FRACTURES OF THE

CLAVICLE

 In adults clavicle fractures are

common, accounting for 2.64 per
cent of fractures and approximately
35 percent of all shoulder girdle
injuries.
Fractures of the midshaft account for
6982 per cent, lateral fractures for
2128 per cent and medial fractures
for 23 per cent.

Mechanism of injury
A fall on the shoulder or the outstretched hand
may break the clavicle. In the common midshaft fracture, the outer fragment is pulled
down by the weight of the arm and the inner
half is held up by the sternomastoid muscle.
In fractures of the outer end, if the ligaments
are intact there is little displacement; but if the
coracoclavicular ligaments are torn, or if the
fracture is just medial to these ligaments,
displacement may be severe and closed
reduction impossible.

Clinical features
The arm is clasped to the chest to prevent
movement.
A subcutaneous lump may be obvious and
occasionally a sharp fragment threatens the
skin.
Though vascular complications are rare, it is
prudent to feel the pulse and gently to
palpate the root of the neck.
Outer third fractures are easily missed or
mistaken for acromioclavicular joint injuries.

Imaging
Radiographic analysis requires at least an anteroposterior view
and another taken with a 30 degree cephalic tilt.
The fracture is usually in the middle third of the bone, and the
outer fragment usually lies below the inner.
Fractures of the outer third may be missed, or the degree of
displacement underestimated, unless additional views of the
shoulder are obtained.
With medial third fractures it is also wise to obtain x-rays of the
sterno-clavicular joint.
In assessing clinical progress, remember that clinical union
usually precedes radiological union by several weeks.
CT scanning with three-dimensional reconstructions may be
needed to determine accurately the degree of shortening or for
diagnosing a sternoclavicular fracture-dislocation, and also to
establish whether a fracture has united.

Classification
Clavicle fractures are usually classified on the basis of their
location:
Group I (middle third fractures),
Group II (lateral third fractures)
Group III(medial third fractures).
Lateral third fractures can be further sub-classified into (a)
those with the coracoclavicular ligaments intact, (b) those
where the coracoclavicular ligaments are torn or detached
from the medial segment but the trapezoid ligament remains
intact to the distal segment, and (c) factures which are intraarticular.
An even more detailed classification proposed by Robinson
(1998) is useful for managing data and comparing clinical
outcomes.

Treatment
MIDDLE THIRD FRACTURES
There is general agreement that undisplaced
fractures should be treated non- operatively.
Most will go on to unite uneventfully with a nonunion rate below 5 percent and a return to
normal function.
Non-operative management consists of applying
a simple sling for comfort.
It is discarded once the pain subsides (between
13 weeks) and the patient is then encouraged to
mobilize the limb as pain allows.

 There is no evidence that the traditional figure-of-eight bandage

confers any advantage and it carries the risk of increasing the
incidence of pressures sores over the fracture site and causing harm
to neurological structures; it may even increase the risk of non-union.
There is less agreement about the management of displaced middle
third fractures.
Treating those with shortening of more than 2 cm by simple splintage
is now believed to incur a considerable risk of symptomatic malunion mainly pain and lack of power during shoulder movements
(McKee et al., 2006) and an increased incidence of non-union.
There is, therefore, a growing trend towards internal fixation of acute
clavicular fractures associated with severe displacement.
Methods include plating (specifically contoured locking plates are
available) and intramedullary fixation.

 LATERAL THIRD FRACTURES

Most lateral clavicle fractures are minimally displaced and extraarticular.
The fact that the coracoclavicular ligaments are intact prevents
further displacement and non-operative management is usually
appropriate.
Treatment consists of a sling for 23 weeks until the pain subsides,
followed by mobilization within the limits of pain.
Displaced lateral third fractures are associated with disruption of
the coracoclavicular ligaments and are therefore unstable injuries.
A number of studies have shown that these particular fractures
have a higher than usual rate of non-union if treated nonoperatively.
Surgery to stabilize the fracture is often recommended.

 However the converse argument is that many of

the fractures that develop non-union do not
cause any symptoms and surgery can therefore
be reserved for patients with symptomatic nonunion.
Operations for these fractures have a high
complication rate and no single procedure has
been shown to be better than the others.
Techniques include the use of a coracoclavicular
screw, plate and hook plate fixation and suture
and sling techniques with Dacron graft ligaments.

