Clavicle Fractures Treatment & Management

  • Author: L Joseph Rubino, MD; Chief Editor: Mary Ann E Keenan, MD   more...
 
Updated: Mar 7, 2012
 

Medical Therapy

Nonoperative treatment of clavicle fractures consists of sling support for 6 weeks. During this period, the patient does perform pendulum exercises for shoulder motion and active range of motion of the elbow and hand. After 6 weeks, the patient begins passive assisted motion of the shoulder and progresses to active range of motion as tolerated. Use of the sling may be discontinued as pain allows.

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Surgical Therapy

When a midshaft clavicle fracture requires surgical fixation, there are 2 methods of fixation that are commonly performed. Both methods involve open reduction of the fracture, followed by either insertion of an intramedullary device or fixation with a plate and screws.[6, 24]

Intramedullary fixation requires a small incision over the fracture site, carried down sharply to the clavicle, without stripping the periosteum. A Steinman pin is the placed in a retrograde fashion past the fracture site. It is recommended that the Steinman pin be threaded in the proximal fragment to prevent migration. If a smooth pin is used, bend the distal tip to prevent migration after crossing the fracture site. Cancellous bone grafting is indicated in cases of comminution and/or bone loss.

Surgical fixation with a plate and screws is another option for midshaft clavicle fractures. An incision is made in line with the clavicle and carried down to periosteum sharply, with caution to leave thick skin flaps for closure. The periosteum is then stripped to expose and reduce the fracture. Plate and screw fixation is then performed using any of a wide variety of plates. Recommendations vary from semitubular plates, dynamic compression plates, low contact dynamic compression plate, or double plating. However, fixation of these fractures with semitubular and reconstruction plates is not as strong biomechanically as fixation with dynamic compression plating or the newer locking-plate technology.

Obtaining purchase in 6 cortices on either side of the fracture is recommended. Lag screw fixation is also appropriate when the fracture pattern allows. Again, cancellous bone grafting is suggested in fractures with comminution and/or bone loss.

Mehmet et al conducted an evaluation of the biomechanical properties and the stability of a locking clavicle plate (LCP), a dynamic compression plate (DCP), and an external fixator (Ex-fix) in an unstable displaced clavicle fracture model under torsional and 3-point bending loading. For both torsion and bending, an overall significant difference was found among the 3 constructs in terms of failure loads; a significant difference was also noted between the LCP and the other 2 models in terms of initial stiffness. The LCP is significantly more stable than the DCP and Ex-fix under torsional and bending cyclic loading in a displaced fracture clavicle model.[25]

When using plate and screw fixation to treat clavicle fractures, the surgeon must remember that the hardware will likely be prominent. Proper closure of these incisions is imperative to decrease the risk of painful, prominent hardware.

Many techniques of surgical fixation of distal clavicle fractures have been described in the literature. In general, surgical fixation is recommended for type II distal clavicle fractures. Treatment of these fractures requires direct visualization and reduction of the fracture fragments through a vertical incision. After the fracture is visualized and reduced, the coracoclavicular interval is stabilized. Stable fracture fixation can be achieved in many ways, including combinations of a coracoclavicular screw, Dacron or Mersilene tape, tension banding, Kirschner wire (K-wire), and clavicular plates. Regardless of the exact technique used, the general principles of fracture reduction and fixation and stabilization of the coracoclavicular interval apply.

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Postoperative Details

Recommendations for postoperative management of clavicle fractures consists of sling support for 2-4 weeks. During this time, the patient performs active range of motion exercises of the elbow and hand and pendulum exercises for shoulder motion. At about 2 weeks, the patient may begin low impact activities. After 3-4 weeks, the patient begins assisted range of motion of the shoulder and progresses to active range of motion as tolerated.

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Complications

Thoracic outlet syndrome has been reported in the literature as a complication of nonunion, malunion, or excessive callus formation with clavicle fractures. The thoracic outlet is the space for passage of the subclavian vessels and brachial plexus. The borders of the thoracic outlet are the scalene muscles, the first rib, and the clavicle. When this space is narrowed for any reason, compression of the structures may occur and produce symptoms of thoracic outlet syndrome.

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Outcome and Prognosis

Most fractures treated nonoperatively heal, with variable amounts of cosmetic deformity. For results or recent studies examining patterns of displacement and clinical outcomes, see Indications, above.

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Future and Controversies

See Indications, above.

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Contributor Information and Disclosures
Author

L Joseph Rubino, MD  Assistant Professor, Department of Orthopedic Surgery, Wright State University

L Joseph Rubino, MD is a member of the following medical societies: Alpha Omega Alpha, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, and Mid-America Orthopaedic Association

Disclosure: Nothing to disclose.

Coauthor(s)

Matthew W Lawless, MD  Assistant Professor of Orthopedic Surgery, Wright State University School of Medicine; Consulting Surgeon, Department of Orthopedic Surgery, Miami Valley Hospital and Dayton Veterans Affairs Medical Center

Matthew W Lawless, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Benjamin P Kleinhenz, MD  Resident Physician, Department of Orthopedic Surgery, Wright State University Boonshoft School of Medicine

Benjamin P Kleinhenz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Lynn A Crosby, MD, FACS  Chief of Shoulder Division, Professor, Department of Orthopedic Surgery, Wright State University School of Medicine

Lynn A Crosby, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American College of Sports Medicine, American College of Surgeons, American Fracture Association, American Medical Association, American Medical Tennis Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Arthroscopy Association of North America, Mid-America Orthopaedic Association, and Orthopaedic Research Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Pekka A Mooar, MD  Professor, Department of Orthopedic Surgery, Temple University School of Medicine

Pekka A Mooar, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Mary Ann E Keenan, MD  Professor, Vice Chair for Graduate Medical Education, Department of Orthopedic Surgery, University of Pennsylvania School of Medicine; Chief of Neuro-Orthopedics Program, Department of Orthopedic Surgery, Hospital of the University of Pennsylvania

Mary Ann E Keenan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, American Society for Surgery of the Hand, and Orthopaedic Rehabilitation Association

Disclosure: Nothing to disclose.

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The displacing forces on a midshaft clavicle fracture.
The displacing forces on a lateral clavicle fracture.
Type I fracture of the distal clavicle (group II). The intact ligaments hold the fragments in place.
A type II distal clavicle fracture. In type IIA, both conoid and trapezoid ligaments are on the distal segment, while the proximal segment, without ligamentous attachments, is displaced.
A type IIB fracture of the distal clavicle. The conoid ligament is ruptured while the trapezoid ligament remains attached to the distal segment. The proximal fragment is displaced.
 
 
 
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