Clavicle fractures are common injuries, especially in young active individuals. The majority occur in the midshaft region due to its thin bone and lack of muscle protection. Treatment depends on the location and degree of displacement/shortening. Nondisplaced fractures are usually treated nonsurgically with slings or strapping. Displaced fractures may require plate fixation, intramedullary nails, or coracoclavicular ligament repair/reconstruction to achieve union and restore function. Complications can include nonunion, malunion, hardware irritation, and neurovascular injury.

1. CLAVICLE FRACTURES
PRESENTED BY
DR. PUSHPENDRA SINGH DHAKAD

2. INTRODUCTION
• Clavicle fractures are common injuries in young, active
individuals.
• Approximately 2.6% of all fractures and for 44% to 66% of
fractures around the shoulder.
• The majority of clavicular fractures (80% to 85%) occur in
the midshaft of the bone
• Distal third fractures are the next most common type (15%
to 20%)
• Medial third fractures are the rarest (0% to 5%)

3. ANATOMY
• 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 middle third and constitutes a vulnerable area to fracture.

4. ARTICULATIONS
Sternoclavicular joint
Four primary stabilizers
• Posterior capsular ligament
• Anterior sternoclavicular ligament
• Costoclavicular ligament
• Intra-articular disc
Acromioclavicular joint
Two primary stabilizers
• coracoclavicular ligament
• acromioclavicular ligament

5. The distal clavicle contains the coracoclavicular
ligaments.
■ The two components are the trapezoid and conoid
ligaments.
■ They provide vertical stability to the
acromioclavicular (AC) joint.
■ They are stronger than the AC ligaments.

7. APPLIED BASIC SCIENCE
Osseous anatomy and muscular/ligamentous attachments play a
pivotal role in determining fracture patterns
# most common at junction of outer and middle 3rd
Thinnest part of bone
 not protected by muscle/ligamentous attachments
Deformity: SCM pulls proximal fragment superiorly and
posteriorly
 weight of arm and pectoralis muscles pull distal segment
medially and inferiorly

9. CLAVICLE FUNCTION
• Power and stability of arm
• Functions as a strut to support the shoulder.
• Transmits physical impacts from the upper limb to the
axial skeleton.
• Muscle attachment .
• Protects neurovascular structures.

10. MECHANISM OF INJURY
Falls onto the affected shoulder leading to a bending force
account for most (87%) of clavicular fracture
direct impact accounting for only 7%
“FOOSH” falls onto an outstretched hand accounting for
6%.

12. 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 (traction injury).
• The skin is often abraded as a result of the injury
mechanism.

13. CLINICAL PRESENTATION
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.
Symptoms
• Anterior shoulder pain
• Swelling

14. Physical exam
Inspection
• May have swelling, bruising, and echymosis of fracture site.
• Visible deformity like shoulder ptosis, with a droopy,
medially driven and shortened shoulder usually seen in
midshaft clavicle fracture.
• From above- the shoulder translates and rotates forward.

15. • From behind- a subtle prominence of the inferior aspect of
the scapula from scapular protraction as it moves with the
distal fragment
• From front- skin tenting (impending open fracture)
Palpation:
• Local temperature
• Tenderness, crepitus
• Break in the continuity b/w the fracture fragment.

16. Range of motion
Protraction and retraction
Elevation and depression
Axial rotation
Adduction and abduction
Auscultation:
The chest should be auscultated for symmetric breath sounds

17. Measurements:
• Shortening of the clavicle should be measured.
• In b/w two points - from midline of the suprasternal notch
to palpable ridge of the AC joint.
• Measuring this length gives the difference between the
involved and normal shoulder girdle.
Neurovascular Examination
Decrease distal pulses, discolouration or oedema may be
present in subclavian vessels.
Decrease distal sensation.

18. RADIOGRAPHIC EVALUATION
Recommended views
• X-ray- AP of bilateral shoulders
• 15° cephalic tilt (zanca view) - helps to determine
superior/inferior displacement.
• Chest X-ray
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.

