Table of Contents
- Introduction
- Symptoms
- Aetiology
- Clinical Findings
- Investigations
- Treatment
- Referrals
- Exercise Prescription
- Evaluation of Treatment Outcomes
- Differential Diagnoses
- Prognosis
- Extra Information
Introduction
The clavicle, an “S”-shaped bone, is the only long bone that ossifies by an intramembranous process. It is the first bone in the body to ossify (fifth week of fetal gestation) and is the last bone to fuse (medial epiphysis at 25 years of age). The clavicle consists of cancellous bone surrounded by an outer layer of compact bone, and it is unique in that it does not have a medullary cavity.
The clavicle serves a variety of functions. First, it acts as a rigid base for muscular attachments of the shoulder, neck, and chest. It also provides protection for the major vessels at the base of the neck and for the nerves and vessels supplying the upper limb. In addition, it forms a strut that holds the GH joint in the parasagittal plane, increasing the range of motion of the shoulder as well as the power of the arm in motions above the horizontal.
The clavicle articulates with the manubrium of the sternum through the SC joint and with the acromion at the AC joint. It is attached to the coracoid by the coracoclavicular ligaments, the conoid medially and the trapezoid laterally.
Symptoms
There is acute onset of localised swelling and pain over the anterior part of the shoulder, with typical deformation, after direct or indirect trauma, often in a young athlete.
Aetiology
It is common in rugby, ice hockey, riding and cycling.
Clinical Findings
A clavicle fracture is usually easy to diagnose since the patient refers to a ‘crack’ and can point to the fracture site where there is bruising, deformation and tenderness on palpation. Vascular complications (wrist pulse) and neurological complications (reflexes and sensation and power of the hand).
Investigations
This is a clinical diagnosis. X-rays should be taken in different planes to demonstrate the fracture and the presence of intermediary
fragments. MRI or CT are usually not required in the acute phase for the diagnosis but may be performed in cases involving great trauma to investigate associated injuries to underlying blood vessels or ribs or to the acromioclavicular joint.
Treatment
An 8-bandage, applied properly, will reduce the pain as well as holding the fracture in the best position for healing, which takes six to eight weeks. Only complicated cases will require surgery.
Referrals
Refer to Dr Kevin Yip (+65 6664 8135) senior consultant orthopaedic surgeon to determine the grade of injury and for consideration of surgery. Refer to physiotherapist to start an eight to twelve week rehabilitation programme back to full sport.
Exercise Prescription
Many sports and activities, such as water exercises and cross-training, can be maintained but avoid further direct or indirect trauma to the shoulder. Running should initially be avoided since the shoulder will be sensitive to this type of impact and holding the arm still while running will cause secondary upper back and neck pain. Swimming should also wait for around six weeks. The specific rehabilitation should aim at a full range of controlled motion, good posture and thoracoscapular control after two months, followed by functional training for up to three months before resuming full sport.
Evaluation of Treatment Outcomes
Normal clinical symptoms and signs. Functional strength, control and flexibility should be comparable with the other shoulder.
Differential Diagnoses
Vascular or neurological injuries, sternoclavicular or acromioclavicular joint dislocation and rib fractures should be ruled out.
Prognosis
Excellent-Good in most cases.
Extra Information
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The clavicle serves as the primary bony connection between the thorax and upper limb.
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A fracture of the clavicle also is known as a broken collarbone.
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Classification:
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By location in the clavicle: proximal, middle, or distal 1/3.
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Fracture displacement and comminution are important factors.
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Clavicle fractures from high-energy trauma may be associated with ipsilateral scapula fractures and represent an unstable floating shoulder.
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Distribution is trimodal:
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Injury occurs in newborns secondary to birth trauma.
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Fractures in adolescents and young adults is secondary to trauma.
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Elderly patients sustain fractures secondary to osteoporosis and falls.
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1 of the most common fractures.
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5% involve the proximal 1/3 of the clavicle.
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70% the middle 1/3
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25% the distal 1/3
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Male gender
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Contact sports
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Large birth size (<4 kg) and older maternal age among newborns (4)
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High-energy trauma
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Falls among the elderly
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Primarily direct trauma to shoulder girdle
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In the adult, clavicle fractures typically result from sports or motor vehicle accidents and are caused by a direct blow to the shoulder.
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Clavicle fractures also can result from severe chest injuries with lung trauma or a dissociation of the shoulder complex from the rib cage.
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In the infant, these injuries frequently are related to difficult deliveries and can occur with brachial plexus palsy.
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Subclavian vascular injury
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Brachial plexus injury
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Scapular fractures
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Shoulder fracture or dislocation
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Lung or rib injury
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Floating shoulder
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Ligamentous injury and disruption
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Pain over the shoulder or clavicle
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Pain in ROM of the shoulder
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Deformity and swelling over the clavicle
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In children, refusal to move the extremity
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If vascular injury is considered, obtain an arteriogram.
