Introduction & Epidemiology
Whatis a Clavicle Fracture?
A break in the continuity of the clavicle resulting from direct
or indirect trauma to the shoulder girdle.
Epidemiological
● Accounts for 2.6–5% of all adult fractures.
● Represents 35–45% of all shoulder girdle injuries.
● Most prevalent in young adults and athletes.
● Midshaft fractures comprise nearly 80% of all cases.
Clinical Significance
● Impacts shoulder function & biomechanics.
● Risk of neurovascular injury & nonunion.
3.
Common Causes
● Fallonto the lateral aspect of the shoulder
● Fall on an outstretched hand (FOOSH)
● Direct blow during contact sports
● Road traffic accidents
Why the Midshaft?
● Transition zone between medial/lateral curves
● Smallest cross-sectional diameter
● Lack of muscular & ligamentous reinforcement
Etiology & Mechanism
4.
Anatomical Region KeyCharacteristics
Medial Third Thick and cylindrical structure
Middle Third Narrowest and weakest segment
Lateral Third Flat and broad
The clavicle is an S-shaped long bone connecting the upper extremity to the axial skeleton. It is the first bone to begin
ossification during embryonic development.
Gross Anatomy
5.
Key Deforming Forces
Understandingmuscle pull is essential, as it
dictates the predictable displacement patterns
seen on X-rays post-fracture.
Clinical Consequences
These deforming forces lead to specific,
recognizable clinical and radiological signs.
• Medial Fragment: Pulled superiorly and
posteriorly by the Sternocleidomastoid muscle.
• Lateral Fragment: Pulled inferiorly by arm
weight, and medially by Pectoralis Major &
Deltoid.
• Significant fragment displacement
• Clavicular shortening and overlap
• Noticeable shoulder drooping
• Visible and palpable deformity under the skin
Muscular Attachments
Ref: Lazarides S, Zafiropoulos G. J Bone Joint Surg Br.
2006;88(3):327-332.
6.
Muscular Attachments &Deforming Forces
Key Muscular Attachments
Muscle Attachment Site & Action
SCM Medial 1/3; Elevates medial fragment
Pectoralis Major Medial 1/2; Pulls medial fragment medially
Deltoid Lateral 1/3; Pulls lateral fragment downwards
Trapezius Lateral 1/3; Ineffective in preventing displacement
7.
Clavicle Fracture ClassificationSystems
Group Allman Neer Robinson Craig
1 Group I: Middle third fracture Type I: Middle third clavicle fracture
Type 1: Medial fifth:
● Nondisplaced Extra-articular
● Nondisplaced Intra-articular
● Displaced Extra-articular
● Displaced Intra-articular
Type I: Middle third fractures
2
Group II: Fracture distal to
CCL, nonunion common
Type II: Lateral third; 3 subtypes:
● Type I: medial to CCL
● Type II: at CCL-trapezoid intact
● Type III: lateral to CCL entering ACJ
Type 2: Middle 3/5:
● 2A: Cortically aligned
(Nondisplaced/Angulated)
● 2B: Displaced (Simple
wedge/Multifragmentary)
Type II: Distal third:
● Minimally displaced/Displaced
● Conoid/Trapezoid status
● Articular/Children
● Comminuted
3
Group III: Proximal end clavicle
fractures
Type III: Medial third fractures
Type 3: Lateral fifth:
● Nondisplaced Extra/Intra-articular
● Displaced Extra/Intra-articular
Type III: Proximal third:
● Minimally displaced/Displaced
● Intra-articular/Epiphyseal
Source: Comparative Analysis of Clavicle Fracture Classification Systems
9.
Distal Clavicle FractureClassifications
Classification Basis of Classification Key Features
Neer Classification (1963)
Relationship of fracture line to coracoclavicular
(CC) ligaments and acromioclavicular (AC) joint
Type I: Lateral to CC ligaments
Type II: Medial to CC ligaments
Type III: Involving AC joint
Neer Modification (1984)
Included considerations for rare fracture
presentations
Added Type IV (metaphyseal-physeal junction displacement) and Type V (small
inferior fragment attached to CC ligaments)
Craig's Modification (1990)
Incorporation of periosteal sleeve avulsions and
comminution for Neer Type II
Expanded Neer Type II: periosteal sleeve avulsion (Type IIa) and comminution (Type
IIb)
Jäger Classification (1984) Fracture relation to CC ligament and intactness
Type I: Lateral to CC (intact)
Type IIA: Conoid ruptured, Trapezoid intact
Type IIB: Conoid intact, Trapezoid ruptured
Type III: Medial to intact CC
Type IV: Pediatric periosteal sleeve avulsion
Source: Table I. Classifications of Distal Clavicle Fracture
10.
Distal Clavicle FractureClassifications (Cont.)
