Clavicle Fractures

Clavicle fractures are common and easily recognized because of their subcutaneous position, as shown in the images below. Fracture union usually progresses regardless of the treatment initiated. Despite the innocuous appearance of clavicle fractures, however, potential treatment difficulties and possible complications warrant careful attention to these injuries. (See Prognosis, Treatment, and Medication.)

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).

The clavicle is the first bone in the body to ossify, beginning at the fifth week of gestation.[2] Through age 5 years, the growth is primarily through intramembranous ossification. The medial epiphysis ossifies late, 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. (For patients aged 22-25 years, the Salter-Harris classification for physial injuries can be used, and nonoperative treatment can often be initiated.) (See Anatomy, Clinical Presentation, DDx, and Workup.)

Historically, clavicle fractures have been considered best treated nonoperatively, with good outcomes. Management typically included the use of either a shoulder sling or a figure-of-eight brace. The vast majority of these fractures healed, with variable amounts of cosmetic deformity.

Studies have examined the different patterns of displacement and clinical outcomes of clavicle fractures according to their location. The medical literature has focused predominantly on fractures of the middle and distal clavicle but is still lacking concerning the management of medial clavicle fractures; the literature does, however, indicate that medial clavicle fractures respond well to nonoperative management. Controversy remains concerning operative versus nonoperative treatment of middle and distal clavicle fractures.[10, 11, 12, 13] (See Treatment and Medication.)

Fracture classification

Multiple attempts have been made to devise a classification scheme for clavicle fractures. The most common system is the following one, created by Allman, in which the clavicle is divided into thirds[1] :

• Group I fractures: Middle third injuries

• Group II fractures: Distal third injuries

• Group III fractures: Medial (proximal) third injuries

Neer made a significant revision to the Allman classification scheme. Group II (distal clavicle) fractures were further divided into 3 types, based on the location of the clavicle fracture in relation to the coracoclavicular ligaments. The reason for this modification was that distal clavicle fractures behave differently depending on the exact location of the injury. The designations are as follows (see Clinical Presentation and Workup)[14] :

• Type I fractures: Minimally displaced and occur lateral to an intact coracoclavicular ligament complex; these fractures may be treated nonoperatively and symptomatically (see the image below)

• Type II 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

• Type III injuries: Minimally displaced or nondisplaced and extend into the acromioclavicular (AC) joint; as with type I fractures, these injuries can be treated symptomatically; the development of late AC degenerative changes can be treated with distal clavicular excision

  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.

The Neer type II fracture was later divided into types IIA and IIB, as follows (see the images below):

• Type IIA - Displaced due to fracture medial to the coracoclavicular ligaments; the conoid and trapezoid remain attached to the distal fragment

• Type IIB - Displaced due to fracture medial to the coracoclavicular ligaments; either the conoid is torn or, more rarely, both the conoid and trapezoid are torn

  Anatomy of the clavicle indicating potential fracture sites.

The clavicle is an S-shaped bone that acts as a strut between the sternum and the glenohumeral joint. Another function of the clavicle is to help protect the neurovascular bundle that runs behind it. The junction of the middle and distal thirds of the clavicle is a common site of fracture because this is the thinnest part of the bone, and there is relatively little protection by muscular attachments.

Numerous muscular and ligamentous forces act on the clavicle, and knowledge of these differing forces is necessary to understand the nature of displacement of clavicle fractures and why certain fracture patterns tend to cause problems if not reduced and surgically stabilized. (See the image below.)

Anatomy of the clavicle indicating potential fracture sites.

The clavicle articulates with the sternum at the sternoclavicular (SC) joint and with the acromion at the AC joint. Many ligamentous structures attach to the clavicle and provide stability for the articulations with the sternum and the acromion. The primary stabilizers of the SC joint are the anterior and posterior capsules. Other ligamentous structures attaching here are the interclavicular ligament and the costoclavicular ligament. Stability of the SC joint in the anterior-posterior plane is derived predominantly from the posterior capsule, with additional stability conferred by the anterior capsule. The interclavicular and costoclavicular ligaments have little effect on stability of the joint.

