Diagnostic Considerations

Complications after group III (medial third of the clavicle) fractures resemble those associated with posterior sternoclavicular dislocations, including pneumothorax and compression or laceration of the great vessels, trachea, or esophagus.

The medial epiphysis ossifies later than the rest of the clavicle, beginning at age 12-19 years, and may not completely fuse until age 22-25 years. Physial injuries around this area may be mistaken for fractures, and care should be taken in evaluating injuries.

Neurovascular injuries, especially those to the ulnar nerve, are also included in the differential diagnosis of clavicle fractures.

Differential Diagnoses

Workup

Allman FL Jr. Fractures and ligamentous injuries of the clavicle and its articulation. J Bone Joint Surg Am. 1967 Jun. 49(4):774-84. [QxMD MEDLINE Link].
Clavicular fractures in adults. DeLee J, Drez D, eds. DeLee and Drez's Orthopaedic Sports Medicine: Principles and Practice. 2nd ed. Philadelphia, Pa: Saunders; 2003. 958-68.
Kochhar T, Jayadev C, Smith J, Griffiths E, Seehra K. Delayed presentation of Subclavian venous thrombosis following undisplaced clavicle fracture. World J Emerg Surg. 2008 Jul 22. 3:25. [QxMD MEDLINE Link]. [Full Text].
Bahk MS, Kuhn JE, Galatz LM, Connor PM, Williams GR Jr. Acromioclavicular and sternoclavicular injuries and clavicular, glenoid, and scapular fractures. J Bone Joint Surg Am. 2009 Oct. 91(10):2492-510. [QxMD MEDLINE Link].
van der Meijden OA, Gaskill TR, Millett PJ. Treatment of clavicle fractures: current concepts review. J Shoulder Elbow Surg. 2012 Mar. 21(3):423-9. [QxMD MEDLINE Link].
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. 2009 Feb. 23(2):106-12. [QxMD MEDLINE Link].
Mueller M, Burger C, Florczyk A, Striepens N, Rangger C. Elastic stable intramedullary nailing of midclavicular fractures in adults: 32 patients followed for 1-5 years. Acta Orthop. 2007 Jun. 78(3):421-3. [QxMD MEDLINE Link].
Pieske O, Dang M, Zaspel J, Beyer B, Löffler T, Piltz S. [Midshaft clavicle fractures--classification and therapy. Results of a survey at German trauma departments]. Unfallchirurg. 2008 Jun. 111(6):387-94. [QxMD MEDLINE Link].
Mueller M, Rangger C, Striepens N, Burger C. Minimally invasive intramedullary nailing of midshaft clavicular fractures using titanium elastic nails. J Trauma. 2008 Jun. 64(6):1528-34. [QxMD MEDLINE Link].
Pujalte GG, Housner JA. Management of clavicle fractures. Curr Sports Med Rep. 2008 Sep-Oct. 7(5):275-80. [QxMD MEDLINE Link].
Kim W, McKee MD. Management of acute clavicle fractures. Orthop Clin North Am. 2008 Oct. 39(4):491-505, vii. [QxMD MEDLINE Link].
Khan LA, Bradnock TJ, Scott C, Robinson CM. Fractures of the clavicle. J Bone Joint Surg Am. 2009 Feb. 91(2):447-60. [QxMD MEDLINE Link].
Virtanen KJ, Malmivaara AO, Remes VM, Paavola MP. Operative and nonoperative treatment of clavicle fractures in adults. Acta Orthop. 2012 Feb. 83(1):65-73. [QxMD MEDLINE Link]. [Full Text].
Neer CS 2nd. Fractures of the distal third of the clavicle. Clin Orthop Relat Res. 1968 May-Jun. 58:43-50. [QxMD MEDLINE Link].
Debski RE, Parsons IM 4th, Woo SL, Fu FH. Effect of capsular injury on acromioclavicular joint mechanics. J Bone Joint Surg Am. 2001 Sep. 83-A(9):1344-51. [QxMD MEDLINE Link].
Simon RR, Koenigsknecht SJ. Clavicle fractures. Emergency Orthopedics: The Extremities. 5th ed. McGraw-Hill; 2007.
Nowak J, Mallmin H, Larsson S. The aetiology and epidemiology of clavicular fractures. A prospective study during a two-year period in Uppsala, Sweden. Injury. 2000 Jun. 31(5):353-8. [QxMD MEDLINE Link].
Nordqvist A, Petersson C. The incidence of fractures of the clavicle. Clin Orthop Relat Res. 1994 Mar. 127-32. [QxMD MEDLINE Link].
Chalidis B, Sachinis N, Samoladas E, Dimitriou C, Christodoulou A, Pournaras J. Acute management of clavicle fractures. A long term functional outcome study. Acta Orthop Belg. 2008 Jun. 74(3):303-7. [QxMD MEDLINE Link].
Jeray KJ. Acute midshaft clavicular fracture. J Am Acad Orthop Surg. 2007 Apr. 15(4):239-48. [QxMD MEDLINE Link].
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. 2005 Aug. 19(7):504-7. [QxMD MEDLINE Link].
Housner JA, Kuhn JE. Clavicle fractures: individualizing treatment for fracture type. Phys Sportsmed. 2003 Dec. 31(12):30-6. [QxMD MEDLINE Link].
Kihlström C, Möller M, Lönn K, Wolf O. Clavicle fractures: epidemiology, classification and treatment of 2 422 fractures in the Swedish Fracture Register; an observational study. BMC Musculoskelet Disord. 2017 Feb 15. 18 (1):82. [QxMD MEDLINE Link].
