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Clavicle Fracture

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  1. See Also
    1. Clavicle Fracture from Birth Trauma
    2. Fall on Shoulder
  2. Epidemiology
    1. Incidence: 5-10% of all Fractures
    2. Bimodal age distribution: Age under 25 and over 55-75 years
  3. Pathophysiology: Mechanism of Injury
    1. Trauma
      1. Fall against lateral shoulder (most common)
      2. Fall on Outstretched Hand
      3. Direct blow to clavicle
    2. No trauma (in children)
      1. Tumor
      2. Rickets
      3. Osteogenesis imperfecta
      4. Physical Abuse
  4. Symptoms
    1. Pain and swelling localized to Fracture site
    2. Patient unable to lift arm due to pain
  5. Signs
    1. Presentation: Holding the affected arm adducted and supported with the opposite hand
    2. Gross clavicular deformity observed or palpated
      1. Localized swelling, bruising, tenderness, and crepitation
    3. Observe for complications
      1. Neurovascular injury of affected arm
      2. Pneumothorax
      3. Subcutaneous Emphysema
  6. Differential Diagnosis
    1. Acromioclavicular Separation
    2. Sternoclavicular Dislocation
  7. Complications
    1. Pneumothorax
    2. Hemothorax
    3. Brachial Plexus Injury
    4. Subclavian artery and subclavian vein injury
    5. Fracture nonunion (1-4%)
      1. Rare, more associated with lateral Fracture (Group 2)
  8. Imaging
    1. Anteroposterior clavicle
    2. Additional views
      1. Suspected non-displaced Fracture
        1. AP view with Cephalic tilt of 45 degrees
      2. Suspected medial clavicle Fracture (Group 3)
        1. Zanca view with 20 degree angle
  9. Classification: Allman Grouping
    1. Group 1: Middle third or midshaft clavicle Fracture (75-80%)
      1. Weakest, thinnest segment of the clavicle and hence most susceptible to Fracture
      2. Overall clavicle shortening with medial segment raised and distal segment lowered
      3. Generally stable Fracture
      4. Occurs most in younger patients
    2. Group 2: Lateral third or distal clavicle Fracture (15-25%)
      1. Unstable if displaced Fracture
      2. AC joint Osteoarthritis if articular surface involved
      3. Revised Neer classification
        1. Type I: Intact coracoclavicular ligaments (conoid and Trapezoid ligaments)
        2. Type 2: Coracoclavicular ligaments torn medially, only Trapezoid attached laterally
        3. Type 3: Clavicle Fracture involving the AC joint
        4. Type 4: Periosteal sleeve disruption in children (not a bony Fracture)
        5. Type 5: Ligament avulsion with with small inferior cortical fragment
    3. Group 3: Medial third or proximal clavicle Fracture (5%)
      1. Associated with neurovascular injury
  10. Management: Based on Allman Group
    1. Group 1 (Middle third)
      1. Conservative therapy (see below) in most cases
      2. Consider operative repair if multiple risks for midshaft Fracture non-union
        1. Clavicle shortening >20 mm
        2. Female gender
        3. Older age
        4. Fracture displacement or comminution
        5. More significant traumatic injuries
    2. Group 2 (lateral third)
      1. Displaced and possibly Neer Type II (unstable and risk of non-union): Surgery
      2. Nondisplaced (Neer Type I and III)
        1. Conservative therapy as with Allman Group 1 Fractures (see below)
      3. Children with Type 4 (uncommon)
        1. Typically treated as AC joint injuries
    3. Group 3 (proximal third)
      1. Neurovascular injury: Emergent orthopedic referral
      2. Nondisplaced (typical): Conservative therapy (see below)
      3. Displaced
        1. Orthopedic referral for surgery
        2. Suggests significant trauma and higher risk for neurovascular injury
        3. Neurovascular injury present
          1. Emergent reduction is critical
          2. Towel clip can be used to grasp clavicle and apply anterior traction
        4. No neurovascular injury
          1. CT Scan of the clavicle to visualize posterior fragments
    4. References
      1. Robinson (2004) J Bone Joint Surg Am 86:1359
      2. Hill (1997) J Bone Joint Surg Br 79:537
  11. Management: Conservative therapy
    1. Sling
      1. Arm sling for comfort (typically used for first 2 weeks)
        1. Under age 12: Sling for up to 3-4 weeks
        2. Over age 12: Sling for up to 4-6 weeks
      2. Avoid figure-of-eight (no benefit, complication risk)
        1. Andersen (1987) Acta Orthop Scand 58:71
    2. Exercises
      1. Elbow range of motion Exercises as soon as able
      2. Shoulder Range of Motion and strength Exercises
        1. Start as tolerated in 2-3 weeks after injury
    3. Return to Play criteria
      1. Full and painless Shoulder Range of Motion with normal shoulder strength
      2. Bony healing by exam and imaging
      3. Timing
        1. Non-contact sports: 6 weeks after injury
        2. Contact sports: 8-16 weeks after injury
    4. References
      1. Stanley (1988) Injury 19:162
  12. Course
    1. Adult: Clavicle Fracture site remains prominent
    2. Child: Site remodels and disappears in months
  13. Referral Indications
    1. Extreme proximal displaced clavicle Fracture (Allman Group 3)
    2. Extreme distal displaced clavicle Fracture (Allman Group 2)
    3. Midshaft displaced clavicle Fracture (Allman Group 1) with multiple nonunion risks
    4. Neurovascular injury
    5. Painful nonunion after 4 months
  14. Complications
    1. Short-term
      1. Pneumothorax
      2. Neurovascular injury
    2. Long-term
      1. Physeal injury in adolescents (Allman Group 3 medial Fractures)
      2. Malunion
      3. Thoracic Outlet Syndrome
      4. Weakness or Paresthesias
      5. Deformity of cosmetic significance
  15. References
    1. Wirth in Greene (2001) Musculoskeletal Care, p. 127-8
    2. Housner (2003) Phys Sports Med 31:30
    3. Pecci (2008) Am Fam Physician 77:65
    4. Quillen (2004) Am Fam Physician 70:1947

Fracture of clavicle (C0159658)

ConceptsInjury or Poisoning (T037)
ICD9810
EnglishClavicle Fracture, CLAVICULAR FRACTURE, Collar bone fracture, Fracture of clavicle, Fracture of collar bone
Spanishfractura clavicular, fractura de la clavicula
Parent ConceptsFracture of upper limb NOS (C0178316), Fracture (C0016658), Fracture of clavicle (C0159658), Fracture of bones of trunk (C0272503), Clavicle injury (C0560626), Duplicate concept (C1274013)
SourcesCOSTAR, ICD9CM, MTH, NCI, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)



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