At the level of the AC joint, the coracoclavicular and AC ligaments provide stability for the joint. The coracoclavicular ligament is actually 2 separate ligaments, the conoid and the trapezoid, which both attach from the coracoid to the inferior surface of the distal clavicle. Debski et al have delineated the different functions of the conoid and trapezoid in resistance to applied loads to the AC joint.[15] The conoid is the predominant restraint to anterior and superior loading, while the trapezoid is the major restraint to posterior loading at the AC joint. The AC ligament is at the superior-lateral aspect of the clavicle and overlies the AC joint.

Three muscles originate on the clavicle, and 3 muscles insert on it. The muscles that take their origin from the clavicle are as follows:

• Sternohyoid

• Pectoralis major

• Deltoid

The muscles that insert on the clavicle are as follows:

• Sternocleidomastoid

• Subclavius

• Trapezius

These 6 muscles may become deforming forces on the clavicle in the presence of a fracture, with the displacement of fracture fragments depending on the location of the fracture in relation to the muscular and ligamentous attachments.

Many other important structures are in extremely close contact with the clavicle and are thus subject to injury in the context of clavicle fractures. The subclavian artery (which becomes the axillary artery as it passes anteriorly to the first rib) and vein are both in close proximity to the middle portion of the clavicle. Additionally, the brachial plexus also passes behind the clavicle posterolateral to the subclavian vessels and is at risk with displaced fractures of the middle clavicle.

The subclavius muscle lies between the clavicle and these neurovascular structures, and, though small, it is believed to prevent more frequent damage to these structures. Reports also exist of injuries to the apices of the lung, most commonly with displaced middle third clavicle fractures.

Because of its subcutaneous position, the clavicle may be fractured easily, with the fracture often being an isolated injury. However, clavicle fractures are also common in the context of high-energy injury or multiple traumatic injuries. In these situations, it is important to examine the patient for other associated injuries, such as rib fractures, scapula fractures, other fractures about the shoulder girdle, pulmonary contusion, pneumothorax, hemothorax, and closed head injuries. (See the image below.)

Clavicle fracture with rib fractures. Remember to look for associated injuries.

The frequency with which the 3 groups of fractures occur is as follows:

• Group I (middle third) - Approximately 80%

• Group II (distal third) - 12-15%

• Group III (medial third) - Less than 5%

Group I fractures

Most group I fractures occur medial to the coracoclavicular ligament, at the junction of the middle and outer third 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. Group I fractures are shown in the images below

Nondisplaced middle clavicle fracture.

Displaced fracture of middle clavicle.

Displaced middle clavicle fracture.

Group II fractures

Fractures of the distal third of the clavicle result from a direct blow to the top of the shoulder. They occur distal to the coracoclavicular ligament.[16]

Group III fractures

Fractures of the medial third of the clavicle occur as a result of a direct blow to the anterior chest. A diligent search for associated injuries should accompany group III 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.

Clavicle fractures may be caused by direct or indirect trauma. The most common mechanism is an indirect one, involving a fall directly onto the lateral shoulder.[17, 18, 19] 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 less common mechanism for clavicle fractures 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.

Occurrence in the United States

The clavicle is the most frequently fractured bone in the body in childhood, accounting for 10-16% of all fractures in this age group.

In adults, clavicle fractures account for 2.6-5% of all fractures and 44% of all shoulder girdle injuries.[20, 21, 22] Middle third (group I) fractures account for 69-82% of all fractures of the clavicle, whereas distal third (group II) fractures account for 12%, and medial third (group III) fractures occur in 6% of cases.[20, 21]

Clavicular injuries affect 1 in 1000 people per year. Bimodal incidence occurs in men younger than 25 years and older than 55 years. Pneumothorax occurs in 3% of patients.

International occurrence

The annual incidence rate of clavicular fractures is estimated to be between 30 and 60 cases per 100,000 population.[12]

An analysis of 2,422 clavicle fractures in patients 15 years of age and older from 2013-2014 recorded in The Swedish Fracture Register reported that 21% of all fractures occurred in males 15-24 years of age and that 43% of all fractures were displaced midshaft fractures. Eleven percent of all fractures were treated operatively acutely with an additional 6% treated operatively after non-operative treatment was abandoned at an early stage (median of 14 days). Of the fractures that were treated operatively 80% were midshaft fractures.[23]

Sex- and age-related demographics

Clavicular injuries occur 2.5 times more commonly in males than in females, reflecting a greater involvement of males in contact and violent sports and motor vehicle accidents (MVAs).

