Clavicle fracture

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 examination 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.

• Common (accounts for ∼ 2.6% of all fractures) ^[1]
• Most commonly occurs in children and adolescents ^[2]
• Most common birth trauma in newborns ^[3]

Epidemiological data refers to the US, unless otherwise specified.

• Direct trauma (∼ 95% of cases) ^[4]
  • Fall onto the shoulder (most common cause), e.g., from bicycle accident
  • Direct blow to the clavicle, e.g., from a football tackle
• Indirect trauma (∼ 5% of cases): mainly falls onto an outstretched hand ^[4]
• Birth trauma (see “Birth-related clavicle fracture”)

• Most common site of fracture is the middle third segment of the clavicle because its weakest point is at the junction of the middle and lateral third of the clavicle.

Allman classification system ^[5]

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

• For general symptoms, see “General principles of fractures.”
• Sagging of the shoulder due to downward distracting force of the weight of the upper limb on the lateral fracture fragment
• Tenting of the skin over the clavicle due to the upward distracting force of the sternocleidomastoid on the medial fracture fragment
• Shortening of the clavicle due to the medial distracting force (adduction) of the pectoralis major on the lateral fracture fragment

• Physical examination
  • Examination for signs of fracture and concomitant injuries
  • Assess for neurovascular compromise and compartment syndrome with the 6 P's: pain, pallor, pulselessness, paresthesia, paralysis, and poikilothermia
    • Weak pulses: possible injury of the subclavian artery
    • Dysfunction of a distal nerve: possible injury of the brachial plexus
    • Massive swelling and discoloration: possible injury of the subclavian vein
• Imaging
  • Best initial test: x‑ray in two projections (see “Diagnostics” in “General principles of fractures”)
  • CT/MRI when associated injuries are suspected or x‑ray findings are inconclusive
• Other: Additional tests may be necessary
  • Arteriography in the case of suspected vascular injury
  • Ultrasound in the case of suspected clavicle fracture in children

• Acromioclavicular joint injury
• Sternoclavicular joint injury
• Rib fracture
• Scapular fracture
• Shoulder dislocation
• Rotator cuff injury

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

• 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

Medial (group III) fractures

• Conservative treatment (similar to group I fractures)
• Displacement is uncommon due to strong ligamentous attachments.
• See “Treatment” in “General principles of fractures.”

• Malalignment with cosmetic abnormalities
• Nonunion

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