Clavicle Fracture in Emergency Medicine

Author: Amir Estephan, MD; Chief Editor: Rick Kulkarni, MD more...

Updated: Sep 28, 2010

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Background
Pathophysiology
Epidemiology
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Background

The clavicle is an oblong bone that connects the shoulder girdle to the trunk. It provides support and mobility for upper extremity function. Clavicle fractures account for 5% of all fractures and nearly half of significant injuries to the shoulder girdle. They are the most common of all childhood fractures.

Anatomically, the acromioclavicular and coracoclavicular ligament attach the clavicle to the scapula laterally. The sternoclavicular and the costoclavicular ligaments anchor the clavicle medially. The sternocleidomastoid and the subclavius muscles also have points of attachment to the clavicle. The clavicle also protects the adjacent brachial plexus, lung, and blood vessels.

Pathophysiology

Clavicular fractures are classified mechanistically and anatomically into 3 types. Approximately 80% of clavicle fractures occur in the middle third (class A), 15% involve the distal or lateral third (class B), and less than 5% involve the proximal or medial third (class C). The anatomy of the clavicle with potential fracture sites marked is shown in the image below.

$Anatomy of the clavicle indicating potential fract$ Anatomy of the clavicle indicating potential fracture sites.

Most class A fractures occur medial to the coracoclavicular ligament, at the junction of the middle and outer thirds of the clavicle. The proximal fragment is typically displaced upward because of the pull of the sternocleidomastoid muscle. The usual mechanism of injury involves a direct force applied to the lateral aspect of the shoulder as a result of a fall, sporting injury, or motor vehicle accident. Class A fractures are shown in the images below.

$Nondisplaced middle clavicle fracture.$ Nondisplaced middle clavicle fracture. $Displaced fracture of middle clavicle.$ Displaced fracture of middle clavicle. $Displaced middle clavicle fracture.$ Displaced middle clavicle fracture.

Fractures of the lateral third (class B) result from a direct blow to the top of the shoulder. They occur distal to the coracoclavicular ligament and are classified further into 3 subtypes. Type I fractures are nondisplaced, and the coracoclavicular ligaments remain intact. Type II fractures are displaced, and there is associated rupture of the coracoclavicular ligament with the proximal clavicular segment typically pulled upward by the sternocleidomastoid muscle. Type III injuries involve the articular surface of the acromioclavicular joint.^[1]

Fractures of the medial third (class C) occur as a result of a direct blow to the anterior chest. A diligent search for associated injuries should accompany all of these fractures because considerably strong forces are required to fracture this area of the clavicle.

Greenstick or buckle-type fractures are common in children. Most of these fractures are nondisplaced and heal uneventfully.

Frequency

International

The annual incidence rate of clavicular fractures is estimated to be between 30 and 60 cases per 100,000 population.^[2]

Mortality/Morbidity

While the overwhelming majority of clavicle fractures are benign, associated life-threatening intrathoracic injuries are possible. Complications vary based on location of fracture (see Complications).

Sex

The male-to-female ratio is 2:1 for clavicle fractures.

Age

Clavicle fractures are the most common of all pediatric fractures. They can present in the newborn period, especially following a difficult delivery, and nearly half of all clavicle fractures occur in children younger than 7 years. A large peak incidence occurs in males younger than 30 years due to sports injuries. A smaller peak of incidence occurs in elderly patients in whom the injury is sustained during low-energy falls and is related to osteoporosis.^[2]

Proceed to Clinical Presentation

Contributor Information and Disclosures

Author

Amir Estephan, MD Resident Physician, Department of Emergency Medicine, Kings County Hospital Center, Brooklyn

Amir Estephan, MD, is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, and Emergency Medicine Residents Association

Disclosure: Nothing to disclose.

Coauthor(s)

Robert J Gore, MD Clinical Assistant Professor, Attending Physician, Assistant Residency Director, Department of Emergency Medicine, Kings County/State University of New York Downstate Hospital

Robert J Gore, MD is a member of the following medical societies: American College of Emergency Physicians, National Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francis Counselman, MD Program Director, Chair, Professor, Department of Emergency Medicine, Eastern Virginia Medical School

Francis Counselman, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Association of Academic Chairs of Emergency Medicine (AACEM), Norfolk Academy of Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Tom Scaletta, MD Chairperson, Department of Emergency Medicine, Edward Hospital; Past-President, American Academy of Emergency Medicine

Tom Scaletta, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

References

Simon RR, Koenigsknecht SJ. Clavicle fractures. In: Emergency Orthopedics: The Extremities. 5^th ed. McGraw-Hill; 2007.
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Cross KP, Warkentine FH, Kim IK, Gracely E, Paul RI. Bedside ultrasound diagnosis of clavicle fractures in the pediatric emergency department. Acad Emerg Med. Jul 2010;17(7):687-93. [Medline].
Lenza M, Belloti JC, Andriolo RB, Gomes Dos Santos JB, Faloppa F. Conservative interventions for treating middle third clavicle fractures in adolescents and adults. Cochrane Database Syst Rev. Apr 15 2009;CD007121. [Medline].
Smekal V, Irenberger A, Struve P, Wambacher M, Krappinger D, Kralinger FS. Elastic stable intramedullary nailing versus nonoperative treatment of displaced midshaft clavicular fractures-a randomized, controlled, clinical trial. J Orthop Trauma. Feb 2009;23(2):106-12. [Medline].
Pujalte GG, Housner JA. Management of clavicle fractures. Curr Sports Med Rep. Sep-Oct 2008;7(5):275-80. [Medline].
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Low AK, Duckworth DG, Bokor DJ. Operative outcome of displaced medial-end clavicle fractures in adults. J Shoulder Elbow Surg. Sep-Oct 2008;17(5):751-4. [Medline].