Introduction

Epidemiology
incidence
clavicle fractures make up 5-10% of all fractures
demographics
often seen in young active patients
Pathophysiology
mechanism
direct blow to lateral aspect of shoulder
fall on an outstretched arm or direct trauma
pathoanatomy
in displaced fractures SCM and trapezius muscles pull the medial fragment
posterosuperiorly, while pectoralis major and weight of arm pull the lateral fragment
inferomedially
open fractures buttonhole through platysma
Associated injuries
are rare but include
ipsilateral scapula fracture
scapulothoracic dissociation
should be considered with significantly displaced fractures
rib fracture
pneumothorax
neurovascular injury
Pediatric Clavicle fractures
fracture patterns include
medial/middle/lateral fractures (listed below)

medial clavicle physeal injury

distal clavicle physeal injury
treatment
pediatric distal clavicle fractures are typically treated non-operatively because of
the great osteogenic capacity of the intact inferior periosteum.
Relevant Anatomy
Acromioclavicular Joint Anatomy
AC joint stability
acromioclavicular ligament
provides anterior/posterior stability
has superior, inferior, anterior, and posterior components
superior ligament is strongest, followed by posterior
coracoclavicular ligaments (trapezoid and conoid)
provides superior/inferior stability
trapezoid ligament inserts 3 cm from end of clavicle
conoid ligament inserts 4.5 cm from end of clavicle in the posterior border
conoid ligament is strongest
capsule, deltoid and trapezius act as additional stabilizers

Classification

Group I - Middle third (80-85%)

Nondisplaced
Less than 100% displacement
Nonoperative

Displaced
Greater than 100% displacement
Nonunion rate of 4.5%
Operative

Group II - Neer Classification of Lateral third (10-15%)

Type I
Fracture occurs lateral to coracoclavicular ligaments (trapezoid, conoid) or
interligamentous
Usually minimally displaced
Stable because conoid and trapezoid ligaments remain intact
Nonoperative

Type IIA
Fracture occurs medial to intact conoid and trapezoid ligament
Medial clavicle unstable
Up to 56% nonunion rate with nonoperative management
Operative

Type IIB
Fracture occurs either between ruptured conoid and intact trapezoid ligament or
lateral to both ligaments torn
Medial clavicle unstable
Up to 30-45% nonunion rate with nonoperative management
Operative

Type III
Intraarticular fracture extending into AC joint
Conoid and trapezoid intact therefore stable injury
Patients may develop posttraumatic AC arthritis
Nonoperative
x
Type IV
A physeal fracture that occurs in the skeletally immature
Displacement of lateral clavicle occurs superiorly through a tear in the thick
periosteum
Clavicle pulls out of periosteal sleeve
Conoid and trapezoid ligaments remain attached to periosteum and overall the
fracture pattern is stable
Nonoperative
x
Type V
Comminuted fracture
Conoid and trapezoid ligaments remain attached to comminuted fragment
Medial clavicle unstable
Operative
x
Group III - Medial third (5-8%)
Anterior displacement

Most often non-operative

Rarely symptomatic
Nonoperative

Posterior displacement
Rare injury (2-3%)
Often physeal fracture-dislocation (age < 25)
Stability dependent on costoclavicular ligaments
Must assess airway and great vessel compromise
Serendipity radiographs and CT scan to evaluate
Surgical management with thoracic surgeon on standby
Operative

Presentation
Symptoms
shoulder pain
Physical exam
deformity
perform careful neurovascular exam
examine skin
Imaging
Radiographs
standard AP view
45 cephalic tilt determine superior/inferior displacement
45 caudal tilt determines AP displacement
CT
may help evaluate displacement, shortening, comminution, articular extension, and
nonunion

useful for medial physeal fractures and sternoclavicular injuries

Treatment
Nonoperative
sling immobilization with gentle ROM exercises at 2-4 weeks
indications
nondisplaced Group I (middle third)
stable Group II fractures (Type I, III, IV)
nondisplaced Group III (medial third)
pediatric distal clavicle fractures (skeletally immature)
outcomes
nonunion (1-5%)
risk factors for nonunion
Group II (up to 56%)
comminution
fracture displacement & shortening (>2 cm)
advanced age and female gender
decreased shoulder strength and endurance
seen with displaced midshaft clavicle fracture healed with > 2 cm of shortening
Operative
open reduction internal fixation
indications
absolute
unstable Group II fractures (Type IIA, Type IIB, Type V)
open fxs
displaced fracture with skin tenting
subclavian artery or vein injury

floating shoulder (clavicle and scapula neck fx)

symptomatic nonunion
posteriorly displaced Group III fxs
displaced Group I (middle third) with >2cm shortening
relative and controversial indications
brachial plexus injury (questionable b/c 66% have spontaneous return)
closed head injury
seizure disorder
polytrauma patient
outcomes
improved results with ORIF for clavicle fractures with >2cm shortening and 100%
displacement
outcome results
improved functional outcome / less pain with overhead activity
faster time to union
decreased symptomatic malunion rate
improved cosmetic satisfaction
improved overall shoulder satisfaction
increased shoulder strength and endurance
increased risk of need for future procedures
implant removal
debridement for infection
coracoclavicular ligament repair vs reconstruction
indication
indicated in group IIb and group III fractures with ligamentous injury
Techniques
Sling Immobilization

technique
sling or figure-of-eight (prospective studies have not shown difference between sling
and figure-of-eight braces)
after 2-4 weeks begin gentle range of motion exercises
no attempt at reduction should be made
complications of nonoperative treatment
nonunion (1-5%)
treatment of nonunion
if asymptomatic, no treatment necessary
if symptomatic, ORIF with plate and bone graft (particularly atrophic nonunion)
Open Reduction Internal Fixation
surgical technique
plate and screw fixation
superior vs anterior plating
superior plating biomechanically higher load to failure and bending
superior plating better for inferior bony comminution
superior plating has higher risk of neurovascular injury during drilling
limited contact dynamic compression plate
3.5mm reconstruction plate
locking plates
precontoured anatomic plates
lower profile needing less chance for removal surgery
intramedullary screw or nail fixation
higher complication rate including hardware migration
hook plate
AC joint spanning fixation
postoperative rehabilitation

sling for 7-10 days followed by active motion

strengthening at ~ 6 weeks when pain free motion and radiographic evidence of
union
full activity including sports at ~ 3 months
complications (~10% to 30%)
hardware complications
~30% of patient request plate removal
superior plates associated with increased irritation
neurovascular injury (3%)
superior plates associated with increased risk of subclavian artery or vein
penetration
adhesive capsulitis
4% in surgical group develop adhesive capsulitis requiring surgical intervention
nonunion (1-5%)
infection (~4.8%)
mechanical failure (~1.4%)
Coracoclavicular ligament repair vs reconstruction
technique
primary repair can be done
most add supplementary suture (mersilene tape, fiberwire, ethibond) tied around
coracoid and either into or around clavicle