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Order a standard AP view of the clavicle and a view with the beam tilted 45° cephalad.
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If a shoulder disorder is suspected, then specific shoulder views, including an axillary view, are needed.
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If posterior displacement of proximal 1/3 fractures is suspected, obtain a CT scan.
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This fracture typically occurs in the middle 1/3 of the clavicle because of the bone’s biomechanics and structure.
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The middle 1/3 of the clavicle experiences the largest bending moment with applied load to the shoulder and has the smallest cross-sectional area.
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Clavicle fractures can be associated with other injuries, including pneumothorax, rib fractures, and humerus fractures.
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Posterior fracture displacement of medial fractures
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Shoulder proximal humerus fracture or dislocation
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AC separation (tearing of the ligaments without fracture)
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AC joint arthrosis
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Rotator cuff disorders
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Pneumothorax or hemothorax
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Injury to the brachial plexus
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Injury to the great vessels
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Head injury
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Scapulothoracic dissociation
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Floating shoulder (fracture of the clavicle and scapula)
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Analgesics and sling immobilization
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Physical therapy for early ROM of the shoulder (Codman exercise)
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Most of these injuries can be managed nonoperatively.
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Most clavicle fractures do not require reduction maneuvers.
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Immobilization for 1 week in a sling and then gentle ROM of the shoulder are treatments of choice for most of these fractures.
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The patient should be referred to an orthopaedic surgeon if any question about treatment arises.
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Midclavicular fractures without large displacements or shortening can be treated with a sling.
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Posterior medial clavicle fractures must be evaluated for the possibility of airway compromise or concurrent injury.
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May need immediate reduction by an orthopaedic surgeon.
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Because the medial growth physis does not close for the clavicle until the patient is ~21 years old, medial fractures in the young adult are typically Salter-Harris type II fractures and eventually remodel .
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The shoulder should be immobilized until comfortable, and then increasing ROM exercises should begin.
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Until tenderness resolves, limit lifting or overhead work.
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With any shoulder injury, care should be taken that appropriate personal care of the armpit is taken.
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Because of pain with abducting the shoulder, this area may be difficult to keep clean.
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Codman exercises should be instituted early in the course, using a pendulum-type movement of the shoulder with the trunk bent and supported.
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Passive ROM to the overhead position increases as the pain diminishes in several weeks.
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Strengthening exercises are used when pain resolves.
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Analgesics should be prescribed as appropriate to the level of pain experienced.
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Narcotics may be required for pain relief.
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Surgery may be needed for:
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Displaced fractures in patients who are highly active or have jobs with overhead activity:
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These patients may be unsatisfied with the deformity that will result from nonoperative treatment .
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Comminuted or displaced midshaft fractures
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Displaced fractures of the lateral 1/5 of the clavicle: Controversy exists as to the effectiveness of surgery
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Open fractures over the clavicle
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Substantially displaced fractures with skin tenting
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Nonunion of previous fractures
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Floating shoulder
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The exact determinants for surgical intervention and the type of surgery are controversial.
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The most common treatment is open reduction and internal fixation with a plate and screws.
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The plate may be placed superiorly, anteriorly, or anteroinferiorly.
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Hardware irritation is common after surgery, requiring plate removal.
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Pin fixation is a less invasive alternative.
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Threaded screws or titanium flexible nails may be used.
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A serious complication of pin fixation is migration of the pin into the intrathoracic region.
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Usually the pin must be removed after fracture healing.
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The prognosis is good for patients with minimally displaced fractures.
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Patients with displaced fractures develop a generally asymptomatic deformity from the fracture.
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Functional deficits are unusual but can occur with markedly displaced fractures.
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Return to full function should occur by 6-12 weeks.
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If the fracture has caused shortening or if a displaced distal clavicle fracture is present, problems with AC arthrosis or function may occur.
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Skin breakdown over the fracture site
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Nonunion or malunion (may require future procedures to realign the bone and permit healing)
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Vascular injury
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Nerve injury
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Pneumothorax
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Residual pain
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Order serial radiographs at intervals of 3-4 weeks to monitor healing.
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Assess the skin carefully to ensure that it has not been compromised.
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Evaluate nerve and vascular function acutely and at follow-up intervals.
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767.2 Clavicle fracture due to birth trauma
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810.00 Interligamentous part clavicle fracture
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810.01 Sternal end clavicle fracture
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810.02 Mid shaft clavicle fracture
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810.03 Acromial end clavicle fracture
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The physician should stress that residual bony deformity may occur after closed treatment.
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Functional limitation is unusual but may occur.
If you would like an appointment / review with our clavicle fracture (broken collarbone, collarbone pain) specialist in Singapore, the best way is to call +65 6664 8135 or click here to book an appointment at the clinic. If you would like to speak to one of our clinicians first, then please contact feedback2@bone.com.sg or SMS/WhatsApp to +65 6664 8135Rest assured that the best possible care will be provided for you.
