Updated: 7/28/2022

Clavicle Fractures - Midshaft

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  • Summary
    • Midshaft Clavicle fractures are common traumatic injuries caused by a direct impact to the shoulder girdle and is most commonly seen in young, active adults.
    • Diagnosis can be made radiographically with AP and cephalic tilt clavicle x-rays. 
    • Treatment is nonoperative or operative based on patient activity and demands, along with degree of displacement, shortening, and comminution. 
  • Epidemiology
    • Incidence
      • common
        • incidence
          • 1 in 1000 people per year
        • prevalence 
          • clavicle fractures account for 2.6-4% of all adult fractures
    • Demographics
      • often seen in young, active patients
        • most common in males < 30 years old
    • Location
      • 75-80% of all clavicle fractures will occur in the middle third segment
  • Etiology
    • Pathophysiology
      • mechanism of injury
        • fall onto lateral aspect of shoulder (85%)
        • direct impact to clavicle 
      • pathoanatomy
        • junction of the outer and middle third is the thinnest part of the bone
          • prone to fracture with axial loading
        • only area not protected by or reinforced with muscle and ligamentous attachments
        • displaced fractures
          • medial fragment pulled posterosuperiorly by sternocleidomastoid muscle 
          • lateral fragment pulled inferomedially by pectoralis major and and weight of arm
        • open fractures usually result from medial fragment "buttonholing" through platysma
    • Associated conditions
      • medical 
        • pneumothorax
        • closed head injury
      • orthopedic
        • ipsilateral scapular fracture (floating shoulder)
        • scapulothoracic dissociation
          • traction injury 
          • significantly distracted/widened fracture fragments
          • widened interval between scapula and spine
          • brachial plexus or vascular injury 
        • rib fracture
        • neurovascular injury
  •  ANATOMY
    • Osteology
      • Shape
        • S-shaped bone
        • flat laterally, tubular centrally, and prismatic medially 
    • Articulations 
      • sternoclavicular joint
        • four primary stabilizers
          • posterior capsular ligament
          • anterior sternoclavicular ligament
          • costoclavicular ligament
          • intra-articular disc
      • acromioclavicular joint
        • two primary stabilizers
          • coracoclavicular ligament 
          • acromioclavicular ligament 
    • Ligaments
      • coracoclavicular (CC) ligaments
        • provide superior/inferior stability to AC joint
        • two components 
          • trapezoid (lateral) 
            • inserts 3 cm medial to distal clavicle
          • conoid (medial) 
            • inserts 4.5 cm medial to distal clavicle
    • Muscles
      • sternocleidomastoid
        • pulls medial segment proximally
        • clavicular head originates superiorly on medial third
        • inserts on mastoid process 
      • deltoid 
        • stabilizes distal clavicle and assists with shoulder abduction
          • shortening of clavicle decreases lever arm of deltoid  
        • originates from anterior lateral third clavicle, acromion, and scapular spine 
        • inserts on deltoid tuberosity
      • trapezius
        • originates from occiput and C-T spine spinous process
        • inserts on lateral posterosuperior third of clavicle, acromion, and scapular spine
      • pectoralis major
        • pulls medially causing shortening 
        • clavicular head originates from anteroinferior surface of medial half of clavicle
        • inserts on crest of greater tubercle of humerus, lateral to bicipital groove
      • subclavius
        • protects NV structures which pass deep to muscle and displace clavicle inferiorly 
        • originates from 1st rib and costal cartilage 
        • inserts on undersurface of clavicle
      • sternohyoid
        • originates on sternal end of clavicle
        • inserts on hyoid bone
      • platysma
        • violated with skin tenting
        • originates from pectoral fascia
        • inserts mandible 
    • Neurovascular structures
      • supraclavicular nerves
        • cutaneous nerves that run vertically over clavicle and supply superior chest wall
      • subclavian vessel
        • passes posterior and underneath clavicle near junction of medial and middle third
        • subclavian vein closest to clavicle and anterior to artery and plexus
      • brachial plexus
    • Biomechanics
      • middle third is weakest portion of clavicle 
        • thinnest and narrowest
        • transitional of the bone in both curvature and in cross-sectional anatomy
        • only area not supported by ligamentous or muscular attachments
  • Classification
      • Neer Classification (simple)
      • Nondisplaced
      • < 100% displacement
      • Nonoperative
      • Displaced
      • > 100% displacement
