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Clavicle Fractures
Clavicle Fractures
Shoulder anatomy
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
Right shoulder complex anterior view
Right shoulder complex posterior view
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
% 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 according to Allman and Neer
AO Classification for Midshaft Clavicle Fractures
AO Classification of Lateral 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:
OR
|
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 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: Ipsilateral glenoid neck fracture and clavicle fracture
Clavicle Plate and Screw Fixation
Surgery Technique
Surgery Approach
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
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
Pendulum shoulder range of motion
Pendulum shoulder strength exercise
Shoulder strengthening with resistance band
Download ASSIC performance fingerprint app or ASSIC strength & conditioning app for shoulder rehab guideline routine under professional supervision
Conservative Management of Clavicle Fractures
- Sling 3-4 weeks: Perform hand ROM exercises
- Passive/active ROM
- Active ROM
- Progressive strengthening
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
Finger adduction strengthening
Finger abduction strengthening
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
Pendulum shoulder range of motion
Flexion with arm on table
Shoulder strengthening with resistance band after union
Download ASSIC Performance Fingerprint or Strength & Conditioning apps for rehab guideline routines
References
- Management of distal clavicle fractures. R Banerjee, B Waterman, J Padalecki, W Roberson. J Am Acad Orthop Surg. 2011 Jul;19(7): 392-401.
- Midshaft clavicle fractures: A critical review. JM Burnham, DC Kim, S Kamineni. Orthopedics. September/October 2016-Volume 39 Issue 5: e814-821.
- Clavicle fractures. M Ropars, H Thomazeau, D Huten. Orthop Traumatol Surg Res. 2017 Feb;103(1S): S53-S59.
- Clavicle fractures. C Morgan, K Bennett-Brown, A Stebbings, L Li, R Dattani. Br J Hosp Med (London). 2020 Jul 2;1-7.
- 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.
- 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.
