Fractures of the clavicle are common injuries, accounting for 2.6-4% of all fractures. In adults, clavicle fractures can be more problematic than in children. Displaced mid-shaft fractures, lateral-third fractures with coracoclavicular ligament disruption, and medial-third fractures threatening mediastinal structures often require surgical fixation, while minimally displaced fractures are usually treated non-operatively with slings or immobilization. Surgical techniques include plating, intramedullary fixation, coracoclavicular screws/plates, and hook plates. Complications can include non/malunion, shoulder stiffness, and for medial fractures, mediastinal injuries from implant migration

1. Fracture Clavicle
Dr. Ashiqur Rahman
Resident Orthopedics
Dhaka Medical college Hospital

2. Introduction
 In children the clavicle fractures easily, but is almost invariably unites
rapidly & without complications.
 In adult this can be much more troublesome injury.
 In adult clavicle # is common, accounting for 2.6-4% of # &
approximately 35% of all shoulder girdle injuries.

3. Mechanism of injury
 A fall on the shoulder or the outstretched hand may break the
clavicle.
 In the common mid-shaft # the lateral fragment is pulled down by the
wt. of the arm & inner, medial half is held by the sternocleidomastoid
muscle.
 If the # of the lateral end, if the ligaments are intact, there is little
displacement; but if coraco-clavicular ligaments are torn or if # is just
medial to these ligaments displacement may be more severe & closed
reduction impossible.
 The clavicle is also a reasonably common site for pathological #.

4. Imaging
1. X-ray atleast AP view & another 30 degrees cephalic tilt.
2. With medial third # it is also wise to obtain X-rays of the sterno-
clavicular joint .
3. CT scanning with 03 dimensional reconstruction may be needed to
determine accurate degree of shortening or for diagnosing a sterno-
clavicular fracture-dislocation.

5. Classification:
Clavicle # is classified on the basis of their location:
(i) Group – I : Middle-third fractures
(ii) Group – II : Lateral-third fractures
(iii) Group – III : Medial-third fractures

6. Lateral third # further classified by Neer:

10. Relative indication of primary fixation for mid-shaft fracture:
(FAP)
1.Fracture-Specific:
- Displacement > 2 cm
- Shortening > 2 cm
- Increasing comminution (>3 fragments)
- Segmental fractures
- Open fractures
- Impending open fractures with soft-tissue compromise
-Obvious clinical deformity (usually associated with displacement
and shortening)
- Scapular malposition and winging at initial examination

11. 2. Associated Injuries:
- Vascular injury requiring repair
- Progressive neurologic deficit
- Ipsilateral upper extremity injuries/fractures
- Multiple ipsilateral upper rib fractures
- ‘Floating shoulder’
- Bilateral clavicular fractures

12. 3. Patient Factors:
- Polytrauma with requirement for early upper extremity
weight bearing/arm use.
- Patient motivation for rapid return of function (e.g., elite
sports or self-employed professional).

13. Treatment
1. Middle third fracture:
- Undisplaced # should be treated non-operatively.
- Most will go on to unite eneventfully with a non-union rate <5%
& a return to normal function.
 Non-operative treatment:
- Applying a simple sling for comfort.
- It is discarded once pain subsides(after 1 – 3 weeks)
- The pt. is then encouraged to mobilize the limb as pain allows.
- There is no evidence that traditional figure of eight bandage
confers any advantages.

14. Rx of displaced middle third #
 There is growing trend towards internal fixation of acute clavicular #
associated with severe displacement, fragmentation or shortening.
 Methods include plating (Specific contoured locking plate are
available) & intra-medullary fixation.

15. Lateral third fracture
 Most of the lateral third # are minimally displaced & extra-articular.
 The fact that the coraco-clavicular ligaments are intact & prevent
further displacement.
 Treatment consist of sling for 2 – 3 weeks until the pain subsides,
followed by immobilization within the limits of pain.

16. Rx of displaced lateral third #
 Associated with disruption of the coraco-clavicular ligament & are
therefore unstable.
 Surgery to stabilize the fracture is often recommended.
 Techniques include the use of a coraco-clavicular screw & plate, hook
plate fixation, suture & sling techniques with dacron graft ligaments &
more recent lateral clavicle locking plate.

17. Plate & screw fixation
 Plating techniques continue to evolve.
 Newer pre-contoured plates allow accurate fitting while maintaining
strength.
 Complications have been reported with 3.5mm reconstruction plates,
which allow easy contouring but may be too weak to maintain
reduction.
 Most commonly used technique is superior placement of the plate,
but when the # configuration allows we prefer antero-inferior plate
placement.

21. Medial third fractures
 Most of these rare # are extra-articular
 They are are mainly managed non-operatively unless # displacement
threatens the mediastinal structures.
 Internal fixation is associated with significant complications, including
migration of the implants into mediastinum, particularly when K-wire
are used.
 Other method of stabilization include graft technique & newer locking
plate.

22. Complications
1. Early :
- Pneumothorax
- Subclavian vessels injury
- Brachial plexus injury
2. Late :
- Non-union
- Malunion
- Stiffness of the shoulder