      • Operative
      • AO classification
      • Type A = Simple
      • A1 = spiral
      • A2 = oblique
      • A3 = transverse
      • Nonoperative vs. operative
      • Type B = Wedge
      • B1 = spiral wedge
      • B2 = bending wedge
      • B3 = fragmented wedge
      • Nonoperative vs. operative
      • Type C = Complex
      • C1 = complex spiral
      • C2 = segmental
      • C3 = irregular
      • Operative
  • Presentation
    • History
      • popping or cracking sound near shoulder after fall
    • Symptoms
      • acute onset of anterior shoulder pain or directly over clavicle
    • Physical exam
      • inspection
        • tender, swelling, crepitus and deformity over clavicle
        • skin tenting (impending open fracture)
      • neurovascular exam
        • assess subclavian vessels and brachial plexus 
  • Imaging
    • Radiographs
      • recommended views
        • clavicle series
          • upright AP clavicle
            • supine may underappeciate displacement with gravity eliminated
          • 15° cephalic tilt (zanca view)
            • eliminates overlapping scapula 
        • shoulder series
          • evaluate for other injuries (ie proximal humerus, scapula)
      • optional views
        • upright chest x-ray 
          • compare shortening with contralateral side
          • evaluate for pneumothorax 
      • findings
        • superior displacement of medial fragment
        • inferior displacement of lateral fragment
        • shortening
      • measurements 
        • shortening 
          • two methods
            • AP clavicle - distance between the corresponding ends of the medial and lateral fragments
            • AP chest - direct comparison of length of clavicle to the contralateral side
              • shortening >2cm associated with decrease shoulder strength and endurance
        • displacement
          • displacement relative to width of clavicle (percent)
            • >100% displacement is a risk factor for nonunion
    • CT 
      • indications  
        • assess fracture pattern for preop planning 
          • comminution, shortening, articular extension, nonunion
        • vascular injury 
        • medial clavicle fracture
        • SC joint dislocation
      • views
        • axial, coronal and 3D reconstruction most useful
        • with contrast if concern for vascular injury 
  • Differential
    • Adult distal third clavicle fx
      • older, osteoporotic patient
      • x-ray may show increased CC distance 
    • Sternoclavicular dislocation
      • high energy mechanism 
      • may present with dysphagia, stridor, asymmetric pulses, paresthesias due to compression of surrounding structures 
      • serendipity view or CT best demonstrate displacement 
    • Acromioclavicular Joint Injury
      • pain and prominence more lateral over AC joint
      • zanca or axillary views shows displaced distal clavicle relative to acromion 
  • Treatment
    • Nonoperative
      • indications
        • < 2cm shortening and displacement
        • < 1cm displacement of the superior shoulder suspensory complex
        • closed and no neurovascular injury
        • low demand patient 
      • modalities 
        • sling
        • figure-of-8 strap
          • elevate and extend shoulder to bring distal fragment to the proximal fragment
      • outcomes 
        • figure-of-8 associated with more pain, shortening, and lower compliance than sling
        • no difference in functional or cosmetic outcomes between sling and figure-of-eight braces
    • Operative
      • indications
        • absolute
          • open fractures
          • displaced fracture with skin tenting
          • subclavian artery or vein injury
          • floating shoulder (clavicle and scapular neck fracture)
        • relative and controversial indications
          • displaced with > 2cm shortening
          • bilateral displaced clavicle fractures
          • brachial plexus injury (questionable because 66% have spontaneous return)
          • closed head injury
          • seizure disorder
          • polytrauma patient
      • techniques
        • intramedullary fixation
        • open reduction internal fixation with plate and screws
      • outcomes
        • operative fixation has higher union rate (>94%)
        • similar or better functional outcomes than nonoperative
        • faster time to union - operative (16.4 weeks) vs. non-operative (28.4 weeks) 
  • Techniques
    • Sling Immobilization
      • technique
        • immobilize using sling or figure-of-eight brace
          • no attempt at reduction should be made
        • rehab 
          • gentle passive ROM exercises at 2 weeks
          • strengthening exercises begin at 6 weeks
          • return to sports at 4-6 months
      • advantage
        • overall good outcomes
        • avoid surgical/hardware complications
      • disadvantage
        • higher nonunion rate compared to operative management
        • slower time to union 
      • complications