Clavicle fractures, the most common of all pediatric fractures, can present even in the newborn period, especially following a difficult delivery. A large peak incidence occurs in males younger than 30 years due to sports injuries. A smaller peak occurs in elderly patients, who tend to sustain clavicle fractures (in association with osteoporosis) during low-energy falls.[12]

Most clavicle fractures treated nonoperatively heal, although with variable amounts of cosmetic deformity. Younger children generally require shorter periods of immobilization (2-4 wk) than do adolescents and adults (4-8 wk).

Complications

Nonunion

Nonunion is a failure to show clinical or radiographic progression of healing after 4-6 months. The following are risk factors for nonunion:

• Fracture comminution

• Significant fracture displacement or shortening

• Type 2 fractures of the distal third of the clavicle

• Refracture

• Female sex

• Advanced age

• Fractures with more than 2 cm of shortening

The nonunion rate for all midclavicle fractures treated nonoperatively is 6%; the rate is 15% for displaced midclavicle fractures treated nonoperatively.[24] Symptoms of nonunion can be pain, motion, or loss of function. Note, however, that many nonunions are asymptomatic and require no treatment. Refer patients with symptomatic nonunion to an orthopedic surgeon to discuss surgical options. In some situations, a bone stimulator to help promote bone healing can be tried before surgery.

Murray et al reported that smoking was the greatest risk factor for nonunion among patients treated nonoperatively for diaphysial clavicle fractures. In a study, the investigators followed the healing course of 941 patients with such fractures and, using multivariate analysis, found that, along with smoking, both comminution and fracture displacement were particularly significant factors in nonunion.

The investigators determined that by using known risk factors, a statistical model can be used to estimate the probability of nonunion in a specific patient and can therefore help to determine whether he or she should be treated surgically. The investigators also concluded that smoking cessation needs to be included in the treatment of diaphysial clavicle fractures.[25]

Malunion

Malunion is when the fracture heals with significant angulation, shortening, and a poor appearance. Mild malunion is common after clavicle fractures, but it is usually not clinically significant. Occasionally, the patient can have pain or a mild limitation in motion or strength. Symptoms from nerve impingement may occur but are uncommon. Surgeries for malunion attempt to restore the clavicular length and correct any angular deformity of the clavicle.

Neurovascular injuries

Group I fractures (middle third of the clavicle) have been associated with injuries to the neurovascular bundle and the pleural dome.

Neurovascular compromise can develop from exuberant callus formation or from malunion. The medial cord and ulnar nerve are affected most often; treatment is surgical in nature. Brachial plexus compression resulting from hypertrophic callus formation may cause peripheral neuropathy.

Intrathoracic injuries

These include the following:

• Pneumothorax

• Subclavian artery and vein injury

• Internal jugular vein injury

• Axillary artery injury

Other

A spike of bone can form subcutaneously after angulated fractures heal. This can be symptomatic for athletes who wear shoulder pads or for backpackers. If a donut pad is not sufficient to relieve symptoms, surgical excision can be considered. Posttraumatic arthritis can develop if a clavicle fracture enters the AC or SC joints.

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

Mortality

While the overwhelming majority of clavicle fractures are benign, there is a possibility of associated, life-threatening intrathoracic injuries.

Kendall et al reported a fatality from an isolated clavicle fracture from transection of the subclavian artery,[26] the first such report in the literature. The fatality may have been due to the fact that the fall was not witnessed and the patient lay unassisted for an unknown period of time. The patient never regained spontaneous circulation, and the injury to the subclavian artery was diagnosed at autopsy. The postmortem examination revealed a midclavicular fracture with transection of the subclavian artery. A 2.6-L hemothorax and damage to parietal and apical pleura were noted, but no other injuries were present.

Although this case is unique, it does emphasize the need to be aware of the potentially catastrophic complications of damage to the vascular structures in close proximity to the clavicle.