McKee RC, Whelan DB, Schemitsch EH, McKee MD. Operative versus nonoperative care of displaced midshaft clavicular fractures: a meta-analysis of randomized clinical trials. J Bone Joint Surg Am. 2012 Apr 18. 94(8):675-84. [QxMD MEDLINE Link].
Murray IR, Foster CJ, Eros A, Robinson CM. Risk factors for nonunion after nonoperative treatment of displaced midshaft fractures of the clavicle. J Bone Joint Surg Am. 2013 Jul 3. 95(13):1153-8. [QxMD MEDLINE Link].
Kendall KM, Burton JH, Cushing B. Fatal subclavian artery transection from isolated clavicle fracture. J Trauma. 2000 Feb. 48(2):316-8. [QxMD MEDLINE Link].
Chien M, Bulloch B, Garcia-Filion P, Youssfi M, Shrader MW, Segal LS. Bedside ultrasound in the diagnosis of pediatric clavicle fractures. Pediatr Emerg Care. 2011 Nov. 27(11):1038-41. [QxMD MEDLINE Link].
Cross KP, Warkentine FH, Kim IK, Gracely E, Paul RI. Bedside ultrasound diagnosis of clavicle fractures in the pediatric emergency department. Acad Emerg Med. 2010 Jul. 17(7):687-93. [QxMD MEDLINE Link].
Gullo J, Singletary EM, Larese S. Emergency bedside sonographic diagnosis of subclavian artery pseudoaneurysm with brachial plexopathy after clavicle fracture. Ann Emerg Med. 2013 Feb. 61(2):204-6. [QxMD MEDLINE Link].
Willis H. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 2: Can ultrasound be used to diagnose clavicle fractures in children?. Emerg Med J. 2012 Jul. 29(7):599-600. [QxMD MEDLINE Link].
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. 2009 Apr 15. CD007121. [QxMD MEDLINE Link].
Grassi FA, Tajana MS, D'Angelo F. Management of midclavicular fractures: comparison between nonoperative treatment and open intramedullary fixation in 80 patients. J Trauma. 2001 Jun. 50(6):1096-100. [QxMD MEDLINE Link].
Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am. 2007 Jan. 89(1):1-10. [QxMD MEDLINE Link].
Hill JM, McGuire MH, Crosby LA. Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg Br. 1997 Jul. 79(4):537-9. [QxMD MEDLINE Link].
Wick M, Müller EJ, Kollig E, Muhr G. Midshaft fractures of the clavicle with a shortening of more than 2 cm predispose to nonunion. Arch Orthop Trauma Surg. 2001. 121(4):207-11. [QxMD MEDLINE Link].
Huang JI, Toogood P, Chen MR, Wilber JH, Cooperman DR. Clavicular anatomy and the applicability of precontoured plates. J Bone Joint Surg Am. 2007 Oct. 89(10):2260-5. [QxMD MEDLINE Link].
Formaini N, Taylor BC, Backes J, Bramwell TJ. Superior versus anteroinferior plating of clavicle fractures. Orthopedics. 2013 Jul. 36(7):e898-904. [QxMD MEDLINE Link].
Demirhan M, Bilsel K, Atalar AC, Bozdag E, Sunbuloglu E, Kale A. Biomechanical comparison of fixation techniques in midshaft clavicular fractures. J Orthop Trauma. 2011 May. 25(5):272-8. [QxMD MEDLINE Link].
Neer CS. Nonunion of the clavicle. JAMA. 1960. 172:1006-1011.
Checchia SL, Doneux PS, Miyazaki AN, Fregoneze M, Silva LA. Treatment of distal clavicle fractures using an arthroscopic technique. J Shoulder Elbow Surg. 2008 May-Jun. 17(3):395-8. [QxMD MEDLINE Link].
Motta P, Bruno L, Maderni A, Tosco P, Mariotti U. Acute lateral dislocated clavicular fractures: arthroscopic stabilization with TightRope. J Shoulder Elbow Surg. 2013 Aug 9. [QxMD MEDLINE Link].
Klein SM, Badman BL, Keating CJ, Devinney DS, Frankle MA, Mighell MA. Results of surgical treatment for unstable distal clavicular fractures. J Shoulder Elbow Surg. 2010 Oct. 19(7):1049-55. [QxMD MEDLINE Link].
Chen CH, Chen WJ, Shih CH. Surgical treatment for distal clavicle fracture with coracoclavicular ligament disruption. J Trauma. 2002 Jan. 52(1):72-8. [QxMD MEDLINE Link].
Kao FC, Chao EK, Chen CH, Yu SW, Chen CY, Yen CY. Treatment of distal clavicle fracture using Kirschner wires and tension-band wires. J Trauma. 2001 Sep. 51(3):522-5. [QxMD MEDLINE Link].
Mizue F, Shirai Y, Ito H. Surgical treatment of comminuted fractures of the distal clavicle using Wolter clavicular plates. J Nippon Med Sch. 2000 Feb. 67(1):32-4. [QxMD MEDLINE Link].
Low AK, Duckworth DG, Bokor DJ. Operative outcome of displaced medial-end clavicle fractures in adults. J Shoulder Elbow Surg. 2008 Sep-Oct. 17(5):751-4. [QxMD MEDLINE Link].
Bentley TP, Journey JD. Fracture, Clavicle. StatPearls [Internet]. 2018 Jan. [QxMD MEDLINE Link]. [Full Text].
Vora D, Baker M, Pandarinath R. Impact of Clavicle Fractures on Return to Play and Performance Ratings in NFL Athletes. Clin J Sport Med. 2017 Dec 1. [QxMD MEDLINE Link].

Media Gallery

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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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