        • malunion
        • poor cosmesis 
        • decreased shoulder strength and endurance
          • displaced midshaft clavicle fractures healed with > 2cm of shortening
    • Open Reduction Internal Fixation with Plate
      • approach
        • beach chair vs. supine
        • direct superior vs. anterior incision
      • technique
        • plate configuration 
          • anterior plating
          • superior plating (compared to anterior plating) 
            • higher load to failure
            • increased plate strength with inferior bone comminution 
            • increased risk of neuromuscular injury 
            • decreased removal of deltoid attachment 
          • dual plating
            •  low rate of symptomatic hardware removal (0-3.7%)
            • biomechanically equivalent or superior to single 3.5mm plate 
        • plate options
          • limited contact, pre-controured, 3.5mm dynamic compression plate
          • 3.5mm reconstruction plate
          • 2.0mm, 2.4mm and 2.7mm plates can be used and combined for dual plating
      • advantages 
        • improved results with ORIF for clavicle fractures with > 2cm shortening and > 100% displacement
        • improved functional outcomes/less pain with overhead activity
        • faster time to union
        • decreased symptomatic nonunion and malunion rate
        • improved cosmetic satisfaction
        • improved overall shoulder satisfaction
        • increased shoulder strength and endurance
      • disadvantage
        • increased risk of need for future procedures
          • implant removal
          • debridement for infection
      • complications 
        • hardware irritation
        • infection
        • neurovascular injury 
        • supraclavicular nerve injury 
        • hardware failure
        • pneumothorax
      • postoperative Rehabilitation
        • early
          • sling for 7-10 days followed by active motion
        • late
          • strengthening at ~6 weeks when pain-free motion and radiographic evidence of union
          • full activity including sports at ~3 months
    • Intramedullary Fixation
      • technique 
        • positioning
          • beach chair or supine
        • approach
          • percutaneous or mini-open 
        • implant choices
          • intramedullary nail
            • goal size of intramedullary nail is 30-40% of midshaft diameter
          • cannulated screws
          • titanium elastic nail
          • Hagle pin
      • advantages
        • smaller incision
        • less soft-tissue disruption
        • avoids supraclavicular nerves that are commonly injured with plating
        • best for simple patterns 
      • disadvantages 
        • higher complication rate
          • hardware migration, implant irritation, secondary procedures
        • biomechanically inferior to plating
        • unable to lock and control rotation 
        • typically requires hardware removal at 6 months
      • contraindications
        • substantial comminution
        • segmental fractures
      • complications
        • hardware migration 
        • loss of reduction 
  • Complications
    • Nonoperative treatment
      • nonunion (~15%)
        • risk factors
          • fracture comminution (Z deformity)
          • fracture displacement
          • female gender
          • advanced age
          • smoker
        • predictors at 6 week
          • motion at fracture site, no callus on x-ray, DASH <40 
            • 0 - 3% nonunion 
            • 2 or 3 - 60% nonunion 
        • treatment 
          • if asymptomatic, no treatment necessary
          • if symptomatic, ORIF with plate and bone graft (particularly atrophic nonunion)
      • malunion (~20%)
        • definition
          • shortening > 3cm
          • angulation > 30°
          • translation > 1cm
        • presentation
          • pain and increased fatigue with overhead activities
          • thoracic outlet syndrome
          • dissatisfaction with appearance
          • difficulty with shoulder straps and backpacks
        • treatment
          • clavicle osteotomy with bone grafting, if symptomatic
    • Operative treatment
      • hardware prominence
        • 8-30% of patient request plate removal
        • superior plates associated with increased irritation
      • neurovascular injury 
        • superior plates associated with increased risk of subclavian artery or vein penetration
        • subclavian thrombosis
      • supraclavicular nerve injury 
        • most common complication 
          • 83% incidence of numbness noted at 2 weeks postop 
            • can improve over time with ~50% having persistent numbness at 1 year
      • nonunion (1-5%)
      • infection (~4.8%)
        • risk factors
          • illicit drug use
          • diabetes
          • previous shoulder surgery
      • mechanical failure (~1.4%)
      • pneumothorax
      • adhesive capsulitis
        • 4% in surgical group develop adhesive capsulitis requiring surgical intervention

