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Clavicle Fractures

Categories
  • Joint/Tendon
Tags
  • Shoulder injury
Shoulder

Clavicle Fractures

Shoulder anatomy

Anatomy:

Shoulder anatomy
Rotator Cuff Muscles

Description:

  • The shoulder joint is a multi-axial joint with muscles crossing it to allow shoulder range of motion (ROM)
  • The rotator cuff muscles are important in allowing shoulder ROM
  • The rotator cuff muscles consists of Subscapularis, Supraspinatus, Infraspinatus and Teres Minor
  • Other important shoulder muscles that allow shoulder ROM include long head of Biceps and the Deltoid muscle
Left Brachial plexus
Right shoulder complex anterior view

Right shoulder complex anterior view

Right shoulder complex posterior view

Right shoulder complex posterior view

Right shoulder view
Right Clavicle

Clavicle Fractures

Clavicle fracture is associated with extreme pain with arm movement. The clavicle is subcutaneous and injury may cause local bruising with visual bump present. Most often clavicle fractures can be managed non operatively.

Group 1: Middle 1/3

Group 2: Lateral 1/3

Group 3: Medial 1/3

Clavicle fractures
% incidence of clavicle fracture position

% incidence of clavicle fracture position

Mechanism of injury:

  • Most commonly a fall to the shoulder with arm on the side
  • Risk factors include contact sports

Presentation:

  • Pain
  • Swelling and bruising
  • Deformity
  • Grinding with moving the shoulder
  • Note any respiratory symptoms

Clinical:

  • Bone tenderness
  • Deformity
  • Palpable fracture
  • Exclude respiratory lung injury

Investigation:

  • X-rays: AP and serendipity views (40°cephalic tilt). Clavicle fracture identification with fracture location
  • CT scan: useful for intra-articular evaluation

Classification of Clavicle Fractures

Classification of clavicle fractures

Classification of clavicle fractures according to Allman and Neer

AO Classification for Midshaft Clavicle Fractures

AO classification for midshaft clavicle fractures

AO Classification of Lateral Clavicle Fractures

AO classification of lateral clavicle fractures

Neer Classification for Distal 1/3 Clavicle Fractures

Neer classification for distal 1/3 clavicle fractures

Neer Classification & Management of Distal 1/3 Clavicle Fractures

Neer Classification Fracture Characteristics Proposed Management
Type I Extra-articular, lateral to CC ligaments Non-operative
Type II A Medial to CC ligaments with intact ligaments, medial clavicle displacement with instability Operative
Type II B 2 Part Fracture:

  • Torn between CC ligaments with torn conoid & intact trapezoid

OR

  • Lateral to CC ligaments with both ligaments torn
Operative
Type III Intra-articular fracture lateral to CC ligaments with extension to ACJ with intact conoid & trapezoid ligaments, stable Non-operative
Type IV Physeal fracture with intact CC ligaments, stable Non-operative
Type V Communited fracture with intact CC ligaments, significant medial clavicle displacement, unstable Operative

Cho’s Classification for Distal 1/3 Clavicle Fractures

Cho’s classification for distal 1/3 clavicle fractures

Cho’s Classification and Proposed Management Algorithm for Distal 1/3 Clavicle Fractures

Cho’s classification and proposed management algorithm for distal 1/3 clavicle fractures

CC: coracoclavicular, IM: intramedullary

Management

Nonsurgical Management for Midshaft Clavicle Fractures:

Indications:
  • < 2cm displacement (shortening)
  • < 1cm superior displacement of suspensory complex
  • Arm sling for 3-4 weeks then gradual ROM
  • Analgesia

Surgery

Indications:
  • Open fracture
  • Skin tenting
  • Neurovascular injury
  • Floating shoulder
  • Symptomatic non-union
Optional:
  • Polytrauma
  • Bilateral clavicle fractures
Fixation options for clavicle fractures:
  • Plate and screw fixation
  • Nail and screw fixation
  • Fixation options for lateral clavicle fractures: Hook plate, tension band wire, transacromial intramedullary fixation, coracoacromial fixation
Floating shoulder

Floating shoulder: Ipsilateral glenoid neck fracture and clavicle fracture

Clavicle Plate and Screw Fixation

Clavicle plate and screw fixation

Surgery Technique

Surgery

Surgery Approach

Surgery approach of Clavicle fractures

Approach: incision superior over clavicle. Medially are branches of suprascapular nerve

Anterior and posterior flaps created

Incise clavipectoral fascia

Laterally may have to release small area of pectoralis major and deltoid attachment

Surgery: Clavicle ORIF plate and screw fixation

Clavicle ORIF plate and screw fixation

Approach: superior to clavicle

Reduce clavicle

Plate and screw fixation

Post Surgery Rehabilitation

Phases of rehabilitation:

  • Sling for 2-3 weeks
  • Rehabilitation include rotator cuff and pericapsular stabilizer strengthening exercises
  • Strengthening exercises after union
Shoulder pendulums

Pendulum shoulder range of motion

Shoulder pendulum_(dumbbells)

Pendulum shoulder strength exercise

Shoulder strengthening with resistance band

Shoulder strengthening with resistance band

Download ASSIC performance fingerprint app or ASSIC strength & conditioning app for shoulder rehab guideline routine under professional supervision

apple app store  google play store

Conservative Management of Clavicle Fractures

  • Sling 3-4 weeks: Perform hand ROM exercises
  • Passive/active ROM
  • Active ROM
  • Progressive strengthening
Arm sling

Shoulder sling

Hand Exercises While in Sling

  • Range of motion hand digital exercises
  • Active wrist motion at 2 weeks post surgery
  • Load bearing and strengthening exercises after union
Active wrist ROM after 2 weeks

Active wrist ROM after 2 weeks

Finger adduction strengthening

Finger adduction strengthening

Resisted finger extension

Finger abduction strengthening

Hand squeeze

Hand grip strengthening

Rehabilitation

Phases of rehabilitation:

  • Immobilization
  • Passive/ assisted ROM/isometric exercise of shoulder girdle
  • Progressive strengthening exercises with resistance exercises after 6-8 weeks
Shoulder pendulums

Pendulum shoulder range of motion

Flexion with arm on table

Flexion with arm on table

Shoulder strengthening with resistance band

Shoulder strengthening with resistance band after union

Download ASSIC Performance Fingerprint or Strength & Conditioning apps for rehab guideline routines

apple app store  google play store

References

  1. Management of distal clavicle fractures. R Banerjee, B Waterman, J Padalecki, W Roberson. J Am Acad Orthop Surg. 2011 Jul;19(7): 392-401.
  2. Midshaft clavicle fractures: A critical review. JM Burnham, DC Kim, S Kamineni. Orthopedics. September/October 2016-Volume 39 Issue 5: e814-821.
  3. Clavicle fractures. M Ropars, H Thomazeau, D Huten. Orthop Traumatol Surg Res. 2017 Feb;103(1S): S53-S59.
  4. Clavicle fractures. C Morgan, K Bennett-Brown, A Stebbings, L Li, R Dattani. Br J Hosp Med (London). 2020 Jul 2;1-7.
  5. Distal clavicle fractures: a new classification system. CH Cho, BS Kim, DH Kim, CH Choi, J Dan, H Lee. Orthop traumatol Surg Res. 2018;104(8): 1231-5.
  6. Current concepts for classification and treatment of distal clavicle fractures. DW Kim, DH Kim, BS Kim, CH Cho. Clinics in Orthopedic Surgery 2020;12:135-144.

Contributor:

Dr N J Kauta

Learn More

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