Clavicle fracture

The most common fracture of the shoulder girdle, usually in the middle third. The sternocleidomastoid lifts the medial fragment; the weight of the arm and pectoralis major pull the lateral fragment down and medially, shortening the clavicle.

Mechanism

Fall onto the shoulder (most), sometimes onto the outstretched hand; sports and cycling.

Clinical findings

• Deformity and tenting of the skin. Check skin integrity, the brachial plexus and the subclavian vessels.
• Look for a "floating shoulder" (associated scapular neck fracture) and rib fractures or pneumothorax with high energy.

Imaging

• AP of the clavicle and a 15–30° cephalic tilt view (shows displacement out of the shoulder silhouette).
• Measure shortening (compare sides) and displacement.
• CT for medial-end fractures (sternoclavicular joint). Chest X-ray in high-energy injuries.

• AP and 15–30° cephalic tilt views. Measure displacement (more than 100% = no bone contact) and shortening (> 15–20 mm matters).

Classification

15.1

Medial end.

15.2

Shaft: A simple, B wedge, C multifragmentary.

15.3

Lateral end (Neer/Craig: displaced fractures medial to the coracoclavicular ligaments are unstable).

Types shown in 3D

15.1

Medial end (rare). Exclude sternoclavicular dislocation (CT); posterior displacement can compress the great vessels.

15.2A

Shaft, simple: the medial fragment rises (sternocleidomastoid), the lateral drops and shortens with the arm.

15.2B

Shaft, wedge (often an inferior butterfly fragment): higher non-union risk if displaced and shortened.

15.3 (Neer II)

Lateral end, medial to or between the coracoclavicular ligaments: the medial fragment is pulled up and the shoulder drops. Unstable: hook plate or coracoclavicular fixation.

Treatment

Non-operative

Most midshaft fractures: sling for comfort 2–3 weeks, early pendulum and range-of-motion exercises. Union in > 85% even if displaced.

Operative

Open fractures, threatened skin, neurovascular injury, floating shoulder, and (discussed with the patient) complete displacement with > 2 cm shortening in active adults: superior or anteroinferior plate, or intramedullary nail. Lateral unstable fractures: hook plate or coracoclavicular fixation.

Aftercare

Avoid heavy lifting and contact sports until union (about 3 months).

Complications

• Non-union (shortening, displacement, smokers)
• Symptomatic malunion
• Plate prominence
• Subclavian vessel injury during drilling (rare, serious)