eMedicine Specialties > Sports Medicine > Shoulder

Clavicular Injuries: Differential Diagnoses & Workup

Author: Kevin J Eerkes, MD, Clinical Assistant Professor, Department of Medicine, New York University School of Medicine; Medical team physician, New York University athletic teams
Coauthor(s): Janos P Ertl, MD, Assistant Professor, Department of Orthopedic Surgery, Indiana University School of Medicine; Chief of Orthopaedic Surgery, Wishard hospital; John B Mitchell, MD, Consulting Staff, Department of Orthopedics, Kaiser Permanente
Contributor Information and Disclosures

Updated: Aug 18, 2008

Differential Diagnoses

Acromioclavicular Joint Injury
Rotator Cuff Injury
Shoulder Dislocation

Other Problems to Be Considered

Hemothorax
Neurovascular injury (especially the ulnar nerve)
Pneumothorax
Rib fracture
Scapular fracture
Sternoclavicular joint injury

Workup

Laboratory Studies

  • Laboratory studies are ordered depending on the severity of trauma. With suspected vascular injury, obtain a complete blood cell (CBC) count to check the hemoglobin and hematocrit values. If a pulmonary injury is suspected or identified, perform an arterial blood gas (ABG) determination, and obtain an expiration posteroanterior (PA) chest film.

Related Medscape topics:
Resource Center Pathology & Lab Medicine
Resource Center Trauma
Resource Center Vascular Surgery
Specialty Site Pulmonary Medicine
Specialty Site Radiology

Imaging Studies

  • Clavicular radiographs
    • Two views are standard for the initial radiography evaluation: An anteroposterior (AP) view and a 45° cephalic tilt view. These will delineate the fracture displacement, as well as medial clavicle and possible first rib fractures.
    • The proximal humerus and scapula should be looked at for possible associated fractures.
    • With regard to fracture patterns, most low-energy fractures that occur in sports result in a minimally displaced oblique fracture at the mid shaft.1,2,3,4,6 As the energy of the lateral force is increased, the fracture tends to be comminuted with a butterfly fragment and shortened. The typical appearance is inferior and medial displacement of the distal fragment, owing to the weight of the upper extremity and medial pull of the pectoralis. The proximal clavicle is pulled in a superior direction by the sternocleidomastoid muscle (see Image 1).
    • A roentgenographic classification of distal clavicle fractures was developed by Neer7 and Rockwood and Jenson.8 They divided the fractures into 3 types, as follows:
      • Type 1 fractures are minimally displaced and occur lateral to an intact coracoclavicular ligament complex. These fractures may be treated nonoperatively and symptomatically.
      • Type 2 fractures occur when the medial fragment is separated from the coracoclavicular ligament complex. The medial fragment is displaced cephalad by the pull of the sternocleidomastoid muscle, and the distal fragment is displaced caudally by the weight of the upper extremity, with the intact coracoclavicular ligament complex. The resulting deformity leads to marked displacement of the fracture ends, predisposing this fracture type to a higher prevalence (up to 30%) of nonunion (see Image 2).
      • Type 3 fractures are nondisplaced and extend into the AC joint. As with type 1 fractures, these injuries can be treated symptomatically. The development of late AC degenerative changes can be treated with distal clavicular excision.
  • Computed tomography (CT) scanning with 3-dimensional (3-D) reconstruction: This imaging study may be obtained to further evaluate displaced fractures. In the case of proximal clavicle fractures, CT scans can show any evidence of posterior displacement of the fracture and injury to the neurovascular structures.
  • Chest radiography: This study may be necessary to evaluate for pneumothorax, hemothorax, and rib fractures and is especially helpful in polytrauma or patients who are comatose.
  • Arteriography: Perform arteriography if a vascular injury is suspected.
  • Shoulder series: These radiographs may be required to rule out additional injuries or fractures (eg, to the scapula or proximal humerus).

Related Medscape topic:
 Specialty Site Radiology

More on Clavicular Injuries

Overview: Clavicular Injuries
Differential Diagnoses & Workup: Clavicular Injuries
Treatment & Medication: Clavicular Injuries
Follow-up: Clavicular Injuries
Multimedia: Clavicular Injuries
References
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References

  1. DeLee J, Drez D, eds. Clavicular fractures in adults. DeLee and Drez's Orthopaedic Sports Medicine: Principles and Practice. 2nd ed. Philadelphia, Pa: Saunders; 2003:958-68.

  2. Jeray KJ. Acute midshaft clavicular fracture. J Am Acad Orthop Surg. Apr 2007;15(4):239-48. [Medline].

  3. [Best Evidence] Zlowodzki M, Zelle BA, Cole PA, Jeray K, McKee MD. Treatment of acute midshaft clavicle fractures: systematic review of 2144 fractures: on behalf of the Evidence-Based Orthopaedic Trauma Working Group. J Orthop Trauma. Aug 2005;19(7):504-7. [Medline].