20. ALLMAN CLASSIFICATION
Group I: Fracture of the middle third (80%).
Group II: Fracture of the distal third (15%).
• Type I: Minimal displacement: interligamentous fracture
between the conoid and trapezoid or between the
coracoclavicular and AC ligaments; ligaments still intact
• Type II: Displaced secondary to a fracture medial to the
coracoclavicular ligaments: higher incidence of nonunion
IIA: Conoid and trapezoid attached to the distal segment
IIB: Conoid torn, trapezoid attached to the distal segment

22. • Type III: Fracture of the articular surface of the AC joint
with no ligamentous injury
Group III: fracture of the proximal third (5%). Minimal
displacement results if the costoclavicular ligaments remain
intact. It may represent epiphyseal injury in children and
teenagers. Subgroups include:
– Type I: Minimal displacement
– Type II: Displaced
– Type III: Intra-articular
– Type IV: Epiphyseal separation
– Type V: Comminuted

23. NEER CLASSIFICATION
Neer Classification used for distal clavicle fracture
• Type I: Distal clavicle fracture with the coracoclavicular liga-
ments intact
• Type II: Coracoclavicular ligaments detached from the medial
fragment, with the trapezoidal ligament attached to the distal
fragment
– IIA (Rockwood): Both conoid and trapezoid attached to
the distal fragment
– IIB (Rockwood): Conoid detached from the medial
fragment
• Type III: Distal clavicle fracture with extension into the AC
joint.

25. GOALS OF TREATMENT
• Achieve bony union with minimal morbidity
• Minimal loss of function
• Minimal residual deformity

26. TREATMENT OPTIONS
Nonoperative/conservative Methods
Indications :
• < 2cm shortening and displacement
• < 1cm displacement of the superior shoulder suspensory
complex
• Closed fracture and no neurovascular injury

27. The common modalities are:
• Cuff and collar sling for undisplaced fractures.
• Strapping of the fracture site after reduction of the fracture
by elevating the arm and bracing the shoulder upwards and
backwards gives good results in both children and adults
• Figure of ‘8’ is popularly used and it acts by retracting the
shoulder girdle, minimizes the overlap and allows more
anatomical healing.

30. OPERATIVE MANAGEMENT
The absolute indications for operative treatment of acute
clavicle fractures are
• Open fracture.
• Associated neurovascular compromise
• Skin tenting with the potential for progression to open
fracture.

32. Stabilization techniques include
• Plate fixation
• Intramedullary fixation
• External fixation
• Coracoclavicular ligament repair or reconstruction in Group
Il
Postoperative rehabilitation-
• Sling for 7-10 days followed by active motion
• Strengthening at ~ 6 weeks when pain free motion and
radiographic evidence of union
• Full activity including sports at ~ 3 months

33. Midclavicular fracture
Plate Fixation
Plate configuration
• Anterior plating
• Superior plating: (compared to anterior plating) higher load to
failure increased plate strength with inferior bone
comminution increased risk of neuromuscular injury
decreased removal of deltoid attachment
• Dual plating: low rate of symptomatic hardware removal (0-
3.7%)biomechanically equivalent or superior to single 3.5mm
plate

34. Plates
LC-DCP
3.5 reconstruction plate
Anatomical plate

36. Advantages
• Improved results with ORIF for clavicle fractures with >
2cm shortening and > 100% displacement
• Improved functional outcomes/less pain with overhead
activity
• Faster time to union
• Decreased symptomatic nonunion and malunion rate
Disadvantage
• Increased risk of need for future procedures
• Implant removal
• Debridement for infection

37. Intramedullary fixation
Implant choices
• Intramedullary nail: Goal size of intramedullary nail is 30-
40% of midshaft diameter
• Cannulated screws
• Titanium elastic nail
• Hagie pin
• Rockwood pin
• Kirschner wire
• Mckeever intramedullary nail

38. Type of intramedullary fixation
Open intramedullary fixation is popular: typically a
threaded pin is inserted through the fracture site, the pin is
removed 3 months after surgery-
Close intramedullary fixation: Smooth titanium nail has
been inserted through the medial clavicle, without opening
the fracture site

40. Advantages
• Smaller incision
• Less soft-tissue disruption
• Avoids supraclavicular nerves that are commonly injured
with plating
• Best for simple patterns
Disadvantages
• Higher complication rate : hardware migration, implant
irritation, secondary procedures
• Biomechanically inferior to plating
• Unable to lock and control rotation
• Typically requires hardware removal at 6 months

41. Distal clavicular fracture
Undisplaced Lateral-End Fractures(Neer TypeI)
• Nonoperative management is the treatment of choice.
• Late excision of the distal segment (through either an
arthroscopic or an open approach)may be used in this
group of patients if the fragment is small

42. Displaced Lateral-End Fractures(Neer Type Il)
Osteosynthesis procedures:
• Transacromial K-wires with or without a tension band
• Coracoclavicular screw
• Plate fixation
• Coracoclavicular banding or taping with or without
acromioclavicular fixation utilizing-dacron or other synthetic
materials
A high rate of delayed union, nonunion,and deformity with
closed treatment of Type II distal clavicle fractures in literature.

