Clavicular Fracture

1. Search strategy

2. Definition

3. Clinically relevant anatomy

4. Epidemiology/etiology

5. Characteristics/ clinical presentation

6. Differential diagnosis

7. Diagnostic procedures

8. Outcome measures

9. Examination

10. Medical management

11. Physical therapy management

12. Key research

13. References

1. Search strategy

A literature search was conducted using pubmed and web of knowledge. The following search terms were used separately and in combination: clavicula fracture, treatment, physiotherapy, epidemiology,… .

2. Definition/Description

Clavicula fracture is a fracture of the clavicular bone.

Type I: Fractures medial tot the ligaments coracoclavicular.
Type II: Fractures at the level of coracoclavicular ligaments, middiafysair.
Type III: Fractures distal to the ligament coracoclavicular and entered the acromioclavicular joint.⁶

3. Clinically Relevant Anatomy

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.

4. 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

5. 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.

6. Differential diagnosis

It may be confused with acromioclavicular separation and sternoclavicular dislocation.

7. Diagnostic procedures

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

8. 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

9. 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.

10. 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.

11. 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

13. 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.