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Clavicle Fracture

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Other Names

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

Background

Case Report: Middle Third Clavicle Fracture
  • This page references all fractures patterns of the Clavicle
    • Can be broken up into distal third, mid third and proximal third

History

  • Etymology: clavicula meaning "tendril, small key, rod, bolt"

Epidemiology

  • Represent 2-5% of all fractures in adults[1]
  • 10-15% of fractures in children[2]
    • Some data suggests it is the most common fracture of childhood (need citation)
  • Incidence of 29-64 per 100,000 person years[3]
  • Bimodal distribution
    • 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

Financial Burden

  • Systematic review (2020)[5]
    • Overall cost for operative treatment is $10,000 USD
    • Overall cost for nonoperative treatment is $8,000 USD
    • Mean absence from work: 8 to 193 days (operative), 24-69 days (nonoperative)

Introduction

Anatomy of the clavicle[6]
Clavicle fractures can loosely be broken down into middle third (A), distal/lateral third (B) and proximal/medial third (C).

General

  • Most common fracture of the shoulder girdle
  • 80% of cases involve the mid shaft of the clavicle
  • The vast majority of cases can be succesfully managed nonoperatively

Mechanism

  • Most cases involve fall directly onto lateral shoulder.
  • Fall on outstretched hand
  • Direct trauma
  • In younger patients, traffic accidents and sports account for most fractures
  • Traffic accident-induced clavicle fractures[7]
    • 39% occur in cyclists
    • 26% in car drivers/ passengers
    • 17% in pedestrians
    • 17% in motorcyclists

Associated Conditions

Anatomy of the Clavicle


Risk Factors


Differential Diagnosis

Differential Diagnosis Shoulder Pain


Clinical Features

The photograph above shows a patient with a mid-clavicle fracture. The distal end of the proximal fracture fragment is causing tenting of the skin (arrow).[8]

History

  • Will report some type of trauma
    • Most commonly fall onto lateral shoulder
    • Patient may report a history of a cracking sound during the injury
  • Complain of anterior shoulder pain, swelling, bruising, deformity
  • Pain localized over the fracture site
  • Arm is often held in adduction, internal rotation
  • Worse with movement of arm

Physical: Physical Exam Shoulder

  • Evaluate for deformity, tenting, open fracture
  • Visible deformity is often present
    • Middle 1/3 typically pulled downward by pectoralis major, latissimus dorsi
  • Tenderness at the site of the fracture
    • Evaluate for skin tenting, which implies impending open fracture
  • Perform careful neurovascular exam

Evaluation

Middle 1/3 clavicle fracture
Distal 1/3 clavicle fracture
Mid-shaft clavicle fracture with callous formation. Vertical arrows show the end of each fracture fragment; the horizontal arrow shows bridging callus at six weeks with a restored cortical bridge.[9]

Radiographs

CT

  • Helpful to evaluate degree of injury i.e. displacement, shortening, comminution
  • Evaluate for articular extension
  • Neurovascular injuries
  • Better evaluates the sternoclavicular/ proximal lesions

Ultrasound

  • A meta-analysis showed ultrasound to be highly sensitive and specific for clavicle fractures[10]
  • It's exact role when compared to CT and XR is not entirely clear

Classification

Allman Classification

  • Type I: Middle 1/3[11]
  • 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[12]
    • 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[13]
    • Most prognostic when predicting delayed union or nonunion of lateral-third fractures
  • Edinburgh (or Robinson) Classification
    • Greatest prognostic value for middle third fractures

Management

Example of application of the same locking plate, and its consequences. A. Anatomic internal fixation by superior locking plate. B. Reduction defect and medial material obstruction. C. Reduction defect and anterior plate positioning, not matching curves.[14]

Medial Third

Nonoperative

  • Almost always nonoperative
  • Typically non- or minimally displaced and rarely involve the sternoclavicular joint
  • Immobilization: Shoulder Sling, less commonly and historically used was a 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%)[15]
    • Studies have supported higher patient satisfaction rates with nonoperative treatment[16]
    • Meta-analys: nonunion rates of nondisplaced (5.9%) vs displaced (15.1%)[17]
  • 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[18][19]
    • Shortening > 2 cm predictive of nonunion/malunion[20]
    • 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[21]
    • 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[22]
  • Most are nondisplaced or minimally displaced and extra-articular[7]
  • 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 Edinburgh type 3B with nonunion rates as high as 28%[2]

