Shoulder

Clavicle Fracture

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Clavicle Fracture

  • Epidemiology
  1. Incidence: 2.6% of all Fractures
  2. Bimodal age distribution: Age under 25 and over 55-75 years
  • Pathophysiology
  • Mechanism of Injury
  1. Trauma
    1. Fall against top or lateral Shoulder (most common)
    2. Fall on Outstretched Hand
    3. Direct blow to clavicle
  2. No Trauma (in children)
    1. Tumor
    2. Rickets
    3. Osteogenesis imperfecta
    4. Physical Abuse
  • Symptoms
  1. Pain and swelling localized to Fracture site
  2. Patient unable to lift arm due to pain
  • Signs
  1. Presentation: Holding the affected arm adducted and supported with the opposite hand
  2. Gross clavicular deformity observed or palpated
    1. Localized swelling, Bruising, tenderness, and crepitation
  3. Observe for complications
    1. Neurovascular injury of affected arm
    2. Pneumothorax
    3. Subcutaneous Emphysema
  • Complications
  1. Pneumothorax
  2. Hemothorax
  3. Brachial Plexus Injury
  4. Subclavian artery and subclavian vein injury
  5. Fracture nonunion (1-4%)
    1. Rare, more associated with lateral Fracture (Group 2)
  • Imaging
  • XRay
  1. Standard Views
    1. Anteroposterior clavicle view
    2. Serendipity views
  2. Additional views
    1. Suspected non-displaced Fracture
      1. AP view with Cephalic tilt of 45 degrees
    2. Suspected medial Clavicle Fracture (Group 3)
      1. Zanca view with 20 degree angle
  • Classification
  • Allman Grouping
  1. Group 1: Middle third or midshaft Clavicle Fracture (75-85%)
    1. Weakest, thinnest segment of the clavicle and hence most susceptible to Fracture
    2. Overall clavicle shortening with medial segment raised and distal segment lowered
    3. Generally stable Fracture
    4. Occurs most in younger patients
  2. Group 2: Lateral third or distal Clavicle Fracture (15-25%)
    1. Unstable if displaced Fracture
    2. AC joint Osteoarthritis if articular surface involved
    3. Nonunion rates as high as 28-44% for conservative, non-surgical management
    4. Revised Neer classification
      1. Type I: Intact coracoclavicular ligaments (conoid and Trapezoid ligaments)
      2. Type 2: Coracoclavicular ligaments torn medially, only Trapezoid attached laterally
      3. Type 3: Clavicle Fracture involving the AC joint
      4. Type 4: Periosteal sleeve disruption in children (not a bony Fracture)
      5. Type 5: Ligament avulsion with with small inferior cortical fragment
  3. Group 3: Medial third or proximal Clavicle Fracture (5%)
    1. Medial Clavicle Fractures may be missed on xray
    2. Associated with multi-system Trauma
    3. Associated with neurovascular injury
    4. Associated with Sternoclavicular Dislocation
      1. Posterior dislocation is associated with serious neurovascular and pulmonary injuries
  • Management
  • Based on Allman Group
  1. Group 1 (Middle third)
    1. Conservative therapy (see below) has been the typical treatment until ~2010
      1. Most mid-Clavicle Fractures are still treated with non-surgical management
      2. However, surgical repair has become a much more common intervention
        1. Locking hardware, curved plates form fit the clavicle improved surgical outcomes
        2. Consider operative repair when displacement or overlap >2 cm
        3. Surgery is associated with lower risk of nonunion, faster return, but higher complication rate
    2. Consider operative repair in active adolescents and adults
      1. Clavicle shortening may cause chronic Shoulder Pain and dysfunction
      2. Consider a 2-4 week trial of conservative therapy prior to surgical intervention
      3. Athletes may elect for immediate repair to decrease time away from sport
    3. Consider operative repair if multiple risks for midshaft Fracture non-union
      1. Clavicle shortening >15mm to 20 mm
      2. Female gender
      3. Older age
      4. Fracture displacement or comminution
      5. More significant Traumatic injuries
      6. Skin Tenting
      7. Precaution: Surgical repair also risks non-union by interrupting vascular supply
  2. Group 2 (Lateral third)
    1. Displaced and possibly Neer Type II (unstable and risk of non-union): Surgery
    2. Nondisplaced (Neer Type I and III)
      1. Conservative therapy as with Allman Group 1 Fractures (see below)
    3. Children with Type 4 (uncommon)
      1. Typically treated as AC joint injuries
  3. Group 3 (Proximal third)
    1. Neurovascular injury: Emergent orthopedic referral
    2. Nondisplaced (typical): Conservative therapy (see below)
    3. Displaced
      1. Orthopedic referral for surgery
      2. Suggests significant Trauma and higher risk for neurovascular injury
      3. Neurovascular injury present
        1. Emergent reduction is critical
        2. Towel clip can be used to grasp clavicle and apply anterior traction
      4. No neurovascular injury
        1. CT Scan of the clavicle to visualize posterior fragments
  4. References
    1. Robinson (2004) J Bone Joint Surg Am 86:1359-65 [PubMed]
    2. Hill (1997) J Bone Joint Surg Br 79:537-9 [PubMed]
  • Management
  • Conservative therapy
  1. Sling
    1. Arm sling for comfort (typically used for first 2 weeks)
      1. Under age 12: Sling for up to 3-4 weeks
      2. Over age 12: Sling for up to 4-6 weeks
    2. Avoid figure-of-eight (no benefit, complication risk)
      1. Andersen (1987) Acta Orthop Scand 58:71-4 [PubMed]
  2. Exercises
    1. Elbow range of motion Exercises as soon as able
    2. Shoulder Range of Motion and strength Exercises
      1. Passive range of motion starting once pain allows
      2. Start as tolerated in 2-3 weeks after injury
  3. Return to Play criteria
    1. Full and painless Shoulder Range of Motion with normal Shoulder strength
    2. Bony healing by exam and imaging
    3. Timing
      1. Non-Contact Sports: 6 weeks after injury
      2. Contact Sports: 8-16 weeks after injury
  4. References
    1. Stanley (1988) Injury 19:162-4 [PubMed]
  • Course
  1. Adult: Clavicle Fracture site remains prominent
  2. Child: Site remodels and disappears in months
  • Management
  • Referral Indications
  1. Urgent referral
    1. Neurovascular injury
    2. Openm Fracture or significant Skin Tenting
  2. Other referral indications
    1. Painful nonunion after 4 months
    2. Extreme proximal displaced Clavicle Fracture (Allman Group 3)
    3. Distal displaced Clavicle Fracture (Allman Group 2)
    4. Midshaft displaced Clavicle Fracture (Allman Group 1) indications
      1. Displaced or overlapping >2 cm (controversial) or
      2. Multiple nonunion risks or
      3. Persistent pain or
      4. Active teens and adults
  • Complications
  1. Short-term
    1. Pneumothorax
    2. Neurovascular injury
  2. Long-term
    1. Physeal Injury in adolescents (Allman Group 3 medial Fractures)
    2. Malunion
    3. Thoracic Outlet Syndrome
    4. Weakness or Paresthesias
    5. Deformity of cosmetic significance (or palpable Fracture callus site)