Clavicle Fracture; Causes, Symptoms, Diagnosis, Treatment

Clavicle fracture
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Clavicle fracture is one of the most common injuries around the shoulder girdle []. It has been reported that fractures of the clavicle account for approximately 2.6% of all fractures []. Incidence in males is usually highest in the second and third decade which decreases thereafter as per age []. In females, it is usually bimodal, with a peak incidence in young and elderly []. Allman classified clavicle fractures into three groups based on their location along the bone. The middle-third fractures are most common and account for approximately 80–85% all clavicular fractures [].

Fractures of the clavicle are common injuries accounting for between 2.6 and 4% of adult fractures and 35% of injuries to the shoulder girdle []. Early reports of clavicle fractures date back to Hippocrates [], who noted that “when a fractured clavicle is fairly broken across it is more easily treated, but when broken obliquely it is more difficult to manage”.

clavicle fracture

 

Anatomy

The clavicle is the first bone in the human body to begin intramembranous ossification directly from mesenchyme during the fifth week of fetal life. Similar to all long bones, the clavicle has both a medial and lateral epiphysis. The growth plates of the medial and lateral clavicular epiphyses do not fuse until the age of 25 years [.

Peculiar among long bones is the clavicle’s S-shaped double curve, which is convex medially and concaves laterally. This contouring allows the clavicle to serve as a strut for the upper extremity, while also protecting and allowing the passage of the axillary vessels and brachial plexus medially. The cross-sectional geometry also changes along its course. It progresses from more tubular medially to flat laterally. This change of contour, which is most acute at the junction of the middle and outer thirds, may explain the frequency of fractures seen in this area [.

The lateral clavicle is anchored to the coracoid process by the coracoclavicular ligament, composed of the lateral trapezoid and medial conoid parts. The static joint stabilizers are the AC ligaments, controlling the horizontal stability, and the CC ligament controlling the vertical stability. The dynamic stabilizers are the deltoid and trapezius muscles. The trapezius muscle attaches at the dorsal aspect of the acromion, part of the anterior deltoid muscle inserts on the clavicle medial to the AC joint. Their force vectors prevent excessive superior migration of the distal clavicle after disruption of the AC and CC ligaments alone [.

The deltoid, trapezius and pectoralis major muscles have important attachments to the clavicle. The deltoid muscle inserts onto the anterior surface of the lateral third of the clavicle, and the trapezius muscle onto the posterior aspect. The pectoralis major muscle inserts onto the anterior surface of the medial two thirds.

Mechanism of Injury of Clavicle Fracture

With the exception of the rare pathologic fracture due to metastatic or metabolic disease, clavicle fractures are typically due to trauma [. Younger individuals often sustain these injuries by way of moderate to high-energy mechanisms such as motor vehicle accidents or sports injuries, whereas elderly individuals are more likely to sustain injuries because of the sequela of a low-energy fall [. Although a fall onto an outstretched hand was traditionally considered the common mechanism, it has been found that the clavicle most often fails in direct compression from the force applied directly to the shoulder. In a study of 122 consecutive patients, 87% clavicle injuries resulted from a fall onto the shoulder, 7% resulted from a direct blow, and 6% resulted from a fall onto an outstretched hand [.

Types of Clavicle Fracture

Classification

GROUP I – Middle third fractures (80%)

GROUP II – Distal third fractures (15%)

  • Type I – Minimally displaced / interligamentous
  • Type II – Displaced fractures, fracture medial to the coracoclavicular ligaments
    • IIA – Both ligaments (conoid and trapezoid) attached to the distal fragment
    • IIB – Conoid tore, trapezoid attached to the distal fragment
  • Type III – Fractures involving articular surface
  • Type IV – intact coracoclavicular ligaments attached to periosteal sleeve plus proximal fragment displaced
  • Type V – Comminuted

GROUP III – Fracture of the proximal third (5%)

  • Type I – Minimally displacement
  • Type II – Displaced
  • Type III – Intra-articular
  • Type IV – Epiphyseal separation
  • Type V – Comminuted

Classification by Robinson (Edinburgh classification)

ED managementthirdFollow-upMiddle

Fracture type
(Mismanagement third)Broad arm sling to support limb for 2 weeks or until comfortable.  No evidence to support Figure of 8 bandages or brace

If age >12 years and shortened >2 cm refer to orthopedics for opinion

Give parent fracture of the clavicle (collarbone) fact sheet.  Advise to give regular analgesia as required