At the initial visit, discuss the following with the patient who has a clavicular injury:

• A visible prominence may remain at the fracture site after it heals; this may be more evident in thin individuals

• Fracture nonunion is possible, and surgery may be necessary

• Refracture is a possibility if the patient engages in contact sports, particularly if he or she returns to play before the bone healing is solid

Educate patients about proper placement and adjustment techniques for a figure-of-eight bandage (clavicle strap) and inform them that paresthesias or edema in the hands or fingers indicate that the strap is too tight and should be removed.

Neonatal clavicle fracture

Advise parents to minimize pressure and movement of the ipsilateral arm during handling of a neonate with a clavicle fracture. The parent may try to pin the shirt sleeve of the affected arm to the front of the child’s shirt to minimize movement.

For patient education information, see the First Aid and Injuries Center, as well as Broken Collarbone (Broken Clavicle) and Shoulder Dislocation.

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.

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.

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

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 fracture illustrating a relatively typical fracture pattern.

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.[27, 28, 29, 30]

In addition, bedside ultrasonography requires minimal formal training and may reduce the length of stay in the emergency department.[27]

If all clavicle fractures are considered together, the vast majority heal with nonoperative management, which includes use of a simple shoulder sling. Studies have found, however, that in cases of specific fracture patterns and locations, not all clavicle fractures behave the same way.

The focus of treatment of middle third fractures remains nonoperative, although evidence is mounting, in support of operative treatment for displaced midshaft clavicle fractures. Management of medial clavicle fractures also has remained nonoperative

The incidence of nonunion of displaced distal third fractures is high, and current recommendations are to fix these injuries surgically.

Consultations

In addition to an orthopedic surgeon if the fracture requires surgical fixation, consultations include the following:

• General or thoracic surgeon: If an associated pneumothorax is identified

• Vascular surgeon: For a suspected subclavian vessel injury

Patients with the following injuries should be sent to a surgeon to determine if operative intervention is necessary:

• Complete fracture displacement[4] : A literature review showed that 15% of displaced midshaft clavicular fractures went on to nonunion when treated nonoperatively[24]  

• Severe displacement causing tenting of the skin with the risk of puncture: This is often seen with type 2 fractures of the distal clavicle.

• Fractures with 2 cm of shortening

• Comminuted fractures with a displaced transverse "zed" (or z-shaped) fragment[4]

• Neurovascular compromise

• Displaced medial clavicular fractures with mediastinal structures at risk[5]

• Polytrauma (with multiple fractures): To expedite rehabilitation

• Open fractures

• An inability to tolerate closed treatment

• Fractures with interposed muscle

• Established symptomatic nonunion: Note that many nonunions are asymptomatic, and no treatment is needed.

• Concomitant glenoid neck fracture (floating shoulder)

Relative indications for open reduction and internal fixation (ORIF) include athletes who require shoulder pads for sports participation, such as in football and hockey. Surgery in this case would be to avoid skin breakdown over pronounced callus formation about the fracture site.

Nonoperative treatment

The focus of treatment of middle third fractures remains nonoperative. Such treatment can be divided into the following 2 categories:

• Simple support of the extremity - As in a sling or a sling and swath

• Reduction and immobilization - Typically with figure-of-eight brace

These treatment options are applicable for almost all middle third clavicle fractures, with the exception of those that are severely displaced or shortened. The image below illustrates the displacing forces that can affect group I fractures.

The displacing forces on a midshaft clavicle fracture.

The advantage of the figure-of-eight brace is that it gives patients the ability to use both hands. The literature, however, shows no real difference in outcomes between patients treated with a figure-of-eight splint versus a sling, so the choice of immobilization should depend on the comfort and functional demands of the patient.[31] Healing time may be as short as 2 weeks for infants, with most adults healing in 4-6 weeks. Immobilization should continue until repeat radiographs show callus formation and healing across the fracture site.

Stiffness is usually not a problem after nonoperative treatment of clavicle fractures. If the patient does require some rehabilitation, it should include forward elevation and external rotation. Laborers may return to light lifting after 6 weeks and full duty at 12 weeks. Athletes may return to contact sports after 3 months.

Grassi et al found that patients treated nonoperatively for uncomplicated midclavicle fractures recovered more quickly than did those who were treated operatively. The investigators examined 40 patients who were treated with a figure-of-eight brace and 40 patients treated with open reduction and intramedullary fixation with a 2.5-mm threaded pin.[32] Patients who were treated nonoperatively had fewer complications and faster return to normal daily activities, heavy lifting, and sports.

