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Clavicle Fractures Workup

  • Author: Benjamin P Kleinhenz, MD; Chief Editor: Craig C Young, MD  more...
 
Updated: Dec 10, 2014
 

Approach Considerations

Laboratory studies are ordered in clavicle fractures according to the severity of trauma. With suspected vascular injury, obtain a complete blood count (CBC) to check the hemoglobin and hematocrit values. If a pulmonary injury is suspected or identified, perform an arterial blood gas (ABG) test and obtain an expiration posteroanterior (PA) chest film. Other imaging studies that can be used in the assessment of a clavicle fracture include the following:

  • Radiography of the clavicle and shoulder
  • Computed tomography (CT) scanning with 3-dimensional (3-D) reconstruction
  • Arteriography
  • Ultrasonography
Next

Imaging Studies

Radiography

Clavicular radiographs

An anteroposterior (AP) view and a 45° cephalic tilt view are standard for the initial radiographic evaluation. These will delineate fracture displacement, as well as fractures to the medial clavicle and first rib. (The proximal humerus and scapula should be looked at for possible associated fractures.) The AP view needs to include the sternoclavicular joint and the shoulder girdle; most clavicle fractures are evident on this view. The 45° cephalad view may be required to define the degree of displacement.

Stress views may be used to identify patterns of displacement and are particularly helpful in the context of fractures of the distal clavicle.

With regard to fracture patterns, most low-energy fractures that occur in sports result in a minimally displaced oblique fracture at the midshaft.[2, 20, 21, 22, 8] 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 medial clavicle is pulled in a superior direction by the sternocleidomastoid muscle. (See the images below.)

Anteroposterior view of middle third clavicle frac Anteroposterior view of middle third clavicle fracture illustrating a relatively typical fracture pattern.
Anteroposterior view of distal clavicle fracture, Anteroposterior view of distal clavicle fracture, type II, showing wide displacement.

Initial radiographs may appear normal despite suggestive clinical findings. In these instances, the arm should be immobilized in a simple sling and the radiographs repeated in 7-10 days if symptoms persist.

Chest radiographs

This study may be necessary to evaluate for pneumothorax, hemothorax, and rib fractures and is especially helpful in polytrauma or in patients who are comatose.

Shoulder series

These radiographs may be required to rule out additional injuries or fractures (eg, to the scapula or proximal humerus).

CT scanning

CT scanning with 3-D reconstruction may be used to further evaluate displaced fractures. In the case of medial clavicle fractures, CT scans can show any evidence of posterior displacement of the fracture and injury to the neurovascular structures.

In addition, CT scanning may be required because routine clavicle radiographs may miss fractures due to overlap of surrounding structures, particularly at either end of the bone.

Arteriography

Perform arteriography if a vascular injury is suspected.

Ultrasonography

Cross et al found that bedside ultrasonography can accurately diagnose clavicle fractures in children. In a prospective study in 100 pediatric emergency department patients, 43 of whom were found via radiography to have clavicle fractures, ultrasonography was reported to have an overall accuracy of 96%, with a positive predictive value of 95% and a negative predictive value of 96%. Ultrasonography caused no more discomfort than radiography.[26, 27, 28, 29]

In addition, bedside ultrasonography requires minimal formal training and may reduce the length of stay in the emergency department.[26]

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Contributor Information and Disclosures
Author

Benjamin P Kleinhenz, MD Clinical Instructor, Mary S Stern Hand Surgery Fellowship, University of Cincinnati College of Medicine; Consulting Surgeon, Hand Surgery Specialists of Cincinnati

Benjamin P Kleinhenz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American Society for Surgery of the Hand

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, 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

Disclosure: Nothing to disclose.

Acknowledgements

Lawrence C Brilliant, MD Clinical Assistant Professor, Department of Primary Care and Community Services, MCP Hahnemann University; Attending Physician, Department of Emergency Medicine, Doylestown Hospital

Lawrence C Brilliant, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

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

Francis Counselman, MD, FACEP 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.

Kevin J Eerkes, MD Clinical Assistant Professor, Department of Medicine, New York University School of Medicine; Medical Team Physician, New York University Athletics

Disclosure: Nothing to disclose.

Janos P Ertl, MD Assistant Professor, Department of Orthopedic Surgery, Indiana University School of Medicine; Chief of Orthopedic Surgery, Wishard HospitalChief, Sports Medicine and Arthroscopy, Indiana University School of Medicine

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.

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.

Joseph P Garry, MD, FACSM, FAAFP Associate Professor, Department of Family and Community Medicine, University of Minnesota Medical School

Joseph P Garry, MD, FACSM, FAAFP is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, and Minnesota Medical Association

Disclosure: Nothing to disclose.

Henry T Goitz, MD Academic Chair and Associate Director, Detroit Medical Center Sports Medicine Institute; Director, Education, Research, and Injury Prevention Center; Co-Director, Orthopaedic Sports Medicine Fellowship

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.

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.

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.

John B Mitchell, MD Consulting Staff, Department of Orthopedics, Kaiser Permanente

Disclosure: Nothing to disclose.

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.

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.

Tom Scaletta, MD Chair, 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.

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

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A posterior view demonstrating a closed clavicle fracture tenting the skin (arrow), which can potentially lead to an open fracture.
Comparison of both clavicles, with the left tenting the skin (wide arrow).
Close-up view of clavicle tenting the skin (arrow).
Comminuted fracture in a hockey player. Note the medial fragment tenting the skin.
Additional view of fracture displacement and comminution in a hockey player. The sternocleidomastoid is the deforming force of the medial fragment.
Radiographs after open reduction and internal fixation of a comminuted fracture in a hockey player.
Anteroposterior view of middle third clavicle fracture illustrating a relatively typical fracture pattern.
Anteroposterior view of distal clavicle fracture, type II, showing wide displacement.
The displacing forces on a midshaft clavicle fracture.
The displacing forces on a distal 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.
Anatomy of the clavicle indicating potential fracture sites.
Nondisplaced middle clavicle fracture.
Displaced fracture of middle clavicle.
Displaced middle clavicle fracture.
Clavicle fracture with rib fractures. Remember to look for associated injuries.
 
 
 
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