If <11 years and undisplaced, follow-up by a GP or fracture clinic is usually not required.  Repeat x-rays are usually not required

If displaced or ≥11 years, follow up with GP or fracture clinic in 1 week

Lateral thirdBroad arm sling to support limb for 2 weeks or until comfortable.  No evidence to support Figure of 8 bandages or brace

If displaced, refer to the nearest orthopedic service on call

Fracture clinic in 5-7 days with x-ray
Medial thirdIf displaced, urgent referral to the nearest orthopedic on call serviceTo be arranged by orthopedic service

Classifications of fractured clavicle

AllmanNordqvist & PeterssonCraigEdinburgh (Robinson)Neer
Group 1: mid thirdUndisplaced
Displaced comminuted
Type 1 : mid thirdMedial third (type 1)Non displaced (1A)1A1 – Extra-articular
1A2 – Intra-articular
Type 1: fracture lateral to the coracoclavicular ligament attachment, which has very minimal displacement
Displaced (1B)1B1 – Extra-articular
1B2 – Intra-articular
Type 2: medial to the ligament attachment
2A – both the conoid and the trapezoid ligaments are attached to the distal fragment
2B – conoid is detached from the proximal fragment while the trapezoid is attached to the distal fragment
Middle third (type 2)Cortical alignment fractures (2A)2A1 – Undisplaced
2A2 – Angulated
Type 3: with intra-articular extension
Group 2: lateral thirdUndisplaced
Displaced
Type 2: Distal 1/3 fractures

a. Minimally displaced
b. Displaced fractures, fracture medial to the C–C ligament
1. Conoid and trapezoid intact
2. Conoid torn, trapezoid intact
c. Fractures into the articular surface
d. Fractures in children, intact C–C ligaments attached to the periosteal sleeve, proximal fragment displaced
 e. Comminuted fractures
Displaced fractures (2B)2B1 – Simple or wedge comminuted
2B2 – Isolated or comminuted segmental
Type 4: occurs in children where a periosteal sleeve gets avulsed from the inferior cortex with the attached coracoclavicular ligament and the medial fragment gets displaced upwards
Type 5: avulsion fracture leaving behind an inferior cortical fragment attached to the coracoclavicular ligament
Group 3: medial thirdUndisplaced DisplacedType 3: Proximal 1/3 fractures

a. Minimally displaced
b. Displaced
c. Intra-articular
d. Epiphyseal separation
e. Comminuted
Distal third (type 3)Cortical alignment fractures (3A)3A1 – Extra-articular
3A2 – Intra-articular
Displaced fractures (3B)3B1 – Extra-articular
3B2 – Intra-articular

Causes of Clavicle Fracture

  • Clavicle fractures  – are most often caused by a direct blow to the shoulder. This can happen during a fall onto the shoulder or a car collision. A fall onto an outstretched arm can also cause a clavicle fracture. In a baby, a clavicle fracture can occur during the passage through the birth canal.
  • Sudden forceful  fall down
  • Road traffic accident
  • Falls – Falling onto an outstretched hand is one of the most common causes of a broken clavicle.
  • Sports injuries – Many wrist fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
  • Motor vehicle crashes – Motor vehicle crashes can cause wrist bones to break, sometimes into many pieces, and often require surgical repair.
  • Have osteoporosis – a disease that weakens your bones
  • Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
  • Walk or do other activities in snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
  • Wave an inadequate – intake of calcium or vitamin D
  • Football or soccer – especially on artificial turf
  • Rugby
  • Horseback riding
  • Hockey
  • Skiing
  • Snowboarding
  • In-line skating
  • Jumping on a trampoline