Overall, however, patients in both groups were satisfied with their results, although 35% of the surgical group had some adverse events during their recovery, most of which were minor. Nonetheless, 3 patients experienced refracture after removal of the intramedullary pin. When these patients were then treated with a figure-of-eight brace, union occurred.

Given the excellent results obtained with nonoperative treatment of uncomplicated midclavicular fractures, such therapy, using a figure-of-eight brace or regular support sling, is recommended. Operative treatment is best suited for more complicated fractures of the middle third of the clavicle.

Surgical studies

Evidence is mounting, however, in support of operative treatment for displaced midshaft clavicle fractures. A prospective, multicenter, randomized trial by the Canadian Orthopaedic Trauma Society found that operative repair for these injuries provided better results than did nonoperative treatment. In the study, involving 132 patients with a displaced midshaft fracture, outcome and complication rates were compared for nonoperative treatment and plate fixation.[33]

The investigators determined that mean time to radiographic union was significantly shorter in the operative group (16.4 wk vs 28.4 wk). Additionally, functional outcomes were improved at all time points measured in the operative group. This study provided level I evidence in support of plate fixation for completely displaced midshaft clavicle fractures in the active adult population.[33]

Similarly, a study by Smekal et al found better results with another operative procedure, elastic stable intramedullary nailing (ESIN), than with nonoperative treatment in the repair of fully displaced midshaft clavicle fractures. Outcomes with regard to the rate of successful bone union, functional outcome, time required for patients to resume their daily activities, and overall patient satisfaction were superior in the operative group than in nonoperative patients. There was also significantly less posttraumatic clavicular shortening in the surgical group.

Fracture shortening

Hill et al examined a subset of clavicle fractures in which initial shortening of the fracture was greater than 2 cm and found a high rate (15%) of nonunion in this population.[34] Also, final shortening of more than 2 cm was associated with unsatisfactory results. Open reduction and internal fixation of these injuries is recommended for patients with displaced middle third clavicle fractures with greater than 2 cm of shortening.

Wick et al reviewed 39 nonunions of midclavicular fractures treated nonoperatively and found a correlation between initial fracture shortening of greater than 2 cm and nonunion.[35] These patients subsequently underwent open reduction and internal fixation with subsequent union of the fracture. The major patient complaint for all of these nonunions was pain, and all patients had complete or near complete resolution of their symptoms. Wick, however, still recommended a trial of conservative treatment prior to open reduction and internal fixation of these fractures.

Reduction and fixation

When a midshaft clavicle fracture requires surgical fixation, the commonly performed involves open reduction of the fracture, followed by either insertion of an intramedullary device or fixation with a plate and screws.[6, 7, 8, 9] Precontoured plates in the S shape of the clavicle have also become available.[36]

When using plate-and-screw fixation to treat clavicle fractures, the surgeon must remember that the hardware will likely be prominent. Proper closure of these incisions is imperative to decrease the risk of painful, prominent hardware.

Intramedullary fixation

Intramedullary fixation requires a small incision over the fracture site. The incision is carried down sharply to the clavicle without stripping the periosteum. A Steinman pin is then placed in a retrograde fashion past the fracture site. It is recommended that the Steinman pin be threaded in the proximal fragment to prevent migration. If a smooth pin is used, bend the distal tip to prevent migration after crossing the fracture site. Cancellous bone grafting is indicated in cases of comminution and/or bone loss.

Plate-and-screw fixation

Surgical fixation with a plate and screws is another option for midshaft clavicle fractures.[37] An incision is made in line with the clavicle and carried sharply down to the periosteum, with caution to leave thick skin flaps for closure. The periosteum is then stripped to expose and reduce the fracture, after which plate-and-screw fixation is performed using any of a wide variety of plates. Recommendations vary from semitubular plates to dynamic compression plates, low-contact dynamic compression plates, and double plating. However, fixation of these fractures with semitubular or reconstruction plates is not as strong biomechanically as fixation with dynamic compression plating or the newer locking-plate technology.

Obtaining purchase in 6 cortices on either side of the fracture is recommended. Lag screw fixation is also appropriate when the fracture pattern allows. Again, cancellous bone grafting is suggested in fractures with comminution and/or bone loss.

