joint. This outcome can
    be treated on a delayed basis with distal clavicle resection. In
    children, a couple of weeks of relative immobilization is all it takes
    before calus begins to provide the splinting necessary for healing of
    the bone ends. In adults, a month of such immobilization will provide
    the same relief.
  • Operative. There are several indications for operative management of clavicle fractures.
    • The clearest indication is the case of an
      open fracture which requires irrigation, debridement, and
      stabilization. The most common form of internal fixation is with plate
      and screws.
    • Fractures lateral to the coracoid may be
      associated with torn coracoclavicular ligaments, in which case the
      shaft of the clavicle tends to displace proximally. This injury variant
      is associated with a higher rate of nonunion. Conservative management
      should be discussed with the patient and placed in the context of the
      patient’s activity level, hand dominance, age, and co-morbidities. If
      this lateral fracture variant is displaced more than 1 cm, strong
      consideration should be given to openly reduce and fix the fracture. A
      method similar to fixation of an acromioclavicular dislocation as
      described in Chap. 14 should be used.
    • Another relative indication for surgery
      is medialization more than 2 cm as determined by the amount of
      overriding of the clavicle shaft fragments. McKee et al. documented
      poorer performance on endurance testing, as well as on a validated
      outcome test, in patients with more than 2 cm of shortening (6) and showed that malunions of this type can improve function and strength with operative correction (7).
    • If the neck of the scapula (glenoid) is
      fractured along with the clavicle, this is also a relative indication
      for surgery. In such a circumstance, a displaced clavicle fracture
      should be fixed to stabilize the “floating shoulder.” This injury
      complex implies that the glenohumeral joint has no support and is one
      type of a double disruption of the superior shoulder suspensory complex
      (8). Other authors have suggested the
      alternative of scapula fixation in that setting instead, and yet others
      have advocated fixation of both injuries (9).
  • Follow-up.
    Patients should be followed up in the office at 2 and 4 weeks after the
    injury to check radiographs to make sure that further displacment has
    not occurred. They need reassurance that discomfort, crepitance, and
    deformity are expected during this phase of healing. After this
    juncture, passive and gentle active range of motion should be
    encouraged, as well as light lifting, guided by the patient’s symptoms.
    Most often, good function has been restored by 3 months post injury, at
    which time restrictions can usually be lifted. Radiographic healing
    should be nearly complete by this juncture but can take months,
    particularly in the elderly.
  • Complications.
    Patients should be counseled from the beginning that they should
    anticipate a lump in the region of the fracture if treated
    nonoperatively. Reported nonunion rates are in the range of 0.1% to
    0.8% (2,6,10), though certain risk factors such as displaced distal fractures and clavicle fractures in the elderly have been identified (10).


1. Robinson CM, Cairns DA. Primary nonoperative treatment of displaced lateral fractures of the clavicle. J Bone Joint Surg (Am) 2004;86:778–782.
2. Wilkins RM, Johnston RM. Ununited fractures of the clavicle. J Bone Joint Surg. (Am) 1983;65:773–778.
3. Allman FL. Fractures and ligamentous injuries of the clavicle and its articulation. J Bone Joint Surg (Am) 1967;9A:774–784.
4. Robinson CM. Fractures of the clavicle in the adult: epidemiology and classification. J Bone Joint Surg (Br) 1988;70:461–464.
5. Andersen K, Jensen PO, Lauritzen J. Treatment of clavicular fractures figure-of-eight bandage versus a simple sling. Acta Orthop Scand 1987;57:71–75.
6. McKee
MD, Pederson EM, Wild LM, et al. Previously unrecognized deficits after
nonoperative treatment of displaced midshaft fracture of the clavicle
detected by patient based outcome measures and objective muscle
strength testing. Conference Proceedings, Defining Indications for New
Techniques in Fracture Fixation, OTA Specialty Day, San Fransisco, CA
7. McKee MD, Wild LM, Schemitsch EH. Midshaft malunions of the clavicle. J Bone Joint Surg (Am) 2003;85A:790–797.
8. Goss TP. Double disruptions of the superior shoulder suspensory complex. J Orthop Trauma 1993;7:99–106.
9. Lenny KS, Lam TP. Open reduction and internal fixation of ipsilateral fractures of the scapular neck and clavicle. J Bone Joint Surg (Am) 1993;75:1015–1018.
10. Robinson,
CM, Court-Brown CM, McQueen MM. Estimation of the risk of nonunion
after a fracture of the clavicle. Paper Presented at: Defining
Indications for New Techniques in Fracture Fixation, OTA Specialty Day,
San Fransisco, CA, 2003.
Selected Historical Readings
Allman FL. Fractures and ligamentous injuries of the clavicle and its articulation. J Bone Joint Surg (Am) 1967;49:774–784.
Neer CS. Fractures of the distal third of the clavicle. Clin Orthop 1968;58:43–50.
Neer CS. Nonunion of the clavicle. JAMA 1960;172:1006–1011.
Rowe CR. An atlas of anatomy and treatment of midclavicular fractures. Clin Orthop 1968;58:29–42.

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