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The clavicle, proximal humerus and the scapula together form the shoulder joint. The clavicle also forms the bony connection between the upper limb and the thorax. It articulates with the acromion process of the scapula laterally, at the acromioclavicular joint, and the manubrium of the sternum medially, at the sternoclavicular joint. Ligaments connect the coracoid process of the scapula to the mid-clavicle. The clavicle protects the brachial plexus, major underlying vessels and the lung apex.
- This is one of the most common acute shoulder injuries.
- It accounts for 2-5% of adult fractures.[1, 2]
- It is more common in children.
- It is the most common of all paediatric fractures.
Mechanism of injury
- It is usually caused by a fall on to the lateral shoulder.
- Less commonly, it occurs after a direct blow to the clavicle or by falling on an outstretched arm.
- It is a common injury in contact sports, cycling and winter sports.
- In the neonate:
- Complication of breech delivery.
- One recognised third-line management of shoulder dystocia is surgical division of the clavicle (cleidotomy).
- History of a fall or trauma.
- Pain, swelling and tenderness around the clavicle.
- There may be obvious deformity, including tenting of the skin and bruising.
- There may be non-use of the arm on the affected side in neonates.
Firstly, assess 'Airway, Breathing, Circulation' (ABC) and manage as necessary.
- Diagnosis of a fractured clavicle can usually be made clinically, as the clavicle is superficial and easily palpable. Examine the clavicle from behind the patient.
- Auscultate and percuss the lung fields to exclude a complicating pneumothorax.
- Perform a neurovascular examination of the upper limb on the affected side - examine the upper limb pulses; look for evidence of decreased perfusion, including changes in skin colour; assess sensation and muscle power.
- Assess and examine for any other injuries.
- Anteroposterior view X-ray of the clavicle detects most fractures.
- Non-displaced fractures may be better seen on a 20° or 45° cephalic tilt view.
- Ensure that there is no co-existing scapular fracture which would mean a 'floating shoulder'.
- Sternoclavicular or acromioclavicular joint disruption may require CT/MRI scanning to characterise fully.
- CXR if pneumothorax is suspected.
- Angiography if vascular damage is suspected.
- Group 1: middle one third of the clavicle (the shaft). Most common (approximately 80%) in both adults and children. If displaced, the lateral fragment is usually pulled down by weight of limb and the medial fragment tends to be displaced upwards by the action of the sternocleidomastoid muscle.
- Group 2: lateral one third of the clavicle (the acromial end). 10-15% of clavicle fractures. Subdivided into:
- Type I - non-displaced/minimal displacement; intact ligaments hold the fragments together.
- Type II - displaced; the coracoclavicular ligament ruptures and the medial segment of the fractured clavicle displaces upwards.
- Type III - articular surface fractures (involving the acromioclavicular joint).
- Group 3: medial one third of the clavicle (the sternal end). 5% of clavicle fractures. If displaced, these have a higher rate of significant intrathoracic or neurovascular injury.
In a GP setting
- Assess ABC, perform a full examination and examine for any other injury, as described above.
- Immobilise in a sling the arm on the affected side.
- Refer to secondary care for X-ray investigation.
After confirmed X-ray diagnosis
- Traditionally, most clavicular fractures have been managed conservatively, even if they are displaced.
- Open fractures obviously need orthopaedic referral.
- Management then depends on the fracture classification:
- Group 1: most are treated conservatively, whether displaced or non-displaced, with immobilisation using a sling, figure-of-eight bandage, and straps or splints. A Cochrane review in 2014 concluded that further research is warranted to determine which method of conservative management is appropriate.Displaced fractures may be considered for surgical treatment, due to the greater risk of non-union, although evidence of superiority over conservative management is limited.
- Group 2: type I and type III fractures can be treated with immobilisation. Type II fractures may require surgery. The method of surgical treatment for clavicular fractures is controversial. Intramedullary screws or nails and plate fixation of the clavicle are the most usual surgical options.
- Group 3: if non-displaced, immobilisation is all that is needed. Displaced fractures may require surgery.
- Analgesia such as paracetamol or, if the pain is severe, opiates, should be prescribed.
- Orthopaedic outpatient follow-up is usually arranged.
- Mobilisation exercises/physiotherapy should be provided.
Recent management developments
Some recent studies have shown that long-term results from conservative, or non-operative management of clavicular fractures are not as favourable as previously considered:
- 42% of people still had sequelae at six months in one study. The same study suggests the exploration of alternative treatment options, including surgery, for certain clavicular fracture types.
- A recent multicentre randomised controlled trial in Canada showed that displaced clavicle shaft fractures treated by surgical plate fixation had improved functional outcome and a lower rate of malunion and non-union when compared with non-operative treatment at one year.
- Another study into non-operative treatment of displaced mid-clavicular shaft fractures detected significant residual deficits in shoulder strength and endurance. However, there was no control group that was treated surgically.
- Intramedullary nailing of mid-clavicular fractures was compared with non-operative treatment in another study. The patients who had undergone nailing showed significantly better results concerning shoulder function, pain, personal satisfaction and cosmetic result. Return to work time was also faster.
The method of surgical treatment for clavicular fractures is controversial. Intramedullary screws or nails and plate fixation of the clavicle are the most usual surgical options. A very recent development is the use of an arthroscopic procedure to stabilise clavicular fractures, using a 'tightrope'.
Complications are uncommon.
- Brachial plexus injury.
- Blood vessel injury (including subclavian vessels, internal jugular vein and axillary artery).
- Non-union and malunion (no radiographic healing at 4-6 months). The rate of non-union was 7% in one series.In another, it was 6.2%. Both studies were undertaken on groups receiving non-operative treatment.
- Deformity due to excessive callus formation during fracture healing.
- Thoracic outlet syndrome.
- Brachial plexus compression due to callus formation.
- Arthritis (more common in fractures involving the articular surface - group 2, type III).
- If managed promptly and correctly, this is excellent.
- Healing normally takes 6-8 weeks in an adult and 3-4 weeks in a child.
- One study showed that asymptomatic non-union does not appear to affect the functional outcome adversely in the medium term.
Further reading and references
; Wheeless' Textbook of Orthopaedics
; Wheeless' Textbook of Orthopaedics
; 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 Aug19(7):504-7.
; Acute shoulder injuries. Am Fam Physician. 2004 Nov 1570(10):1947-54.
; Royal College of Obstetricians and Gynaecologists, March 2012
; Fractures and ligamentous injuries of the clavicle and its articulation. J Bone Joint Surg Am. 1967 Jun49(4):774-84.
; Wheeless' Textbook of Orthopaedics
; Sequelae from clavicular fractures are common: a prospective study of 222 patients. Acta Orthop. 2005 Aug76(4):496-502.
; Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am. 2007 Jan89(1):1-10.
; Deficits following nonoperative treatment of displaced midshaft clavicular fractures. J Bone Joint Surg Am. 2006 Jan88(1):35-40.
; Treatment of mid-clavicular fractures in adults. Early results after rucksack bandage or elastic stable intramedullary nailing. Unfallchirurg. 2005 Sep108(9):707-14.
; Arthroscopic 'tightrope' stabilisation of neer type 2 clavicular fractures. Science Direct. January 2007.
; Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. J Bone Joint Surg Am. 2004 Jul86-A(7):1359-65.
; Primary nonoperative treatment of displaced lateral fractures of the clavicle. J Bone Joint Surg Am. 2004 Apr86-A(4):778-82.
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