Authors: Koval, Kenneth J.; Zuckerman, Joseph D.

Title: Handbook of Fractures, 3rd Edition

Copyright ©2006 Lippincott Williams & Wilkins

> Table o f Conte nts > III - Upper Extre mity Fr acture s and Dislo cations > 11 -
C lavicle Fr acture s

11
Clavicle Fractures
EPIDEMIOLOGY
 Middle third fractures account for 80% of all clavicle fractures,
whereas fractures of the lateral and medial third of the clavicle
account for 15% and 5%.

ANATOMY
 The clavicle is the first bone to ossify (fifth week of gestation)
and the last ossification center (sternal end) to fuse, at 22 to
25 years of age.
 The clavicle is S-shaped, with the medial end convex forward and
the lateral end concave forward.

 It is widest at its medial end and thins laterally.

 The medial and lateral ends have flat expanses that are linked by
a tubular middle, which has sparse medullary bone.

 The clavicle functions as a strut, bracing the shoulder from the

trunk and allowing the shoulder to function at optimal strength.
  The medial one-third protects the brachial plexus, the
subclavian and axillary vessels , and the superior lung . It is
strongest in axial load.

 The junction between the two cross-sectional configurations

occurs in the middle third and constitutes a vulnerable area to
fracture, especially with axial loading. Moreover, the middle third
lacks reinforcement by muscles or ligaments distal to the
subclavius insertion, resulting in additional vulnerability.

 The distal clavicle contains the coracoclavicular ligaments.

o The two components are the trapezoid and conoid

ligaments .

o They provide vertical stability to the acromioclavicular

(AC) joint.

o They are stronger than the AC ligaments.

MECHANISM OF INJURY
 Falls onto the affected shoulder account for most (87%) of
clavicular fractures, with direct impact accounting for only 7% and
falls onto an outstretched hand accounting for 6%.
 Although rare, clavicle fractures can occur secondary to muscle
contractions during seizures or atraumatically from pathologic
mechanisms or as stress fractures.

CLINICAL EVALUATION
 Patients usually present with splinting of the affected extremity,
with the arm adducted across the chest and supported by the
contralateral hand to unload the injured shoulder.
  A careful neurovascular examination is necessary to assess the
integrity of neural and vascular elements lying posterior to the
clavicle.

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 The proximal fracture end is usually prominent and may tent the
skin. Assessment of skin integrity is essential to rule out open
fracture.
 The chest should be auscultated for symmetric breath sounds.
Tachypnea may be present as a result of pain with inspiratory
effort; this should not be confused with diminished breath sounds,
which may be present from an ipsilateral pneumothorax caused by
an apical lung injury.

ASSOCIATED INJURIES
 Up to 9% of patients with clavicle fractures have additional
fractures, most commonly rib fractures.
 Most brachial plexus injuries are associated with proximal third
clavicle fractures.

RADIOGRAPHIC EVALUATION
 Standard anteroposterior radiographs are generally sufficient to
confirm the presence of a clavicle fracture and the degree of
fracture displacement.
 A 30-degree cephalad tilt view provides an image without the
overlap of the thoracic anatomy.

 An apical oblique view can be helpful in diagnosing minimally

displaced fractures, especially in children. This view is taken with
 the involved shoulder angled 45 degrees toward the x-ray source,
which is angled 20 degrees cephalad.

 Computed tomography may be useful, especially in proximal third

fractures, to differentiate sternoclavicular dislocation from
epiphyseal injury, or distal third fractures, to identify articular
involvement.

CLASSIFICATION
Descriptive
Clavicle fractures may be classified according to anatomic description,
including location, displacement, angulation, pattern (e.g., greenstick,
oblique, transverse), and comminution.

Allman
 Group I: fracture of the middle third (80%). This is the most
common fracture in both children and adults; proximal and distal
segments are secured by ligamentous and muscular attachments.
 Group II: fracture of the distal third (15%).

o This is subclassified according to the location of the

coracoclavicular ligaments relative to the fracture:

Type Minimal displacement : interligamentous fracture between the

I: conoid and trapezoid or between the coracoclavicular and AC
ligaments; ligaments still intact ( Fig. 11.1)

Type Displaced secondary to a fracture medial to the coracoclavicular

II: ligaments: higher incidence of nonunion

IIA: Conoid and trapezoid attached to the distal segment ( Fig. 11.2)
IIB: Conoid torn, trapezoid attached to the distal segment ( Fig. 11.3 )

Type Fracture of the articular surface of the AC joint with no

III: ligamentous injury: may be confused with first-degree AC joint
separation ( Fig. 11.4 )

Figure 11.1. A type I fracture of the distal clavicle (group II).

The intact ligaments hold the fragments in place.

(From Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD, eds.
Rockwood and Green’s Fractures in Adults , 4th ed, vol. 1.
Philadelphia: Lippincott-Raven, 1996:1117 .)