Mehmet et al conducted an evaluation of the biomechanical properties and the stability of a locking clavicle plate (LCP), a dynamic compression plate (DCP), and an external fixator (Ex-fix) and found significant differences between them. The investigators used an unstable displaced clavicle fracture model under torsional and 3-point bending loading. For torsion and bending, an overall significant difference was found between the 3 types of fixation equipment in terms of failure loads; a significant difference was also noted between the LCP and the other 2 models in terms of initial stiffness. The LCP was significantly more stable than the DCP and Ex-fix when subjected to torsional and bending cyclic loading.[38]

Much controversy exists in the literature regarding the appropriate management of fractures of the distal third of the clavicle. Incidence of nonunion of these fractures is high, and current recommendations are to fix these injuries surgically. Neer found that although distal third clavicle fractures are rare, they account for approximately half of all clavicular nonunions.[39] Many different procedures have been described to fix these fractures, and intramedullary fixation is gaining popularity. However, a problem exists with migration of intramedullary wires.

Many articles have been published focusing on the treatment of distal third clavicle fractures. As mentioned previously, these injuries account for about 12-15% of all clavicle fractures.[40]

Type I fractures

Fractures of the distal clavicle are further divided into types I-III. In type I injuries, the coracoclavicular ligaments are intact and the fracture is usually minimally displaced or nondisplaced. The first image below illustrates displacing forces; the second image illustrates a type I 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.

Type I fractures, as well as type III fractures (discussed below), are treated symptomatically with ice, analgesics, and a sling for support. Early motion with passive shoulder range-of-motion exercises is strongly urged to prevent the development of degenerative arthritis and to reduce the risk of adhesive capsulitis.

Type II fractures

Type II fractures are at the level of the coracoclavicular ligaments and are further subdivided into IIA and IIB fractures, as follows:

• Type IIA - The conoid and trapezoid ligaments remain intact and the fracture is medial to the ligaments

• Type IIB - These involve a disruption of the conoid ligament, with the trapezoid ligament remaining intact and attached to the distal fracture fragment; included in the IIB fracture is the more rare variant in which both the conoid and trapezoid are ruptured

Type IIB injuries tend to have significant displacement of the fracture fragments because of the loss of the downward restraint of the medial fragment by the coracoclavicular ligaments. Type II fractures are depicted in the images below.

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.

Operative treatment

Many techniques of surgical fixation of distal clavicle fractures have been described in the literature. In general, surgical fixation is recommended for type II distal clavicle fractures. Treatment of these fractures requires direct visualization and reduction of the fracture fragments through a vertical incision. After the fracture is visualized and reduced, the coracoclavicular interval is stabilized.[41]

Stable fracture fixation can be achieved in many ways, including through combinations of a coracoclavicular screw, Dacron or Mersilene tape, tension banding, a Kirschner wire (K-wire), and clavicular plates. Regardless of the exact technique used, the general principles of fracture reduction and fixation and stabilization of the coracoclavicular interval apply.

Orthopedic consultation before 72 hours is recommended for type IIB clavicle fractures, because these injuries have a 30% incidence of nonunion and may require surgical repair.[10] If surgery is delayed, the results of treatment may be more problematic.[42]

Chen et al reported that 10 of 11 patients had good to excellent results with their repair technique for type IIB fractures. This procedure involves reconstruction of the conoid ligament with Mersilene tape, with the torn ligament being primarily repaired as well. The fracture is fixed with a number 7 or smaller steel wire. The wire fixation and the Mersilene tape provide stability for the fracture, allowing the repaired coracoclavicular ligament to heal.[43]

All fractures in Chen's study united within 6 months, and 10 of 11 fractures maintained the coracoclavicular reduction. Nine of the 11 patients had full pain relief and restoration of their full range of motion, and 10 of the patients were satisfied with the surgery and stated they would undergo the procedure again for treatment of this fracture.

Kao et al reported on an operative technique with which 11 of 12 fractures formed bony unions, with these patients experiencing pain-free range of motion. The study included 7 patients with displaced type IIA fractures and 3 patients with type IIB fractures; all of them underwent open reduction and internal fixation with Kirschner wires (K-wires) and a tension band.[44] Also included were 2 patients with comminuted distal clavicle fractures. Kao et al's technique spared the soft tissue around the fracture site, including the AC joint, with dissection limited only to the fracture site.

