History
The patient may hear a snapping or cracking sensation at the time of the injury, Pain, swelling, and possible deformity over the clavicle may be observed.
Clavicle fractures may be caused by direct or indirect trauma. The most common mechanism is an indirect one in which the athlete falls onto the lateral shoulder, causing a compressive force across the clavicle. Examples of a direct mechanism would be a blow from a hockey stick or a direct fall onto the clavicle. At-risk athletes include those in football, hockey, and soccer and those at risk for falling during roller skating, skiing, bicycling, or horseback riding. A very high prevalence is also noted in MVAs. A less common mechanism is a fall onto an outstretched hand (ie, a FOOSH injury). The radiographs below depict clavicle fracture in a hockey player.
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.
Physical Examination
The patient may cradle the injured extremity with the uninjured arm.
The shoulder may appear shortened relative to the opposite side and may droop. Swelling, ecchymosis, and tenderness may be noted over the clavicle. Abrasion over the clavicle suggests the fracture was from a direct mechanism. Crepitus from the fracture ends rubbing against each other may be noted with gentle manipulation.
A thorough upper extremity examination is necessary, and special attention should be paid to the neurovascular status. Identification of an associated distal nerve dysfunction indicates a brachial plexus injury, and decreased pulses may indicate a subclavian artery injury. Venous stasis, discoloration, and swelling indicate a subclavian venous injury. [2, 3]
Difficulty breathing or diminished breath sounds on the affected side may indicate a pulmonary injury, such as a pneumothorax. Palpation of the scapula and ribs may reveal a concomitant injury. Tenting and blanching of the skin at the fracture site may indicate an impending open fracture, which most often requires surgical stabilization.
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A posterior view demonstrating a closed clavicle fracture tenting the skin (arrow), which can potentially lead to an open fracture.
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Comparison of both clavicles, with the left tenting the skin (wide arrow).
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Close-up view of clavicle tenting the skin (arrow).
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Comminuted fracture in a hockey player. Note the medial fragment tenting the skin.
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Additional view of fracture displacement and comminution in a hockey player. The sternocleidomastoid is the deforming force of the medial fragment.
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Radiographs after open reduction and internal fixation of a comminuted fracture in a hockey player.
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Anteroposterior view of middle third clavicle fracture illustrating a relatively typical fracture pattern.
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Anteroposterior view of distal clavicle fracture, type II, showing wide displacement.
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The displacing forces on a midshaft clavicle fracture.
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The displacing forces on a distal clavicle fracture.
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Type I fracture of the distal clavicle (group II). The intact ligaments hold the fragments in place.
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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.
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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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Anatomy of the clavicle indicating potential fracture sites.
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Nondisplaced middle clavicle fracture.
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Displaced fracture of middle clavicle.
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Displaced middle clavicle fracture.
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Clavicle fracture with rib fractures. Remember to look for associated injuries.
