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Clavicle Fracture

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Other Names

  • Collar Bone Fracture
  • Midshaft Clavicle Fracture
  • Clavicle Shaft Fracture

Background

  • This page references all fractures patterns of the Clavicle
    • Can be broken up into distal third, mid third and proximal third

Epidemiology

  • Represent 2-5% of all fractures in adults[1]
  • 10-15% of fractures in children[2]
  • Incidence of 29-64 per 100,000 person years[3]
  • Bimodal distribution of young males (under 30) and elderly patients (over 70)[4]
  • Midshaft, diaphyseal or middle third
    • 2/3 of clavicle fractures in adults[1]
    • 90% of clavicle fractures in children
  • Lateral shaft/ third
    • 25% of all clavicle fractures
  • Medial shaft/ third
    • 2-3% of clavicle fractures

Pathophysiology

  • Mechanism
    • Fall on outstretched hand
    • Direct trauma

Associated Injuries

Pathoanatomy

Lateral

Medial


Risk Factors


Differential Diagnosis


Clinical Features

  • General: Physical Exam Forearm
  • History
    • Will report some type of trauma
    • Complain of anterior shoulder pain, swelling, bruising, deformity
  • Physical
    • Evaluate for deformity, tenting, open fracture
    • Perform careful neurovascular exam

Evaluation

  • Radiographs
    • Standard Radiographs Shoulder may act as a screening tool, consider bilateral
    • Need dedicated clavicle views
    • Zanca view (15°) cephalic tilt
      • Helpful to determine cranial/caudal displacement
      • Weighted stress views no longer utilized
  • CT
    • Helpful to evaluate degree of injury i.e. displacement, shortening, comminution
    • Evaluate for articular extension
    • Neurovascular injuries

Classification

Allman Classification

  • Type I: Middle 1/3[5]
  • Type II: Lateral 1/3
  • Type III: Medial 1/3

Neer Classification

  • Describes lateral 1/3 clavicle fractures[2]
  • Type 1: distal to the CC ligaments, minimally displaced fracture that is typically stable
  • Type II: medial fragment that is discontinuous with the CC ligaments
    • Craig modification: Importance of coronoid ligament[6]
    • Separately classifies intra-articular and pediatric clavicle fractures
  • Type III: intra-articular fracture of the acromioclavicular joint with intact CC ligaments

Edinburgh (or Robinson) Classification

  • Uses Allman classification: medial (type I), middle (type II), and lateral (type III) thirds[7]
  • Fracture is then subdivided based on magnitude of displacement
    • Type A: Less than 100% displacement
    • Type B: Greater than 100% displacement
  • Type III can be further subdivided based on articular surface involvement
    • Subgroup 1: No articular involvement
    • Subgroup 2: Interarticular extension
  • Type II can be categorized by the degree of fracture comminution
    • Subgroup 1: Simple or wedge-type fracture patterns
    • Subgroup 2: Segmental fracture patterns

Summary

  • Modified Neer (Craig) Classification[8]
    • Most prognostic when predicting delayed union or nonunion of lateral-third fractures
  • Edinburgh (or Robinson) Classificatio
    • Greatest prognostic value for middlethird fractures

Management

Medial Third

Nonoperative

  • Almost always nonoperative
  • Typically non- or minimally displaced and rarely involve the sternoclavicular joint
  • Immobilization: Shoulder Sling or Figure 8 Brace
    • Duration 2 to 6 weeks
    • Encourage early range of motion
  • Avoid contact sports for at least 4 to 5 months

Operative

  • Indications
    • Injury or risk to mediastinal structures
    • "Floating shoulder" polytrauma
    • Significantly displaced
  • Technique
    • Closed reduction in the emergency department if possible
    • Open reduction and internal fixation definitively

Pediatric Considerations

  • Most often involve the medial epiphysis of the clavicle
  • Doesn't ossify until age 20-25
  • Easily confused with sternoclavicular joint dislocation

Middle Third

Nonoperative

  • Typically first line therapy
    • Supported by Neer, Rowe studies stating non-union rates higher with surgical (3%) than non-surgical (1%)[9]
    • Studies have supported higher patient satisfaction rates with nonoperative treatment[10]
    • Meta-analys: nonunion rates of nondisplaced (5.9%) vs displaced (15.1%)[11]
  • Indications
    • Nondisplaced (Edinburgh type 2A)
    • < 2 cm shortening, <1 cm displacement, no neurovascular injuries
  • Place in Shoulder Sling or Figure 8 Brace

Operative

  • Hard indications:
    • Skin tenting
    • Open
    • Neurovascular compromise
    • Multiple trauma
    • Floating shoulder
  • Displaced midshaft (Edinburgh type 2B)
    • More controversial, nonop being called into question
    • Canadian ortho trauma society has several large studies showing higher nonunion rates with nonoperative approach[12][13]
    • Shortening > 2 cm predictive of nonunion/malunion[14]
    • Nonunion rate as high as 20% in displaced, comminuted fractures treated nonsurgically[7]
  • Surgical management should be considered in younger patients with clavicle shortening or deformity