Classification Basis of Classification Key Features
Edinburgh Classification
(1998)
Subclassification of shaft fractures according to
displacement and degree of comminution
Type 3A1/A2: Non-displaced (extra/intra-articular)
Type 3B1/B2: Displaced (extra/intra-articular)
AO Classification (2018)
Based on fracture pattern, anatomical location,
and complexity
15.3A: Extra-articular simple
15.3B: Extra-articular wedge
15.3C: Complex intra-articular
Cho Classification (2018)
Fracture displacement and stability as well as
fracture location
Type I: Stable/Minimally displaced (<5mm)
Type II: Displaced (>5mm). Subtypes IIA-IID based on CC ligament involvement and
comminution
Xue Classification (2024) Relationship of fracture line to ligament footprints Type I: Lat. to trapezoid; Type II: Between ligaments; Type III: Medial to conoid
Source: Literature Review of Distal Clavicle Fracture Classifications
11.
Standard Views
AP View:Initial evaluation to
identify general fracture location.
15-45° Cephalic Tilt:
Demonstrates displacement
clearly and improves visualization
of clavicular shortening.
Key Parameters
Carefully assess the precise
fracture location, degree of
displacement, angulation, overall
shortening, presence of
comminution, and any articular
extension.
CT Indications
Required for complex cases
including medial-end fractures,
intra-articular involvement,
suspected neurovascular
compromise, or for detailed
pre-operative planning.
Radiological Assessment
Ref: Ahrens PM, Garlick NI, Barber J, Tims EM. Bone Joint J.
2017;99-B:1345-1354.
12.
Midshaft Fracture
Highest Frequency:69-82%
This is the most common presentation of clavicle injuries
due to the anatomical weakness of the middle third.
Superior displacement of medial fragment
Inferior displacement of lateral fragment
Pronounced fragment overlap & shortening
Clinical Relevance:
Displacement >2 cm significantly increases the risk of nonunion
and long-term functional impairment.
13.
Radiological Findings
Fractures locateddistal to the coracoclavicular ligaments
often present unique challenges. Displacement is highly
variable depending on ligament integrity.
• Possible acromioclavicular (AC) joint involvement
• Superior migration of the medial fragment if ligaments
tear
• Key Assessment: Check Conoid & Trapezoid ligament
integrity
Clinical Relevance: Higher incidence of delayed union and nonunion
compared to midshaft fractures.
Lateral Third Fracture
Ref: Neer CS. Clin Orthop Relat Res. 1968;58:43-50.
14.
Diagnostic Challenges Fracturesnear the sternoclavicular articulation are often poorly visualized on standard plain
radiographs, frequently necessitating advanced imaging like CT scans to determine morphology and mediastinal
involvement.
Displacement Risks While relatively rare, these fractures may demonstrate dangerous posterior displacement towards
the mediastinum, presenting immediate risks to underlying vital anatomy.
Associated Complications Requires critical and urgent evaluation due to the proximity of vital structures. Potential
life-threatening complications include tracheal compression, esophageal injury, and great vessel lacerations.
Medial Third Fracture
Ref: Throckmorton TW, Kuhn JE. J Shoulder Elbow Surg.
2007;16(1):49-54.
15.
Surgical Techniques
1. OpenReduction Internal Fixation (ORIF)
Anatomical reduction followed by fixation using plates and screws.
Considered the operative gold standard.
Indications:
● Displaced midshaft fractures
● Shortened clavicle fractures
● Unstable fracture patterns
Advantages:
● Stable fixation & early mobilization
● Restoration of length and alignment
● Lower risk of malunion
2. Intramedullary Fixation
Implant placed within the medullary canal. Modern standard uses
Titanium Elastic Nails (TEN).
Historical Implants:
● Rockwood pins
● Hagie pins
Advantages:
● Minimally invasive (smaller incision)
● Less soft tissue disruption
● Superior cosmetic outcomes
Key Takeaway: ORIF remains the preferred surgical treatment for displaced midshaft fractures, while intramedullary fixation serves as a
minimally invasive alternative in selected cases.
16.
Rehabilitation Phase One:0 to 6 weeks
Goals
● Protect the fractured clavicle
● Prevent shoulder stiffness
● Regain range of motion
● Control pain and swelling
Sling & Arm Use
Sling: Use most of the time for first 2 weeks. Remove 4-5x
daily for pendulum exercises.
Elevation: Do not elevate arm above 90° in any plane.
Lifting: Limit to 1-2 lbs. Avoid excessive reaching/rotation.
Showering
Permitted once incision heals.
Bend at waist to wash under arm
(passive motion).
ICE Program
Freq: 4-5x daily (7 days/week)
Duration: 15-20 minutes
Exercise Program
● Pendulum exercises
● Supine external rotation
● Assisted elevation (limit 90°)
● Isometric rotation at neutral
● Elbow and forearm exercises
● Ball squeeze exercise
● Scapular retraction
Frequency: 4-5 times/day, 7 days/week.
17.
Phase Two: 7to 12 Weeks
Goals
● Protect the clavicle fracture
● Improve shoulder range of motion
● Begin gentle strengthening
Activities
Sling: No longer necessary unless instructed.
