• Clinical science

Clavicle fracture

Abstract

Clavicle fractures are common fractures that usually affect children and adolescents and typically occur from a direct fall onto the shoulder. Clavicle fractures are classified according to the fracture location with the use of the Allman classification. More than two-thirds of cases are due to a fracture in the middle third of the clavicle (group I of the Allman classification). Patients usually present with nonspecific symptoms such as swelling, focal tenderness, and reduced movement of the arm in some cases, more specific signs such as shortening and drooping of the shoulder can occur. Clinical presentation and physical exam help confirm the diagnosis. X-ray is routinely performed to confirm the diagnosis. Further testing may be necessary in certain cases (e.g., arteriography in the case of potential vascular injury). Treatment depends on the location of the fracture and includes conservative and/or surgical measures.

Epidemiology

  • Common (account for approx. 2.6% of all fractures)
  • Most commonly occurs in children and adolescents

References:[1]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

  • Direct fall onto the shoulder, e.g., while cycling (∼85% of cases)
  • Direct blow (∼5% of cases)
  • Indirect trauma, like falling onto an outstretched hand (∼5% of cases)

References:[1]

Classification

Allman classification system

The Allman classification system categorizes fractures of the clavicle according to fracture location.

Group Location of fracture
I Midshaft fracture/middle third (∼ 69% of cases)
II Lateral/distal third
III Medial/proximal third

References:[1]

Neer classification of distal clavicle fractures[2]

Neer's original classification of distal clavicle fractures (group II according to Allman) from 1968 was revised and modified by Rockwood and Craig.

Type Location of fracture Associated ligament injuries
I
  • No ligamentous injury
IIa
  • No ligamentous injury
IIb
III
  • No ligamentous injury
IV
  • Childhood injury with periosteal disruption
  • No ligamentous injury
V
  • No ligamentous injury

Clinical features

References:[1][2]

Diagnostics

  • Physical examination
  • Imaging
    • Best initial test: X‑ray in two projections (anteroposterior view, 45° cephalic tilt view) (see radiographic signs of fracture)
    • CT/MRI when associated injuries are suspected or X‑ray findings are inconclusive
  • Additional tests may be necessary, e.g., arteriography and complete blood count (CBC) in the case of suspected vascular injury, or ultrasonography in the case of suspected clavicle fracture in children.

References:[2]

Treatment

Midshaft (group I) fractures

  • Mostly conservative treatment (e.g., simple shoulder sling) for 4–6 weeks
  • Exception: excessively shortened or displaced fractures (require surgery)

Lateral (group II) fractures

Treatment depends on the type of fracture according to Neer classification (see “Classification” above).

  • Stable fractures
    • Conservative treatment (e.g., simple shoulder sling)
  • Unstable fractures
    • Surgical fixation (e.g., tension banding, clavicular plate) is typically indicated
    • If needed, ligament repair (in type IIb fractures)

Medial (group III) fractures

References:[2]

Complications

  • Malalignment with cosmetic abnormalities
  • Nonunion

We list the most important complications. The selection is not exhaustive.

last updated 11/15/2018
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