 MEDIAL THIRD FRACTURES

Most of these rare fractures are extra-articular.
They are mainly managed non-operatively unless
the fracture displacement threatens the
mediastinal structures.
Initial fixation is associated with significant
complications, including migration of the
implants into the mediastinum, particularly when
K-wires are used.
Other methods of stabilization include suture and
graft techniques and the newer locking plates.

Complications
EARLY
Despite the close proximity of the
clavicle to vital structures, a
pneumothorax, damage to the
subclavian vessels and brachial
plexus injuries are all very rare.
stiff and take months to regain
movement.

LATE
Non-union In displaced fractures of the shaft nonunion occurs in 115 per
cent. Risk factors include increasing age, displacement, comminution and
female sex.
However accurate prediction of those fractures most likely to go on to
non-union remains difficult.
Symptomatic non-unions are generally treated with plate fixation and
bone grafting if necessary.
This procedure usually produces a high rate of union and satisfaction.
Lateral clavicle fractures have a higher rate of nonunion (11.540 per
cent).
Treatment options for symptomatic non-unions are excision of the lateral
part of the clavicle (if the fragment is small and the coracoclavicular
ligaments are intact) or open reduction, internal fixation and bone
grafting if the fragment is large.
Locking plates and hooked plates are used.

 Malunion All displaced fractures heal in a

nonanatomical position with some shortening and
angulation, however most do not produce symptoms.
Some may go on to develop periscapular pain and this
is more likely with shortening of more than 1.5cm.
In these circumstances the difficult operation of
corrective osteotomy and plating can be considered.
Stiffness of the shoulder This is common but
temporary; it results from fear of moving the fracture.
Unless the fingers are exercised, they also may become

FRACTURES OF THE
SCAPULA

Mechanisms of injury
The body of the scapula is fractured by a crushing
force, which usually also fractures ribs and may
dislocate the sternoclavicular joint.
The neck of the scapula may be fractured by a blow
or by a fall on the shoulder; the attached long head of
triceps may drag the glenoid downwards and laterally.
The coracoid process may fracture across its base or
be avulsed at the tip.
Fracture of the acromion is due to direct force.
Fracture of the glenoid fossa usually suggests a
medially directed force (impaction of the joint) but
may occur with dislocation of the shoulder.

Clinical features
The arm is held immobile and there may
be severe bruising over the scapula or the
chest wall.
Because of the energy required to damage
the scapula, fractures of the body of the
scapula are often associated with severe
injuries to the chest, brachial plexus, spine,
abdomen and head.
Careful neurological and vascular
examinations are essential.

Classification
Fractures of the scapula are divided
anatomically into scapular body,
glenoid neck, glenoid fossa, acromion
and coracoid processes.

Fractures of the scapular body

Fractures of the glenoid neck
Intra-articular glenoid fossa fractures (Ideberg modified
by Goss)
Type I Fractures of the glenoid rim
Type II Fractures through the glenoid fossa, inferior fragment
displaced with subluxed humeral head
Type III Oblique fracture through glenoid exiting superiorly (may
be associated with acromioclavicular dislocation or fracture)
Type IV Horizontal fracture exiting through the medial border of
the scapula
Type V Combination of Type IV and a fracture separating the
inferior half of the glenoid
Type VI Severe comminution of the glenoid surface

Fractures of acromion process

Type I Minimally displaced
Type II Displaced but not reducing subacromial space
Type III Inferior displacement and reduced
subacromial space
Fractures of coracoid process
Type I Proximal to attachment of the coracoclavicular
ligaments
and usually associated with acromioclavicular
separation
Type II Distal to the coraco-acromial ligaments

 Intra-articular fractures Type I glenoid fractures, if displaced, may result in

instability of the shoulder.
If the fragment involves more than a third of the glenoid surface and is
displaced by more than 5 mm surgical fixation should be considered.
Anterior rim fractures are approached through a delto-pectoral incision and
posterior rim fractures through the posterior approach.
Type II fractures are associated with inferior subluxation of the head of the
humerus and require open reduction and internal fixation. Types III, IV, V and VI
fractures have poorly defined indications for surgery.
Generally speaking, if the head is centred on the major portion of the glenoid
and the shoulder is
stable a non-operative approach is adopted.
Comminuted fractures of the glenoid fossa are likely to lead to osteoarthritis in
the longer term.
Fractures of the acromion Undisplaced fractures are treated non-operatively.
Only Type III acromial fractures, in which the subacromial space is reduced,
require operative intervention to restore the anatomy.