About clavicle fracture, pathogenesis, clinical feature, diagnosis, treatment, management

1. CLAVICULAR
FRACTURE
Niranjani Balachandran
Mohanraj kanagaraju

2. Clavicle fracture
• It is also known as broken collarbone, often as
a result of indirect or direct trauma to shoulder
region.
• Very common injuries in adults (2-5%) and
children (10-15%) and represent the 44-66% of
all shoulder fractures.
• It is the most common fracture of childhood.(
perinatal fracture with birth trauma)
• A fall onto the lateral shoulder most frequently
causes a clavicle fracture.
• While most clavicle fractures treated
conservatively, severely displaced or
comminuted fractures may require surgical
fixation.

3. How common they are?
• Clavicle fractures represent 2% to 10%
of all fractures.
• Affect 1 in 1000 people per year
• Approximately two-third of all clavicle
fractures occurring in males between
ages of 13 and 20 years , 20% in women
• The middle third of the clavicle is
fractured in 69% of cases following the
distal third in 28% of cases and the
proximal third in 3% of cases

4. Clinical anatomy
• It is located subcutaneously between
the sternum and the scapula, connects
the arm to the body.
• It is the first bone in human body to
begin intra-membranous ossification
directly from mesenchyme during the fifth
week of fetal life.
• Similar to all long bones, it has both a
medial and lateral Clavicular epiphysis
but it lacks a well defined medullary
cavity.
• It S shaped double curve, which is
convex medially and concave laterally.

5. How do they occur?
• Younger individuals often sustain these
injuries by way of moderate to high-energy
mechanisms such as motor vehicle accidents
or sports injuries.
• 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 a
force applied directly to the shoulder.
• About 87% of reported cases, a clavicle fracture
results from a fall directed onto the lateral
shoulder.

6. How are they classified?
They typically described using the Allman classification
system, dividing the clavicle into 3 groups based on location
which was later revised by Neer ( in which Group 2 was further
classified into 3 types)
Group 1: fractures of the middle third or mid shaft. They
defined by shortening/comminution/angulation
Group 2: fractures of distal or lateral third ( common site for
non-union. Around and lateral to coracoclavicular ligaments)
Group 3: fractures of the proximal or medial third.(
sternoclavicular dislocation)
Robinson’s classification was more specific for different
fracture pattern in middle third.
Craig’s classification was more specific for fractures of lateral

7. What do they look like- clinically?
The patient may appear with the following signs and symptoms:
A patient may cradle the injured extremity with the uninjured
arm
May report snapping or cracking sound when injury occurs
Shoulder may appear shortened relative to opposite side and
may droop
Swelling, ecchymosis, and tenderness over the clavicle
Abrasion over clavicle suggest fracture from direct
mechanism
Crepitus from fracture ends rubbing against each other with
gentle manipulation.
Difficulty breathing or diminished breath sound on affected
side indicate pulmonary injury, such as pneumothorax

9. What investigations should be ordered?
• Diagnosis can often made by history and physical
examination
• Laboratory studies ordered according to the severity of
the trauma.
• With suspected vascular injury, obtain a CBC to check
the hemoglobin and hematocrit values
• If a pulmonary injury suspected perform an arterial
blood gas test and obtain an expiration posteroanterior
chest film.
• Other imaging studies are
• Radiography of clavicle and shoulder
• CT
• Arteriography
• Ultrasonography

10. What do they look like on X-
ray?

12. When is reduction required?
• Clavicle fracture managed either surgically or
conservatively based upon various factors include
• Location
• Nature of the fracture
• Open Vs closed injury
• Age
• Neurovascular compromises
• Traditionally, conservative management can done
with sling immobilization and subsequent
rehabilitation
• It provide satisfactory results for undisplaced
fractures

13. Surgical treatment
• Chief goal is to achieve a healed Clavicular strut in normal
anatomical position as possible
• Indications for operation
Severe displacement caused by comminution
Symptomatic non-union
Neurovascular injury
Open fracture
Type 2 distal fracture
Multiple trauma
Floating shoulder
Inability to tolerate closed immobilization
Cosmetic reason

15. Surgical procedure
• It includes
• Internal fixation with plates and screws
• Intramedullary fixation
• The routine removal of metal work was recommended for IM nails but not
for plate fixation in mid-shaft displaced fracture.
• In displaced lateral clavicle fracture routine removal of metalwork was
performed for
• Hook plate fixation
• Screw fixation
• Cerclage wire fixation
• Tension band wire fixation
• Not performed for,
• Non ACJ spanning plate fixation
• Suture fixation
• These fixation methods are necessary for lateral clavicle fracture as it
involves acromioclavicular joint and various ligaments that may become
injured during fracture.

17. What are the potential complications
associated?
• Subclavian vessel injury
• Hemopneumothorax
• Brachial plexus paresis
• Thoracic outlet syndrome
• Nonunion
• Malunion
• Post traumatic arthritis
• Refracture

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