Symptoms of Clavicle Fracture

  • Pain – particularly with arm movement or on the front part of the upper chest
  • Often – after the swelling has subsided, the fracture can be felt through the skin.
  • Sharp pain – when any movement is made
  • Referred pain – dull to extreme ache in and around clavicle area, including surrounding muscles
  • Possible nausea – dizziness, and/or spotty vision due to extreme pain
  • Bruising –  swelling, or bulging over your collarbone
  • Decreased feeling – or a tingling feeling in your arm or fingers
  • Swelling – ecchymosis, and tenderness may be noted over the clavicle
  • Abrasion – over the clavicle may be noted, suggesting that the fracture was from a direct mechanism
  • Crepitus from – the fracture ends rubbing against each other may be noted with gentle manipulation
  • Difficulty breathing – or diminished breath sounds on the affected side may indicate a pulmonary injury, such as a pneumothorax
  • Palpation of the scapula – and ribs may reveal a concomitant injury
  • Tenting and blanching of the skin – at the fracture site may indicate an impending open fracture, which most often requires surgical stabilization
  • The shoulder may appear shortened – relative to the opposite side and may droop
  • Non-use – of the arm on the affected side is a neonatal presentation
  • Associated distal nerve dysfunction indicates a brachial plexus injury
  • Decreased pulses may indicate a subclavian artery injury
  • Venous stasis discoloration and swelling indicate a subclavian venous injury.
  • Pain where the broken bone is
  • Having a hard time moving your shoulder or arm, and pain when you do move them
  • A shoulder that seems to be sagging
  • A cracking or grinding noise when you raise your arm
  • The bone that is pushing against or through the skin
  • The patient may cradle the injured extremity with the uninjured arm

Diagnosis of Clavicle Fracture

clavicle fracture

Physical Examination

  • In a clavicle fracture, there is usually an obvious deformity, or “bump,” at the fracture site. Gentle pressure over the break will bring about pain. Although it is rare for a bone fragment to break through the skin, it may push the skin into a “tent” formation.
  • During the physical examination, a dropped shoulder on the affected side, swelling, and hematoma at the middle third of the clavicle are usually observed. Often the fracture elements are palpable. Assessment of possible skin compromise and neurovascular status is important. In addition to the physical assessment, radiological assessment is part of the diagnostic workup.
  • The basic method to check for a clavicle fracture is by an X-ray of the clavicle to determine the fracture type and extent of the injury. In former times, X-rays were taken of both clavicle bones for comparison purposes. Due to the curved shape in a tilted plane X-rays are typically oriented with ~15° upwards facing tilt from the front.[rx]

Differential Diagnosis/ Associated Injuries

  • Scapholunate ligament tear
  • Median nerve injury
  • TFCC (triangular fibrocartilage complex) injury, up to 50% when ulnar styloid fx also present
  • Carpal ligament injury – Scapholunate Instability(most common), lunotriquetral ligament
  • Tendon injury, attritional EPL rupture, usually treated with EIP tendon transfer
  • Compartment syndrome
  • DRUJ (Distal Radial Ulnar Joint) Instability
  • Galeazzi Fracture: highly associated with distal 1/3 radial shaft fractures[rx]

Plain radiographs

  • Radiographic imaging is important in diagnosis, classification, treatment and follow-up assessment of these fractures. The routine minimal evaluation for distal radius fractures must include two views-a postero-anterior (PA) view and lateral view.[]
  • The PA view should be obtained with the humerus abducted 90 degrees from the chest wall, so that the elbow is at the same level as the shoulder and flexed 90 degrees.[] The palm is maintained flat against the cassette

Computed Tomography

  • CT may be useful and can give significant information in comparison with that obtained with conventional radiography in the evaluation of complex or occult fractures, distal radial articular surface, distal radio-ulnar joint, ventromedial fracture fragment (as described by Melone),[] assessments of fracture healing as well as post-surgical evaluation.[]
  • CT may be indicated for the confirmation of occult fractures suspected on the basis of physical examination when plain films are normal.

Magnetic Resonance Imaging

  • Although this modality is not the first choice in evaluating acute distal radius fractures, it is a powerful diagnostic tool to assess bony, ligamentous and soft tissue abnormalities associated with these fractures.
  • MRI has proved to be a very important diagnostic tool for delineating perforation of triangular fibrocartilage complex (TFCC),[] perforation of interosseous ligaments of the proximal carpal row, evaluating occult fractures, post-traumatic or avascular necrosis of carpal bones.