  4. Housner JA, Kuhn JE. Clavicle fractures: individualizing treatment for fracture type. Phys Sportsmed. Dec 2003;31(12):30-6. [Full Text].

  5. Kochhar T, Jayadev C, Smith J, Griffiths E, Seehra K. Delayed presentation of subclavian venous thrombosis following undisplaced clavicle fracture. World J Emerg Surg. Jul 22 2008;3:25. [Medline]. [Full Text].

  6. Pieske O, Dang M, Zaspel J, et al. [Midshaft clavicle fractures - classification and therapy : Results of a survey at German trauma departments.] [German]. Unfallchirurg. Jun 2008;111(6):387-94. [Medline].

  7. Neer CS 2nd. Fractures of the distal third of the clavicle. Clin Orthop Relat Res. May-Jun 1968;58:43-50. [Medline].

  8. Rockwood CA Jr, Jenson KL. X-ray evaluation of shoulder problems. In: Rockwood CA Jr, Matsen FA III, eds. The Shoulder. 2nd ed. Philadelphia, Pa: WB Saunders; 1998:199-231.

  9. Chalidis B, Sachinis N, Samoladas E, et al. Acute management of clavicle fractures. A long term functional outcome study. Acta Orthop Belg. Jun 2008;74(3):303-7. [Medline].

  10. Anderson K. Evaluation and treatment of distal clavicle fractures. Clin Sports Med. Apr 2003;22(2):319-26, vii. [Medline].

  11. Andersen K, Jensen PO, Lauritzen J. Treatment of clavicular fractures. Figure-of-eight bandage versus a simple sling. Acta Orthop Scand. Feb 1987;58(1):71-4. [Medline].

  12. Mueller M, Rangger C, Striepens N, Burger C. Minimally invasive intramedullary nailing of midshaft clavicular fractures using titanium elastic nails. J Trauma. Jun 2008;64(6):1528-34. [Medline].

  13. Huang JI, Toogood P, Chen MR, Wilber JH, Cooperman DR. Clavicular anatomy and the applicability of precontoured plates. J Bone Joint Surg Am. Oct 2007;89(10):2260-5. [Medline].

  14. Checchia SL, Doneux PS, Miyazaki AN, Fregoneze M, Silva LA. Treatment of distal clavicle fractures using an arthroscopic technique. J Shoulder Elbow Surg. May-Jun 2008;17(3):395-8. [Medline].

  15. Allman FL Jr. Fractures and ligamentous injuries of the clavicle and its articulation. J Bone Joint Surg Am. Jun 1967;49(4):774-84. [Medline]. [Full Text].

  16. Bronstein RD. Taking the trauma out of clavicle fractures. J Musculoskel Med. Oct 2001;485-94.

  17. Neviaser JS. Injuries of the clavicle and its articulations. Orthop Clin North Am. Apr 1980;11(2):233-7. [Medline].

  18. Wang SJ, Wong CS. Extra-articular Knowles pin fixation for unstable distal clavicle fractures. J Trauma. Jun 2008;64(6):1522-7. [Medline].

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Further Reading

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Keywords

clavicular injuries, clavicle fracture, clavicle fractures, clavicle dislocation, shoulder injury, shoulder girdle injury, collar bone fractures, broken collar bone

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Contributor Information and Disclosures

Author

Kevin J Eerkes, MD, Clinical Assistant Professor, Department of Medicine, New York University School of Medicine; Medical team physician, New York University athletic teams
Disclosure: Nothing to disclose.

Coauthor(s)

Janos P Ertl, MD, Assistant Professor, Department of Orthopedic Surgery, Indiana University School of Medicine; Chief of Orthopaedic Surgery, Wishard hospital
Janos P Ertl, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Hungarian Medical Association of America, and Sierra Sacramento Valley Medical Society
Disclosure: Nothing to disclose.

John B Mitchell, MD, Consulting Staff, Department of Orthopedics, Kaiser Permanente
Disclosure: Nothing to disclose.

Medical Editor

Joseph P Garry, MD, Director of Sports Medicine and Sports Medicine Fellowship, Associate Professor of Family Medicine and Exercise and Sport Science, Department of Family Medicine, East Carolina University Brody School of Medicine
Joseph P Garry, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Heart Association, American Medical Society for Sports Medicine, North American Primary Care Research Group, and North Carolina Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Henry T Goitz, MD, Chief, Sports Medicine, Associate Professor, Department of Orthopaedic Surgery, Medical College of Ohio
Henry T Goitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Orthopaedic Society for Sports Medicine
Disclosure: Nothing to disclose.

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Craig C Young, MD, Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Sports Medicine Fellowship Director, Medical College of Wisconsin
Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa, and Wilderness Medical Society
Disclosure: Nothing to disclose.

 
 
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