Fractured Clavicle

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.

• One of the most common acute shoulder injuries.
• Accounts for 2–5% of adult fractures.^1,2
• More common in children.
• Most common of all paediatric fractures.³

• Usually caused by a fall onto the lateral shoulder.
• Less commonly occurs after a direct blow to the clavicle or by falling on an outstretched arm.²
• 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).⁴

• 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 nonuse of the arm on the affected side in neonates.

Firstly assess ABC (Airway, Breathing, Circulation) 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 Xray of the clavicle detects most fractures.
• Non-displaced fractures may be better seen on a 20 or 45-degree cephalic tilt view.
• Ensure that there is no co-existing scapula fracture which would mean a 'floating shoulder'.
• Sternoclavicular or acromioclavicular joint disruption may require CT/MRI scanning to fully characterise.
• Chest Xray if suspect pneumothorax.
• Angiography if suspect vascular damage.

Allman classification⁵

• Group 1: Middle one third of the clavicle (the shaft). Most common (approximately 80%) in both adults and children.⁶ 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.⁶ 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%.⁶ If displaced have higher rate of significant intrathoracic or neurovascular injury.²

In a GP setting

• Assess ABC, perform a full examination and examine for any other injury as described above.
• Immobilize the arm on the affected side in a sling.
• Refer to secondary care for Xray investigation.

• 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: Can be treated conservatively, whether displaced or non-displaced, with immobilisation using a sling or figure-of-eight bandage (clavicle strap).
  • 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 nondisplaced, 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.
• Mobilization exercises/physiotherapy should be provided

Some recent studies have shown that long term results from conservative, or nonoperative, management of clavicular fractures are not as favourable as previously considered:

• 42% of people still had sequelae at 6 months in one study. The same study suggests the exploration of alternative treatment options, including surgery, for certain clavicular fracture types.⁷
• A recent multicentre randomized 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 nonunion when compared to nonoperative treatment at one year.⁸
• Another study into nonoperative treatment of displaced midclavicular shaft fractures detected significant residual deficits in shoulder strength and endurance. However, there was no control group that were treated surgically.⁹
• Intramedullary nailing of mid-clavicular fractures was compared to nonoperative 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.¹⁰

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 stabilize clavicular fractures using a 'tightrope'.¹¹

Complications are uncommon.

Acute

• Pneumothorax
• Haemothorax
• Brachial plexus injury
• Blood vessel injury (including subclavian vessels, internal jugular vein and axillary artery)

• Nonunion and malunion (no radiographic healing at 4-6 months). The rate of nonunion was 7% in one series⁷ and 6.2% in another.¹² Both studies were undertaken on groups receiving nonoperative treatment.
• Deformity due to excessive callus formation during fracture healing
• Thoracic outlet syndrome
• Brachial plexus compression due to callus formation³
• 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 nonunion does not appear to adversely affect the functional outcome in the medium term.¹³