Arm Use: Daily activities permitted. Avoid lifting >2 lbs,
forceful pushing/pulling.
Movement: Avoid reaching behind body or head.
Bathing: Continue Phase One precautions.
Schedule
Days: 7 per week
Frequency: 1-3 times per day
Note: Focus on stretching and active motion
drills.
Exercise Program
● Supine/Standing ER
● Supine assisted elevation
● Elevation in scapular plane
● Behind-back IR (limit beltline)
● Horizontal adduction
● Hands behind-head stretch
● Proprioception drills
Strengthening / Theraband
● Internal & External Rotation
● Biceps curls
● Row
● Forward (serratus) punch
Dynamic Strengthening
● Side-lying ER
● Prone row, extension, T's, Y's
● Standing scaption
● Isotonic biceps curl
● Rhythmic stabilization
● Scapulohumeral rhythm
18.
Phase Three: 13to 18 Weeks
Goals
● Protect the clavicle fracture
● Regain full range of motion
● Continue strengthening progression
Activities & Arm Use
● Use for normal daily activities (dressing, bathing,
self-care)
● Avoid carrying objects > 1 lb
● Avoid forceful pushing or pulling
● Avoid lifting weighted objects overhead
Schedule
Stretching: 7 days/wk, 1-2x daily
Strengthening: 7 days/wk, 1x daily
Stretching / ROM
● Pendulum exercises
● Doorway stretch / Standing ER
● Wall slide stretch
● Hands-behind-head stretch
● Standing forward flexion
● Behind-the-back IR
● Supine cross-chest stretch
● Sleeper stretch
● ER at 90° abduction stretch
Theraband Program
● External / Internal rotation
● Standing forward punch
● Dynamic hug
● Seated row
● Biceps curl
● W's
Dynamic Strengthening
● Side-lying ER
● Prone T's, Y's, Rows, Extension
● Full-can scaption
● Progressive resistance (5-16 lb)
● Rhythmic stabilization drills
● Week 16: Limited weight training
(per physician approval)
19.
Phase Four: 19to 28 Weeks After Surgery
Goals
● Progression of functional activities
● Maintain full range of motion
● Continue progressive strengthening
● Advance sports/recreational activity
Frequency & Core Program
Stretching: 5-7 days/wk, 1x daily
Strengthening: 3 days/wk, 1x daily
Continue Phase Three protocols.
Consultation
Weight Training: Consult physician & PT.
Interval Sports: Golf, Tennis, Swimming,
Throwing.
Plyometric Program (Reserved for throwing/overhead athletes)
The following drills focus on dynamic stability and explosive control:
● Rebounder throws with arm at side
● Overhead wall dribbles
● Rebounder throwing with weighted ball
● Deceleration drills with weighted ball
● Wall dribbles at 90°
● Wall dribble circles
23.
References
1. Robinson CM.Fractures of the clavicle in the adult. Epidemiology and
classification. J Bone Joint Surg Br. 1998;80(3):476-484.
2. Postacchini F, Gumina S, De Santis P, Albo F. Epidemiology of clavicle
fractures. J Shoulder Elbow Surg. 2002;11(5):452-456.
3. Canadian Orthopaedic Trauma Society. Nonoperative treatment
compared with plate fixation of displaced midshaft clavicular fractures. A
multicenter randomized clinical trial. J Bone Joint Surg Am. 2007;89(1):1-10.
4. Ahrens PM, Garlick NI, Barber J, Tims EM. The Clavicle Trial: A multicenter
randomized controlled trial comparing operative with nonoperative
treatment of displaced midshaft clavicle fractures. Bone Joint J.
2017;99-B(10):1345-1354.
5. Neer CS. Fractures of the distal third of the clavicle. Clin Orthop Relat
Res. 1968;58:43-50.
6. Craig EV. Fractures of the clavicle. In: Rockwood CA Jr, Matsen FA III,
editors. The Shoulder. 3rd ed. Philadelphia: Saunders; 2004. p. 455-519.
7. Lazarides S, Zafiropoulos G. Conservative treatment of fractures at the
middle third of the clavicle: The relevance of shortening and clinical
outcome. J Bone Joint Surg Br. 2006;88(3):327-332.
8. Throckmorton TW, Kuhn JE. Fractures of the medial end of the clavicle. J
Shoulder Elbow Surg. 2007;16(1):49-54.
9. Cho CH, Kim BS, Kim DH, Choi CH, Kim CK, Lee KJ. Distal clavicle fractures:
A new classification system. Orthop Traumatol Surg Res.
2018;104(8):1231-1235.
10. Massachusetts General Hospital Sports Physical Therapy Service.
Rehabilitation Protocol for Clavicle Fracture (Post-Operative). Boston,
Massachusetts General Hospital; 2023.
11. Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. 9th ed.
Philadelphia: Wolters Kluwer; 2023.
12. Standring S, editor. Gray's Anatomy: The Anatomical Basis of Clinical
Practice. 42nd ed. London: Elsevier; 2020.