Another surgical option for distal clavicle fractures involves using a Dacron arterial graft as a sling around the medial fracture fragment and the coracoid. This acts to stabilize the medial fragment in a reduced position in the superior/inferior plane. This procedure was performed on 11 acute distal clavicle fractures, all of which united with full range of motion.

Four other patients included in this study were previously diagnosed as having established nonunions. These patients underwent fixation of the nonunion with a lag screw, iliac crest bone grafting, and stabilization with a Dacron sling. All of the patients subsequently developed bony union of the fracture site with full range of motion. Of note, the Dacron sling did cause some slight erosion of the clavicle that was in contact with the sling; however, this did not progress and did not cause any problems for the patients. The sling is also thought to allow for the return of function of the coracoclavicular ligaments. Once the coracoclavicular ligaments reconstitute, the Dacron sling becomes redundant.

The use of Wolter clavicular plates for unstable, comminuted distal clavicle fractures was reported to result in good bony union and range of motion in all 16 patients in a series by Mizue et al.[45] This procedure, however, requires a second operation for removal of the plate and is recommended only for injuries that are severely comminuted and unstable.

Type III fractures

Type III injuries are distal to the coracoclavicular ligaments and involve the acromioclavicular (AC) joint. These fractures are usually minimally displaced or nondisplaced and are treated nonoperatively, as previously described.

Current management of medial clavicle fractures remains nonoperative, including with ice, analgesics, and a sling for support, and the treatment results have been consistently good. Significant displacement is rare because of the extensive ligamentous attachments. However, if significant displacement occurs with this fracture, further imaging studies are warranted. A CT scan should help to define the nature of the fracture displacement and the status of the nearby neurovascular structures.

Group III fractures may be associated with intrathoracic injuries or the development of late complications, such as arthritis.[46]

Once the fracture pain begins to subside and the patient is weaning off pain medications, begin range-of-motion exercises with the shoulder and elbow out of the sling to prevent stiffening of these joints. Exercises should be performed within the limits of comfort.

As pain continues to improve, isometric exercises of the shoulder girdle and arm musculature can begin. These can be performed under the supervision of a physical therapist or by the patient on his or her own, with an instructional handout for guidance.

As fracture healing progresses, based on clinical and radiographic examination findings, isotonic exercises can begin using light weights or elastic bands for resistance.

For athletes, return to play depends on the location and severity of the clavicle fracture, the degree of clinical and radiographic healing, and the sport played.

Noncontact sports

Return to noncontact sports is allowed when (1) the clavicle fracture is healed (ie, no tenderness is present, and radiographs show callus formation) and (2) the patient has full, painless range of motion and has regained near-normal strength. These milestones are usually reached at about 6 weeks from the time of the injury.

Contact sports

Return to contact sports takes much longer because the risk of refracture is high. The return to play should be delayed until the fracture union is solid, which can take from 2-6 months from the time of the injury or 4-6 weeks after clinical and radiographic union. A donut pad or fiberglass shoulder shell may be used for extra protection.

A study that included 17 NFL athletes who suffered a clavicle fracture reported a 3.47 months median return to play after injury with no significant impact on performance. However, this data needs to be interpreted with caution since 3 additional players never returned to play and 3 others did not return to play for an entire season and all 6 players were excluded from the performance analysis.[48]

Rehabilitation Program

Content.

Control discomfort with nonsteroidal anti-inflammatory drugs (NSAIDs), and if pain continues, add a narcotic analgesic. The latter often have a sedative effect, which is beneficial for patients who have sustained trauma. Acetaminophen is the drug of choice (DOC) for treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs, as well as in those who have upper gastrointestinal (GI) disease or are taking oral anticoagulants.

Prophylactic intravenous antibiotics that cover typical skin flora (eg, cefazolin sodium) are necessary with open fractures. Tetanus immunization also may be indicated.

Class Summary

NSAIDs are a drug of choice for pain resulting from injuries. In cases of severe pain, opioid analgesic agents may be prescribed.

Ibuprofen (Motrin, Advil, Neoprofen, Ultraprin)

Ibuprofen inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis. It is used to provide relief of cervical myofascial pain.

