Overview
Clavicle fractures are among the most common fractures encountered in orthopaedic practice, accounting for approximately 2–5% of all fractures and nearly 35–45% of shoulder girdle injuries. They are particularly common in young active individuals due to sports injuries and road traffic accidents, but also occur in elderly osteoporotic patients following low-energy falls.
The clavicle acts as a strut between the sternum and scapula, maintaining shoulder alignment and allowing effective transmission of forces from the upper limb to the axial skeleton. Fractures of the clavicle may disrupt this biomechanical relationship and can lead to shoulder dysfunction if not appropriately managed.
Most clavicle fractures occur in the middle third due to the bone’s inherent structural weakness at this location, where the curvature changes and ligamentous support is minimal. Advances in fixation techniques have expanded surgical indications in recent years, especially for displaced fractures.
Anatomy and Biomechanics
- Only bony connection between upper limb and axial skeleton
- Acts as a strut maintaining scapular position
- Protects neurovascular structures including subclavian vessels and brachial plexus
- Provides attachment for multiple muscles
Muscle attachments significantly influence fracture displacement. The sternocleidomastoid muscle pulls the medial fragment superiorly, while the weight of the arm and pectoralis major pull the lateral fragment inferiorly and medially.
Epidemiology
- 2–5% of all fractures
- 35–45% of shoulder girdle fractures
- Most common in young males
- Bimodal age distribution
| Age Group | Common Cause |
|---|---|
| Young adults | Sports injuries, road accidents |
| Children | Falls during play |
| Elderly | Low energy falls |
Classification
Clavicle fractures are classified based on anatomical location and fracture pattern.
| Type | Location | Incidence |
|---|---|---|
| Group I | Middle third fractures | ~80% |
| Group II | Distal third fractures | ~15% |
| Group III | Medial third fractures | ~5% |
Distal clavicle fractures are further classified using the Neer classification, which depends on the integrity of the coracoclavicular ligaments.
Clinical Features
- Pain and swelling over clavicle
- Visible deformity or step
- Drooping of affected shoulder
- Reduced shoulder movement
- Tenderness along clavicle
The patient often supports the affected arm with the opposite hand. Skin tenting may be present in significantly displaced fractures.
Investigations
- X-ray clavicle with AP view
- 15° cephalic tilt view
- CT scan in complex fractures
Radiographs help determine fracture location, displacement, comminution, and shortening.
Management Principles
Management depends on fracture location, displacement, patient activity level, and presence of complications.
Nonoperative Management
- Sling immobilization
- Figure of eight bandage (less commonly used)
- Analgesics
- Early pendulum exercises
Most undisplaced or minimally displaced midshaft clavicle fractures heal successfully with conservative treatment.
Operative Management
Surgical fixation is increasingly recommended for displaced fractures with shortening or comminution.
| Technique | Indications |
|---|---|
| Plate fixation | Displaced midshaft fractures |
| Intramedullary nail | Simple fracture patterns |
| Hook plate | Distal clavicle fractures |
Indications for Surgery
- Open fractures
- Neurovascular compromise
- Significant displacement
- Shortening greater than 2 cm
- Skin tenting
- Floating shoulder injuries
Complications
- Nonunion
- Malunion
- Neurovascular injury
- Hardware irritation
- Infection
Exam Pearls
- Middle third fractures are most common
- Sternocleidomastoid elevates medial fragment
- Weight of arm displaces lateral fragment downward
- Most undisplaced fractures treated conservatively
- Displacement greater than 2 cm increases nonunion risk