Clavicular Fracture

Original Editor - Sofie Van Cutsem

Top Contributors - Elvira Muhic, Manisha Shrestha, Sofie Van Cutsem, Lucinda hampton, Nupur Smit Shah, Kim Jackson, WikiSysop, Claire Knott, Tony Lowe, Naomi O'Reilly and Karen Wilson  

Clinical Anatomy

The collarbone (clavicle) is located between the ribcage (sternum) and the shoulder blade (scapula), and it connects the arm to the body. The clavicle is the first bone in the human body to begin intramembranous ossification directly from mesenchyme during the fifth week of fetal life. Similar to all long bones, the clavicle has both a medial and lateral epiphysis. The growth plates of the medial and lateral clavicular epiphyses do not fuse until the age of 25 years.Peculiar among long bones is the clavicle’s S-shaped double curve, which is convex medially and concave laterally. This contouring allows the clavicle to serve as a strut for the upper extremity, while also protecting and allowing the passage of the axillary vessels and brachial plexus medially. 

Clavicle Fracture (Broken Collarbone)

A clavicle fracture is also known as a broken collarbone. Clavicle fractures are very common injuries in adults (2–5%) and children (10–15%) (1) and represent the 44–66% of all shoulder fractures (2). Despite the high frequency the choice of proper treatment is still debated. Both conservative and surgical management are possible, and surgeons must choose the most appropriate management modality according to the biologic age, functional demands, and type of lesion.

Mechanism of injury

Younger individuals often sustain these injuries by way of moderate to high-energy mechanisms such as motor vehicle accidents or sports injuries, whereas elderly individuals are more likely to sustain injuries because of the sequela of a low-energy fall. Although a fall onto an outstretched hand was traditionally considered the common mechanism, it has been found that the clavicle most often fails in direct compression from force applied directly to the shoulder.

Classfication

Classification by Allman

Multiple attempts have been made to devise a classification scheme for clavicle fractures. The most common system is the following one, created by Allman, in which the clavicle is divided into thirds:

• Type I fractures: Middle third injuries
• Type II fractures: Distal third injuries
• Type III fractures: Medial (proximal) third injuries

Classification by Neer

Fractures of the lateral third of the clavicle were further sub classified by Neer, (10) recognizing the importance of the coraco-clavicular (CC) ligaments for the stability of the medial fracture segment.

• Type I lateral clavicle fracture occurs distal to the CC ligaments, resulting in a minimally displaced fracture that is typically stable.
• Type II injuries are characterized by a medial fragment that is discontinuous with the CC ligaments. In these cases, the medial fragment often exhibits vertical instability after loss of the ligamentous stability provided by the CC ligaments.
• Type III injuries are characterized by an intra-articular fracture of the acromio-clavicular joint with intact CC ligaments. Although these fractures are typically stable injuries, they may ultimately result in traumatic arthrosis of the acromio-clavicular joint.

Classification by Robinson (Edinburgh classification)

A more detailed classification system (Edinburgh classification) was proposed by Robinson (4). Similar to earlier descriptions, the primary classification is anatomically divided into medial (type I), middle (type II), and lateral (type III) thirds. Each of these types is then subdivided based on the magnitude of fracture fragment displacement. Fracture displacement of less than 100% characterizes subgroup A, whereas fractures displaced by more than 100% account for subgroup B. Type I (medial) and type III (lateral) fractures are further subdivided based on articular involvement. Subgroup 1 represents no articular involvement, and subgroup 2 is characterized by intra-articular extension. Similarly, type II (middle) fractures are sub-categorized by the degree of fracture comminution. Simple or wedge-type fracture patterns make up subgroup 1, and comminuted or segmental fracture patterns represent subgroup 2.

References

References will automatically be added here, see adding references tutorial.