51. MEDIAL CLAVICULAR
FRACTURE
These fractures are usually managed non-operatively unless
fracture displacement produces superior mediastinal
compromise.
In these circumstances, an emergent attempt at closed
reduction should be made with open reduction performed
next if this is unsuccessful
Internal fixation
The use modified Baler plate and use of Mersilene or other
strong braided interosseous suture

52. 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.
The structures commonly injured are subclavian vessels and
the medial cord of the brachial plexus through which the
ulnar nerve is derived.
The ulnar nerve is the commonest nerve to be injured in
fracture clavicle due to its compression between it and the
first rib.

53. The commonest reason for brachial plexus irritation
following clavicular fracture is the chronic thoracic outlet
syndrome (TOS) that results from clavicular malunion.
Subclavian vessels are at risk with superior plating.
■ Posttraumatic arthritis: This may occur after intra-articular
injuries to the sternoclavicular or AC joint.
■ Hardware prominence
■ Infection

54. ■ Malunion: Malunion is very common due to difficulty in
holding the fracture fragments in position because of the
distracting forces already explained.
■ Nonunion: The incidence of nonunion following clavicle
fractures ranges from 0.1% to 13.0%, with 85% of all non-
unions occurring in the middle third.

55. PAEDIATRICS CLAVICLE FRACTURE
• The clavicle is one of the most commonly fractured bones in
children, representing 5% to 15% of all pediatric fractures.
• The most common location for a clavicle fracture is the
midshaft of the bone, accounting for up to 80% of fractures.

56. MECHANISM OF INJURY
• Neonates can sustain a clavicle fracture during the
birthing process, especially those babies who are large
for gestational age or those involved in difficult
deliveries
• Toddlers and children who sustain clavicle fractures may
sustain the injury due to a fall or injuries sustained
during child abuse.

57. SIGNS AND SYMPTOMS
CLAVICLE FRACTURES
• Clavicle fractures in neonates commonly present after
difficult deliveries with decreased active movement about
the shoulder region.
• Crying upon passive movement of the shoulder and entire
upper extremity, swelling, crepitation, and an
asymmetrical bony contour.
• The Moro (startle) reflex may be decreased as well.

58. TREATMENT OPTIONS FOR
CLAVICLE FRACTURES
• The mainstay of treatment of pediatric and adolescent clavicle
fractures is nonoperative, allowing the fracture to form callous
and heal in situ, even if significant displacement is present.
• Conservative Treatment Plan
– Newborn to perambulatory children: Treated symptomati-
cally, binding arm to the chest.
– Ambulatory stage (2–12 years): Figure of ‘8’ bandages,
tightened after three days and later one week.
– Twelve years to maturity: Commercially available figure
of‘8’ harness

59. Fractures that should proceed directly to operative
intervention include
• Open fractures,
• Fractures with skin at risk of necrosis
• Fractures with associated neurovascular injuries.

61. SUMMARY
1. Most mid-shaft clavicular fractures heal without incident
when length and alignment are maintained
• Nondisplaced and minimally displaced fractures should
be treated nonsurgically, preferably with a sling for patient
comfort
• Acceptable cosmetic and functional results, as well as
union rates can be expected

62. 2. The risk of complications from non-surgical management
may be significantly higher:
• Those with completely displaced (1.5 to 2cm) and
comminuted fractures
• Possibly those who are female or of advanced age
The current literature suggests that surgical stabilization,
with either plates or IM device, should be considered the
preferred treatment option for these more complex acute
midshaft clavicular fractures

63. REFERENCES
• Canale S. T. Azar F. M. Beaty J. H. & Campbell W. C. (2017). Campbell's
operative orthopaedics (Thirteenth). Elsevier.
• Rockwood, C.A. et al. (2015) Rockwood and Green's fractures in
adults. Philadelphia (Pa): Wolters Kluwer Health.
• Flynn, J.M. et al. (2020) Rockwood & Wilkins' fractures in
children. Philadelphia: Lippincott Williams & Wilkins.
• Egol, K.A., Koval, K.J. and Zuckerman, J.D. (2020) Handbook of
fractures. Philadelphia: Wolters Kluwer.
• Ebnezar, J., Ebnezar, J. and John, R. (2017) Textbook of
orthopedics: Includes clinical examination methods in
orthopedics. New Delhi: Jaypee Brothers Medical Publishers.

64. Thank you