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/Work

  • Depends largely on age, location, severity, degree of healing and the occupation/sport
  • Most patients can return to pre-injury levels around 6-8 weeks
  • Avoid contact sports, strenuous activities until clinically healed
  • General return to sport guidelines
    • Full range of motion
    • Normal strength of the shoulder
    • No pain with forceful palpation of the fracture site
  • Noncontact sports may return sooner than contact/ collision sports
  • Return to play after surgical management[23]
    • Some experts recommend hardware removal before return to play
    • This typically occurs 1 year after placement

Prognosis and Complications

Prognosis

  • In most cases in healthy patients, prognosis is excellent

Complications

  • Nonunion: high risk
    • Middle 1/3: Rate is 6% for all fractures, 15% for displaced fractures treated nonoperatively (need citation)
    • Predictors of non-union: increasing displacement, comminution, advanced age, female gender, smoking status[24]
  • Shoulder dysfunction
  • Residual pain
  • Malunion
    • Shortening greater than 2 cm associated with neurological and functional problems[25]
    • Nonunion rates for distal third clavicle fractures range from 28% to 44% (need citation)
    • Many patients with clavicle fracture nonunion are asymptomatic and do not require any further treatment
  • Poor cosmesis
  • Surgical complications
  • Brachial Plexus Injury
  • Great vessel injury
  • Post-traumatic arthritis

See Also

Internal

External


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 2.2 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. Kask G, Raittio L, Mattila VM, Launonen AP. Cost-Effectiveness of Operative Versus Non-Operative Treatment for Clavicle Fracture: a Systematic Literature Review. Curr Rev Musculoskelet Med. 2020 Aug;13(4):391-399. doi: 10.1007/s12178-020-09640-0. PMID: 32383036; PMCID: PMC7340703.
  6. Image courtesy of getbodysmart.com
  7. 7.0 7.1 7.2 7.3 . Robinson CM. Fractures of the clavicle in the adult. Epidemiology and classification. J Bone Joint Surg Br 1998;80:476-84.
  8. Riccio AI, Parikh SN. Examination of the injured child. In: Pediatric Musculoskeletal Physical Diagnosis: A Video-Enhanced Guide, 1st ed, Noonan K, Kocher M (Eds), Lippincott Williams & Wilkins 2020. Copyright © 2014 Wolters Kluwer Health, Inc.
  9. Nicholson, J. A., et al. "What is the role of ultrasound in fracture management?: diagnosis and therapeutic potential for fractures, delayed unions, and fracture-related infection." Bone & Joint Research 8.7 (2019): 304-312.
  10. Hassankhani A, Amoukhteh M, Jannatdoust P, Valizadeh P, Gholamrezanezhad A. A systematic review and meta-analysis on the diagnostic utility of ultrasound for clavicle fractures. Skeletal Radiol. 2024 Feb;53(2):307-318. doi: 10.1007/s00256-023-04396-3. Epub 2023 Jul 12. PMID: 37433884.
  11. Allman FL Jr. Fractures and ligamentous injuries of the clavicle and its articulation. J Bone Joint Surg Am 1967;49:774-84.
  12. 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.
  13. 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
  14. Ropars, M., H. Thomazeau, and D. Huten. "Clavicle fractures." Orthopaedics & Traumatology: Surgery & Research 103.1 (2017): S53-S59.
  15. Rowe CR. An atlas of anatomy and treatment of midclavicular fractures. Clin Orthop Relat Res 1968;58:29-42.
  16. 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.
  17. 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.
  18. 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
  19. . McKee MD, Wild LM, Schemitsch EH. Midshaft malunions of the clavicle. J Bone Joint Surg Am 2003;85:790-7.
  20. 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.
  21. 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.
  22. 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.
  23. Schlegel, TF, Hawkins, RJ. Fractures of the shoulder girdle. In: Shoulder Injuries in the Athlete: Surgical Repair and Rehabilitation, Hawkins, RJ, Misamore, GW (Eds), Churchill Livingstone, New York 1996. p.219.
  24. Evidence-Based orthopedics. (2012). Wiley-Blackwell. https://doi.org/10.1002/9781119413936
  25. McKee MD, Wild LM, Schemitsch EH. Midshaft malunions of the clavicle. J Bone Joint Surg Am. 2003 May;85(5):790-7.
Created by:
John Kiel on 4 July 2019 09:45:47
Authors:
Last edited:
16 May 2024 18:29:28
Categories:
Trauma | Shoulder | Upper Extremity | Fractures | Acute | Chest