Treatment of Clavicle Fracture

clavicle fracture

Treatment available can be broadly

  • Get medical help immediately – If you fall on an outstretched arm, get into a car accident or are hit while playing a sport and feel intense pain in your shoulder area, then get medical care immediately. Fractured clavicles cause significant pain in the front part of your shoulder, closer to the base of your neck. You’ll innately know that something is seriously wrong because you won’t be able to lift your arm up. Other symptoms include immediate swelling and/or bruising near the fracture, grinding sounds with arm movements and potential numbness and tingling in the arm/hand.
  • Apply ice to your fractured clavicle. After you get home from the hospital (regardless if you had surgery or not), you should apply a bag of crushed ice (or something cold) to your injured clavicle in order to reduce the swelling and numb the pain. Ice therapy is effective for acute (recent) injuries that involve swelling because it reduces blood flow by constricting local blood vessels. Apply the crushed ice to your clavicle for 15 minutes three to five times daily until the soreness and inflammation eventually fades away
    Lightly exercise after the pain fades. After a couple of weeks when the swelling has subsided and the pain has faded away, remove your arm sling for short periods and carefully move your arm and shoulder in all different directions. Don’t aggravate the clavicle so that it hurts, but gently reintroduce movements to the involved joints and muscles. Start cautiously, maybe starting with light calisthenics and then progress to holding light weights (five-pound weights to start). Your clavicle needs to move a little bit during the later phases of the injury to stimulate complete recovery.
  • Practice stretching and strengthening exercises – of the fingers, elbow, and shoulder if your doctor recommends them.
  • A splint – which you might use for a few days to a week while the swelling goes down; if a splint is used initially, a cast is usually put on about a week later.
  • A cast – which you might need for six to eight weeks or longer, depending on how bad the break is (you might need a second cast if the first one gets too loose after the swelling goes away.)
  • Get a supportive arm sling – Due to their anatomical position, fractured clavicles can’t be casted like a broken limb can. Instead, a supportive arm sling or “figure-eight” splint is typically used for support and comfort, either immediately after the injury if it’s just a hairline fracture or following surgery, if it’s a complicated fracture. A figure-eight splint wraps around both shoulders and the base of your neck in order to support the injured shoulder and keep it positioned up and back. Sometimes a larger swath of material is wrapped around the sling to keep it closer to your body. You’ll need to wear the sling constantly until there is no pain with arm movements, which takes between two to four weeks for children or four to eight weeks for adults.
  • Get a referral to physical therapy. Once you’ve recovered and able to remove your arm sling splint for good, you’ll likely notice that the muscles surrounding your shoulder and upper chest look smaller and feel weaker. That’s because muscle tissue atrophies without movement. If this occurs, then you’ll need to get a referral for some physical rehabilitation. Rehab can start once you are cleared by your orthopedist, are pain-free, and can perform all the basic arm and shoulder movements. A physiotherapist or athletic trainer can show you specific rehabilitation exercises and stretches to restore your muscle strength, joint movements and flexibility
  • Rigid fixation – osteosynthesis with locking plate, hook plate fixation, fixation with a distal radius locking plate, coracoclavicular screws, Knowles pin fixation.
  • Flexible fixation – simple k wire fixation, tension band wiring, suture anchors, vicryl tape, dacron arterial graft for coracoclavicular ligament reconstruction.

Rest your shoulder

Once you’re discharged from the hospital in an arm sling, your top priority is to rest your shoulder and not further inflame the injury. Of course, the arm sling not only provides support, but it also restricts movement, which is why you should keep it on even during sleep. Avoiding the temptation to move your shoulder and arm will help the bone mend quicker and the pain fades away sooner.
  • Depending on what you do for a living and if the injury is to your dominant side, you may need to take a couple of weeks off work to recuperate.
  • Healing takes between four to six weeks in younger people and up to 12 weeks in the elderly, but it depends on the severity of the fractured clavicle.
  • Athletes in good health are typically able to resume their sporting activities within two months of breaking their clavicle, depending on the severity of the break and the specific sport.
  • Sleeping on your back (with the sling on) is necessary to keep the pressure off your shoulder and prevent stressing the clavicle injury.

Eat nutritiously during your recovery

  • All bones and tissues in the body need certain nutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins is proven to help heal broken bones of all types, including clavicles.[rx] Therefore, focus on eating lots of fresh produce (fruits and veggies), whole grains, lean meats, and fish to give your body the building blocks needed to properly repair your clavicle. In addition, drink plenty of purified water, milk, and other dairy-based beverages to augment what you eat.
    • Broken bones need ample minerals (calcium, phosphorus, magnesium, boron) and protein to become strong and healthy again.
    • Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines and salmon.
    • Important vitamins that are needed for bone healing include vitamin C (needed to make collagen), vitamin D (crucial for mineral absorption), and vitamin K (binds calcium to bones and triggers collagen formation).
    • Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, most fast food items and foods made with lots of refined sugars and preservatives.