Pediatric Considerations

  • Less controversial than adults due to rapid bone healing and remodeling capabilities
  • Virtually all are treated nonoperatively
  • Surgical indications
    • Open
    • Neurovascular compromise
    • Consider degree of shortening, displacement
  • Treat with Shoulder Sling or Figure 8 Brace
    • No difference between sling or figure 8 brace for alignment or union rates but sling better tolerated[15]
    • Immobilize for 6-8 weeks
    • Need radiographic evidence of healing prior to return to play

Lateral Third

Nonoperative

  • Treatment modality of choice
  • 98% of patients have good outcomes with minimally displaced or nondisplaced fractures[16]
  • Most are nondisplaced or minimally displaced and extra-articular<ref name="ref3">
  • Stable fractures (Neer Type I, III, IV)
  • Treat with Shoulder Sling or Figure 8 Brace

Operative

  • Hard indications:
    • Skin tenting
    • Open
    • Neurovascular compromise
    • Multiple trauma
    • Floating shoulder
  • Soft indication
    • Coracoclavicular ligament stabilizes distal clavicle
    • Injury see in Ediburgh type 3B with nonunion rates as high as 28%<ref name="ref2">

Pediatric Considerations

  • Lateral clavicle physis fuses at approximately age 25
  • Injuries more common to the physis, i.e. separation, than cortical break
  • Most can be treated nonoperatively

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play

  • Needs to be updated

Complications

  • Nonunion: high risk
  • Shoulder dysfunction
  • Residual pain
  • Malunion
  • Surgical complications

See Also


References


  1. 1.0 1.1 Nordqvist A, Petersson C (1994) The incidence of fractures of the clavicle. Clin Orthop Relat Res 300:127–132
  2. 2.0 2.1 Neer CS II. Fractures of the distal third of the clavicle. Clin Orthop Relat Res 1968;58:43-50.
  3. Postacchini F, Gumina S, De Santis P, Albo F (2002) Epidemiology of clavicle fractures. J Shoulder Elbow Surg 11(5):452–456
  4. Stanley D, Trowbridge EA, Norris SH. The mechanism of clavicular fracture. A clinical and biomechanical analysis. J Bone Joint Surg Br 1988;70:461-4
  5. Allman FL Jr. Fractures and ligamentous injuries of the clavicle and its articulation. J Bone Joint Surg Am 1967;49:774-84.
  6. Craig EV. Fractures of the clavicle. In: Rockwood CA, Green DP, editors. Fractures in adults. 6th ed., Vol 1. Philadelphia: Lippincott Williams & Wilkins; 2006. p. 1216-7.
  7. 7.0 7.1 . Robinson CM. Fractures of the clavicle in the adult. Epidemiology and classification. J Bone Joint Surg Br 1998;80:476-84.
  8. O’Neill BJ, Hirpara KM, O’Briain D, McGarr C, Kaar TK. Clavicle fractures: a comparison of five classification systems and their relationship to treatment outcomes. Int Orthop 2011;35:909-14. doi:10. 1007/s00264-010-1151-0
  9. Rowe CR. An atlas of anatomy and treatment of midclavicular fractures. Clin Orthop Relat Res 1968;58:29-42.
  10. Eskola A, Vainionpaa S, Myllynen P, Patiala H, Rokkanen P. Outcome of clavicular fracture in 89 patients. Arch Orthop Trauma Surg 1986; 105:337-8.
  11. Zlowodzki M, Zelle BA, Cole PA, Jeray K, McKee MD. Treatment of acute midshaft clavicle fractures: systematic review of 2144 fractures. J Orthop Trauma 2005;19:504-7.
  12. McKee MD, Pedersen EM, Jones C, Stephen DJ, Kreder HJ, Schemitsch EH, et al. Deficits following nonoperative treatment of displaced midshaft clavicular fractures. J Bone Joint Surg Am 2006; 88:35-40. doi:10.2106/JBJS.D.02795
  13. . McKee MD, Wild LM, Schemitsch EH. Midshaft malunions of the clavicle. J Bone Joint Surg Am 2003;85:790-7.
  14. 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;79:537-41.
  15. Andersen K, Jensen PO, Lauritzen J. Treatment of clavicular fractures. Figure-of-eight bandage versus a simple sling. Acta Orthop Scand 1987;58:71-4.
  16. Robinson CM, Court-Brown CM, McQueen MM, Wakefield AE. Estimating the risk of nonunion following non-operative treatment of a clavicle fracture. J Bone Joint Surg Am 2004;86:1359-65.
Created by:
John Kiel on 4 July 2019 09:45:47
Authors:
Last edited:
13 November 2020 13:38:29
Categories:
Trauma | Shoulder | Upper Extremity | Fractures | Acute | Chest