Clavicle fracture

This page is for adult patients; see Clavicle fracture (peds) for pediatric patients

Background

Calvicular anatomy (left anterior view).

• Generally secondary to shoulder trauma (direct trauma over the clavicle is less common)
• Fractured segment:
  • Type I: Middle third (80% of fractures)
  • Type II: Lateral third (15% of fractures)
  • Type III: Medial third (5% of fractures)
• Distal fracture may be associated with coracoclavicular ligament rupture
• Medial fracture may be associated with intrathoracic injuries

Clinical Features

Right clavicle fracture.

Right clavicle fracture.

Presentation

• Direct trauma to lateral shoulder/clavicle or fall on outstretched arm
• Swelling, deformity, and tenderness overlying the clavicle
• Affected arm may be supported by the contralateral arm

Associated Injuries

Rare, but important to evaluate for

• Type I (middle)
  • Subclavian artery/vein injury
  • Nerve root and/or brachial plexus injury
• Type II (lateral)
  • Coracoclavicular ligament injury
  • AC joint dislocation/subluxation
• Type III (medial)
  • Intrathoracic injury
  • Rib fracutre
  • Sternal fracture

Differential Diagnosis

Thoracic Trauma

• Airway/Pulmonary
  • Bronchial injury
  • Diaphragmatic trauma
  • Hemothorax
  • Pneumomediastinum
  • Pulmonary contusion
  • Tracheal injury
  • Trachobronchial injury
  • Traumatic pneumothorax
    • Tension pneumothorax
• Cardiac/Vascular
  • Cardiac injury
    • Blunt cardiac injury
      • Cardiac contusion
      • Commotio cordis
    • Penetrating cardiac injury
    • Cardiac tamponade
  • Traumatic aortic transection
• Musculoskeletal
  • Clavicle fracture
    • Clavicle fracture (peds)
  • Rib fracture
    • Flail chest
  • Scapular fracture
  • Scapulothoracic dissociation
  • Sternoclavicular dislocation
  • Sternum fracture
  • Thoracic and lumbar fractures and dislocations
• Other
  • Esophageal injury or Perforation
  • Pneumomediastinum
  • Pneumopericardium
  • Traumatic asphyxia

Shoulder and Upper Arm Diagnoses

Traumatic/Acute:

• Shoulder Dislocation
  • Anterior shoulder dislocation
  • Posterior shoulder dislocation
  • Inferior shoulder dislocation
• Clavicle fracture
• Humerus fracture
• Scapula fracture
• Acromioclavicular joint injury
• Glenohumeral instability
• Rotator cuff tear
• Biceps tendon rupture
• Triceps tendon rupture
• Septic joint

Nontraumatic/Chronic:

• Rotator cuff tear
• Impingement syndrome
• Calcific tendinitis
• Adhesive capsulitis
• Biceps tendinitis
• Subacromial bursitis
• Cervical radiculopathy

Refered pain & non-orthopedic causes:

• Referred pain from
  • Neck
  • Diaphragm (e.g. gallbladder disease)
• Brachial plexus injury
  • Rucksack paralysis
• Axillary artery thrombosis
• Thoracic outlet syndrome
• Subclavian steal syndrome
• Pancoast tumor
• Myocardial infarction
• Pneumonia
• Pulmonary embolism

Evaluation

Left clavicle fracture on xray.

Workup

• Assess distal pulse, motor, and sensation
• X-ray
  • May be seen on chest x-ray, shoulder x-ray, or dedicated clavicle films (preferred)
• If high suspicion and no fracture on plain films, consider CT

Diagnosis

Allman Classification

• Type I: Middle third
• Type II: Lateral third
• Type III: Medial third

Management

• Pain management
• Place the affected extremity in a sling or shoulder immobilizer

• Orthopedic surgery consultation in the ED for:
  • Displaced fracture with skin tenting
  • Open fracture
  • Neurovascular compromise
  • Adolescent fractures with significant shortening (>2cm)

Disposition

• Almost all may be discharged with orthopedic surgery follow-up (if no indications for immediate surgical management; see above)

Speciality Care

• Type I (middle)
  • Almost all non-operative
• Type II (lateral)
  • Depends on stable vs unstable clasification pattern (e.g. Neer IIA, IIB, V)
• Type III (medial)

See Also

• Clavicle fracture (peds)
• Fractures (main)