     

Physical therapy

  • Although there will be some pain, it is important to maintain arm motion to prevent stiffness. Often, patients will begin doing exercises for elbow motion immediately after the injury.  After a clavicle fracture, it is common to lose some shoulder and arm strength. Once the bone begins to heal, your pain will decrease and your doctor may start gentle shoulder exercises. These exercises will help prevent stiffness and weakness. More strenuous exercises will be started gradually once the fracture is completely healed.

Follow-up care

  • You will need to see your doctor regularly until your fracture heals. During these visits, he or will take x-rays to make sure the bone is healing in a good position. After the bone has healed, you will be able to gradually return to your normal activities.

Breathing Exercise

  • To elevate breathing problem or remove the lung congestion.

Medications

Medication can be prescribed to ease the pain. 

Surgery

The evidence for different types of surgery for breaks of the middle part of the clavicle is poor as of 2015.[10]

Surgery is considered when one or more of the following conditions present.

  • Comminution with separation (bone is broken into multiple pieces)
  • Significant foreshortening of the clavicle (indicated by shoulder forward)
  • Skin penetration (open fracture)
  • Associated nervous and vascular trauma (brachial plexus or supraclavicular nerves)
  • Nonunion after several months (3–6 months, typically)
  • Displaced distal third fractures (high risk of nonunion)

Open reduction and internal fixation. This is the procedure most often used to treat clavicle fractures. During the procedure, the bone fragments are first repositioned (reduced) into their normal alignment. The pieces of bone are then held in place with special metal hardware.

Common methods of internal fixation include:

  • Plates and screws – After being repositioned into their normal alignment, the bone fragments are held in place with special screws and metal plates attached to the outer surface of the bone. After surgery, you may notice a small patch of numb skin below the incision. This numbness will become less noticeable with time. Because the clavicle lies directly under the skin, you may be able to feel the plate through your skin.
  • Pins or screws –  Pins or screws can also be used to hold the fracture in good position after the bone ends have been put back in place. The incisions for pin or screw placement are usually smaller than those used for plates.
    Pins or screws often irritate the skin where they have been inserted and are usually removed once the fracture has healed.
  • Precontoured locking plates
  • Hook plate
  • Distal radius plates
  • Coracoclavicular screws
  • Flexible coracoclavicular fixation
  • Arthroscopic treatment
  • Intra-medullary fixation
  • Tension band fixation

Complications

There are risks associated with any type of surgery. These include:

  • Nonunion (1-5%)
  • Infection (~4.8%)
  • Pneumothorax
  • Adhesive capsulitis
  • 4% in the surgical group develop adhesive capsulitis requiring surgical intervention
  • Bleeding
  • Problems with wound healing
  • Blood clots
  • Damage to blood vessels or nerves
  • Reaction to anesthesia
  • Hardware prominence
  • Malunion with cosmetic deformity
  • Restriction of ROM
  • Difficulty with bone healing
  • Lung injury
  • Hardware irritation
  • Fracture comminution (Z deformity)
  • Fracture displacement
  • Increased fatigue with overhead activities
  • Thoracic outlet syndrome
  • Dissatisfaction with appearance
  • The difficulty with shoulder straps, backpacks and the like
  • ~30% of patient request plate removal
  • Superior plates associated with increased irritation
  • Superior plates associated with increased risk of subclavian artery or vein penetration
  • Subclavian thrombosis

Rehabilitation of Clavicle Fracture

  • A rehabilitation protocol was started after removal of the bandage in group 1 and immediately after plate fixation in group 2. Gentle pendulum exercises of the shoulder in the sling/arm pouch were allowed as per pain tolerance immediately after surgery in the surgically treated group and after 3 weeks in the conservative group.
  • At 3 weeks, gentle active range of motion of the shoulder was allowed with abduction limiting to 90°. Subsequently, the active range of motion exercises that are to be performed at home is advised. At four to 6 weeks, active to an active assisted range of motion in all planes were allowed.
  • When fracture union (defined as radiographic union with no pain or motion with manual stressing of the fracture) was evident, muscle strengthening exercises were also allowed. At eight to 12 weeks, isometric and isotonic exercises were prescribed to the shoulder girdle muscles with a return to full activities (including sports) at 3 months.
  • Regular follow-up was done every fortnight for the initial 6 weeks, then at 06 weeks, 03 and 06 months using the patient’s subjective evaluation, functional outcome, and radiographic assessment. Patients’ subjective evaluation was investigated by direct interview at the follow-up visits. Functional outcome was graded on the standardized clinical evaluation and completion of the Constant and Murley score [].

References

Clavicle fracture

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