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 Group III: fracture of the proximal third (5%). Minimal
displacement results if the costoclavicular ligaments remain
intact. It may represent e piphyseal injury in children and teenagers. Subgroups
include:

Type I: Minimal displacement

Type II: Displaced

Type III: Intraarticular

Type IV: Epiphyseal separation

Type V: Comminuted

Figure 11.2. A type IIA distal clavicle fracture. In type IIA,

both conoid and trapezoid ligaments are on the distal
segment, whereas the proximal segment without
ligamentous attachments is displaced.

(From Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD, eds.
Rockwood and Green’s Fractures in Adults , 4th ed, vol. 1.
Philadelphia: Lippincott-Raven, 1996:1118 .)
 Figure 11.3. A type IIB fracture of the distal clavicle. The
conoid ligament is ruptured, whereas the trapezoid ligament
remains attached to the distal segment. The proximal
fragment is displaced.

(From Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD, eds.
Rockwood and Green’s Fractures in Adults , 4th ed, vol. 1.
Philadelphia: Lippincott-Raven, 1996:1118 .)

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OTA Classification of Clavicle Fractures

See Fracture and Dislocation Compendium at
http://www.ota.org/compendium/index.htm .

TREATMENT

Nonoperative
 Most clavicle fractures can be successfully treated nonoperatively
with some form of immobilization.
 Comfort and pain relief are the main goals. A sling has been shown to give the same results as a
figure-of-eight bandage, providing more comfort and fewer skin problems.

Figure 11.4. A type III distal clavicle fracture, involving

only the articular surface of the acromioclavicular joint. No
ligamentous disruption or displacement occurs. These
fractures present as late degenerative changes of the joint.

(From Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD, eds.
Rockwood and Green’s Fractures in Adults , 4th ed, vol. 1.
Philadelphia: Lippincott-Raven, 1996:1119 .)

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 The goals of the various methods of immobilization are as follows:

o Support the shoulder girdle, raising the lateral fragment in
an upward, outward, and backward direction.
 o Depress the medial fragment.

o Maintain some degree of fracture reduction.

o Allow for the patient to use the ipsilateral hand and elbow.

 Regardless of the method of immobilization utilized, some degree

of shortening and deformity usually result.

 In general, immobilization is used for 4 to 6 weeks .

 During the period of immobilization, active range of motion of the

elbow, wrist, and hand should be performed.

Operative
 The surgical indications for midshaft clavicle fractures are
controversial.
 The accepted indications for operative treatment of acute clavicle
fractures are open fracture, associated neurovascular
compromise, and skin tenting with the potential for progression
to open fracture.

 Controversy exists over management of midshaft clavicle fractures

with substantial displacement and shortening (>1 to 2 cm).

o Although most displaced midshaft fractures will unite,

studies have reported shoulder dysfunction and patient
dissatisfaction with the resulting cosmetic deformity.

 Controversy also exists over management of type II distal clavicle

fractures.

o Some authors have indicated that all type II fractures

require operative management.

o Others report that if the bone ends are in contact, healing

can be expected even if there is some degree of
 displacement. In this situation, nonoperative management
consists of sling immobilization and progressive range of
shoulder motion.

 Operative fixation may be accomplished via the use of:

o Plate fixation: This is placed either on the superior or the

anteroinferior aspect of the clavicle.

 Plate and screw fixation requires a more extensive

exposure than intramedullary devices but has the
advantage of more secure fixation.

 Plate and screw fixation is more likely to be prominent,

particularly if placed on the superior aspect of the
clavicle.

o Intramedullary pin (Hagie pin, Rockwood pin): This is placed

in antegrade fashion through the lateral fragment and then
in retrograde fashion into the medial fragment.

 Use of intramedullary fixation requires frequent

radiographic follow-up to monitor the possibility of
hardware migration and a second procedure for
hardware removal.

 Intramedullary pins are prone to skin erosion at the

hardware insertion site laterally.

o Operative treatment of type II distal clavicle fractures

consists of reducing the medial fragment to the lateral
fragment. This is accomplished by using either
coracoclavicular fixation (Mersilene tape, sutures, wires,
or screws) or fixation across

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 the AC joint, through the lateral fragment and into the
medial fragment.

COMPLICATIONS
 Neurovascular compromise : This is uncommon and can result
from either the initial injury or secondary to compression of
adjacent structures by callus and/or residual deformity.
 Malunion: This may cause an unsightly prominence, but operative
management may result in an unacceptable scar.

o The effect of malunion on functional outcomes remains

controversial.

 Nonunion: The incidence of nonunion following clavicle fractures

ranges from 0.1% to 13.0%, with 85% of all nonunions occurring
in the middle third.

o Factors implicated in the development of nonunions of the

clavicle include (1) severity of initial trauma, (2) extent of
displacement of fracture fragments, (3) soft tissue
interposition, (4) refracture, (5) inadequate period of
immobilization, and (6) primary open reduction and internal
fixation.

 Posttraumatic arthritis: This may occur after intraarticular injuries

to the sternoclavicular or AC joint.