Indomethacin (Indocin)

Indomethacin is thought to be the most effective NSAID for the treatment of ankylosing spondylitis, although no scientific evidence supports this claim. It is used for relief of mild to moderate pain; it inhibits inflammatory reactions and pain by decreasing the activity of COX, which results in a decrease of prostaglandin synthesis.

Naproxen (Naprosyn, Naprelan, Aleve, Anaprox)

Naproxen is used for relief of mild to moderate pain; it inhibits inflammatory reactions and pain by decreasing the activity of COX, which results in a decrease of prostaglandin synthesis.

Diclofenac (Voltaren, Cataflam XR, Zipsor, Cambia)

Diclofenac inhibits prostaglandin synthesis by decreasing COX activity, which, in turn, decreases the formation of prostaglandin precursors.

Ketoprofen

Ketoprofen is used for relief of mild to moderate pain and inflammation. Small dosages are indicated initially in small patients, elderly patients, and patients with renal or liver disease. Doses higher than 75 mg do not increase the therapeutic effects. Administer high doses with caution, and closely observe the patient's response.

Celecoxib (Celebrex)

Celecoxib primarily inhibits COX-2. COX-2 is considered an inducible isoenzyme, induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited; thus, GI toxicity may be decreased. Seek the lowest dose of celecoxib for each patient. It is extensively metabolized in the liver primarily via cytochrome P450 2C9.

Although increased cost can be a negative factor, the incidence of costly and potentially fatal GI bleeds is clearly less with COX-2 inhibitors than with traditional NSAIDs. Ongoing analysis of cost avoidance of GI bleeds will further define the populations that will most benefit from COX-2 inhibitors.

Class Summary

Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained fractures.

Acetaminophen and codeine (Tylenol #3)

This combination is indicated for the treatment of mild to moderate pain.

Acetaminophen (Tylenol, Aspirin Free Anacin, Cetafen, APAP 500, Mapap Extra Strength)

Acetaminophen is the drug of choice for the treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs, as well as in those with upper GI disease or those who are taking oral anticoagulants.

Hydrocodone bitartrate and acetaminophen (Vicodin ES, Lortab, Lorcet Plus, Norco, Maxidone)

This agent is indicated for the relief of moderately severe to severe pain.

Oxycodone and acetaminophen (Percocet, Primlev, Roxicet, Endocet)

The oxycodone/acetaminophen combination is indicated for the relief of moderately severe to severe pain.

Class Summary

Therapy must cover all likely pathogens in the clinical setting.

Cefazolin

This agent is a first-generation semisynthetic cephalosporin that, by binding to 1 or more penicillin-binding proteins, arrests bacterial cell wall synthesis and inhibits bacterial replication. It is primarily active against skin flora, including Staphylococcus aureus.

Gentamicin

Gentamicin is an aminoglycoside antibiotic used for gram-negative bacterial coverage. It is commonly used in combination with an agent against gram-positive organisms and one that covers anaerobes. The drug is used in conjunction with ampicillin or vancomycin for prophylaxis in patients with open fractures.

Dosing regimens are numerous and are adjusted based on creatinine clearance (CrCl) and changes in volume of distribution. Gentamicin may be given intravenously or intramuscularly.

Ampicillin

Ampicillin is used along with gentamicin for prophylaxis in patients with open fractures. It interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms.

Vancomycin

This potent antibiotic is directed against gram-positive organisms and is active against enterococcal species. It is useful in septicemia and skin structure infections. Vancomycin is used in conjunction with gentamicin for prophylaxis in penicillin-allergic patients with open fractures.

Dose adjustment may be necessary in patients with renal impairment.

Class Summary

Tetanus toxoid is used for immunization against tetanus. A booster injection in previously immunized individuals is recommended to prevent the disease.

Tetanus toxoid

This agent induces active immunity against tetanus. Immunizing agents of choice for most adults and children older than 7 years are the tetanus and diphtheria toxoids. Booster doses are administered to maintain tetanus immunity throughout life.

Pregnant patients should receive only tetanus toxoid, not a diphtheria antigen ̶ containing product.

In children and adults, tetanus toxoid may be administered into the deltoid or midlateral thigh muscles. In infants, the preferred site of administration is the midthigh laterally.