Original Editor - Sofie Van CutsemTop Contributors - Elvira Muhic, Manisha Shrestha, Sofie Van Cutsem, Lucinda hampton, Nupur Smit Shah, Kim Jackson, WikiSysop, Claire Knott, Tony Lowe, Naomi O'Reilly and Karen Wilson

The clavicula is a long bone and forms the anterior part of the shoulder girdle. It is located directly above the first rib and is mounted horizontally at the upper and front of the thorax. It articulates laterally with the acromion and medially with the manubrium sterni.

Epidemiology/etiology

5 to 10 % of all fractures are clavicle fractures and the fractures are most common in children and young adults. ^{2, 3} It happens mostly by falling on the lateral shoulder and upper arm during contact sport. It also happens by falling on an outstretched arm or elbow or by a direct trauma to the clavicle. ²

Clinical presentation

The most common symptoms of a clavicular fracture are; pain in de area of the fracture and crackling of the clavicula. The clavicula has an abnormal contour and the patient is unable to lift his arm due to pain. The patient hold his affected arm adducted and supports with his opposite hand. This position is more comfortable than another because it limits the pull from the weight of the arm on the fractured bone. ³ You can see bruising and swelling located in the area of the fracture. There is also tenderness and crepitation.^{2, 3}
There can be complications such as; pneumothorax, hemothorax, brachial plexus injury and subclavian vein injury. ² Therefore it is important to do a neurovascular and lung examination.

Differential diagnosis

It may be confused with acromioclavicular separation and sternoclavicular dislocation.

Diagnostic procedures

Diagnose can often be made by an ‘anamneses’ and physical examination. It is confirmed by a radiography. ³

Outcomes measures

Studies have shown thatoperative treatment results in a lower rate of fracture nonunion and improves patient-oriented outcomes compared with non treatment (conservative treatment). ³

Examination

During inspection you will see bruising and swelling in the area of the fracture. The contour of the clavicula is different. The patient stand in a antalgic position. The patient hold his affected arm adducted and supports with his opposite hand.
During examination you will see that the patient is unable to lift his arm due to pain.

Medical management

Most clavicula fractures are treated conservatively with an 8-bandage for 3-6 weeks. Open reduction and internal fixation is rarely required. In case of displacement, there is sometimes surgery required. ⁷
Surgery is necessary in case of: ^{4, 3}
-nerve, blood or pleural injury
-a lateral fractures extending to the articular surface
-a lateral fracture combined with a rupture of the coracoclavicular ligament
-non-ossified fractures which is over de 6 months old and is still symptomatic
-a fracture that have high potential for union.

Physical therapy management

The goals of the treatment are to restore normal anatomy, limit pain and promote a quick return to activity or play. ³ The patient starts treatment after 1 week guided by pain. Under the age of 12 the patient has to wear a sling for 3-4 weeks, over the age 12 for 4-6 weeks. The treatment starts with passive mobilization, shoulder and elbow range of motion must be regained. Pendulum exercises can be started as soon as pain allows it. Then gradual progression to active range of motion and strengthening exercises over 4 to 8 weeks. ³ The patient can return to his hobbies when he is able to do full and painless shoulder range of motion with normal shoulder strength.
When the bone is fully healed, the patient can participate at non-contact sports 6 weeks after injury and at contact sports 8-16 weeks after injury. ³

References

1. Juraj Artner, atlas of human skeletal anatomy, P.42, 2002.
level of evidence: 5 Grade of recommendation: E
2. S. Mozes, Family practice notebook, LLC, 2011.
-> D. Standley, Norris SH, Recovery fractures of clavicle treated conservatively, 1998.
level of evidence: 5 Grade of recommendation: E
3. M. Pecci, J. Kreher, MD, Boston university, Clavicle fractures, jan. 2008.
level of evidence: 1 Grade of recommendation: B
4. I. Kunnamo, Evidence based medicine guidelines, p. 575, 2005.
Level of evidence: 5 Grade of recommendation: E
5. D. Quillen, M. Wuchner, R. Hatch, acute shoulder injuries, nov. 2004.
level of evidence: 5 grade of recommendation: E
6. J. Rubino, clavicle fractures, Medscape, 2012.
7. Prof H. De Boeck, orthopedie en traumatology, p33, 2012.