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Technique Guides (1)
Flashcards (93)
Cards
1 of 93
Questions (23)

(SBQ18TR.1) A 28-year-old male sustains the injury seen in Figure A. After discussing the risks and benefits of surgery, he elects to pursue nonoperative treatment. Of the following possible complications from nonoperative treatment, which is the most likely?

QID: 211111
FIGURES:

Skin necrosis

2%

(27/1623)

Nonunion

90%

(1465/1623)

Complex regional pain syndrome (CRPS)

1%

(21/1623)

Sternoclavicular joint arthritis

1%

(11/1623)

Acromioclavicular joint arthrosis

5%

(84/1623)

L 2 A

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(SBQ12TR.3.1) A 32-year-old female sustained a closed clavicle fracture after a fall as shown in Figures A and B. After a long discussion of the risks and benefits the patient elects to undergo nonoperative management. When discussing nonunion, which of the following is the best estimate for risk of nonunion with nonoperative treatment?

QID: 214312
FIGURES:

1%

1%

(24/1677)

5%

18%

(302/1677)

15%

49%

(818/1677)

30%

20%

(340/1677)

50%

11%

(185/1677)

L 4 B

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(SBQ12TR.23) A 25-year-old patient is involved in a motor vehicle accident. An isolated orthopaedic injury is sustained to the upper extremity with no compromise of skin integrity or neurovascular function. A radiograph of the injury is shown in Figure A. The patient is interested in pursuing surgical intervention. What is a reported outcome of surgery when compared to nonoperative management at 1 year postoperatively?

QID: 3938
FIGURES:

Increased rates of symptomatic nonunion

3%

(151/4943)

Similar rates of symptomatic nonunion

8%

(394/4943)

No differences in cosmetic results

2%

(112/4943)

Increased functional outcome scores

79%

(3925/4943)

Improved range of motion of the shoulder

7%

(335/4943)

L 2 B

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(SBQ12TR.3) A 22-year-old left hand dominant laborer sustains the injury shown in Figures A and B as the result of a fall from a ladder. Which of the following has been shown to be true regarding operative versus nonoperative treatment of this injury?

QID: 3918
FIGURES:

Decreased chance of nonunion with nonoperative treatment

4%

(253/6153)

Improved Constant and DASH scores with operative treatment at all time points

69%

(4216/6153)

Increased symptomatic malunion rate with operative treatment

1%

(88/6153)

No change in shoulder abduction strength

19%

(1144/6153)

Increased time to union with operative treatment

7%

(429/6153)

L 1 B

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(OBQ11.118) A 35-year-old right hand dominant man falls from a ladder and sustains the injury seen in Figure A. When discussing the risks and benefits of operative versus nonoperative treatment for his fracture, which of the following is true?

QID: 3541
FIGURES:

No difference in shoulder function

8%

(416/5138)

Higher risk of nonunion with operative management

2%

(82/5138)

Higher risk of symptomatic malunion or nonunion with nonoperative management

82%

(4221/5138)

Earlier return to sport with nonoperative management

1%

(26/5138)

No difference in union rates

7%

(373/5138)

L 1 B

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(OBQ10.101) A 32-year-old female sustains an isolated midshaft clavicle fracture, as shown in Figure A. Her clinical exam does not reveal skin tenting or neurovascular injury, but shortening is measured at 2.6 cm. Which of the following treatment methods has been shown to have the lowest rate of nonunion and symptomatic malunion?

QID: 3195
FIGURES:

Open reduction and internal fixation with plating

91%

(1841/2019)

Open reduction and percutaneous pinning

1%

(19/2019)

Closed reduction and percutaneous pinning

1%

(18/2019)

Closed reduction and external fixation

0%

(1/2019)

Nonoperative treatment with a sling and early range of motion

6%

(130/2019)

L 1 B

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(SBQ08UE.37.1) A 62-year-old woman falls off a bike and sustains the injury shown in Figure A. She presents to clinic for her 6-month follow-up appointment and reports persistent pain. Current imaging is shown in Figure B. Which of the following factors is not a risk factor to the development of this patient’s diagnosis?

QID: 212889
FIGURES:

Shortening of 3cm

2%

(45/2007)

Comminution

4%

(74/2007)

Sling immobilization as opposed to figure-of-eight brace

84%

(1694/2007)

Female gender

7%

(146/2007)

Advanced age

2%

(41/2007)

L 5 A

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(OBQ08.219) A 22-year-old male sustains a right shoulder injury after being thrown from his motorcycle. After nine months of conservative treatment, he continues to complain of pain. A current radiograph is shown in Figure A. What is the most appropriate treatment?

QID: 605
FIGURES:

Addition of a bone stimulator

0%

(4/1230)

Figure of eight brace

1%

(8/1230)

Closed reduction and percutaneous pinning

0%

(2/1230)

Open reduction and intramedullary nailing

6%

(69/1230)

Open reduction and compression plating

93%

(1141/1230)

L 2 C

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(OBQ08.168) A 20-year-old woman is involved in a high-speed motor vehicle collision and sustains bilateral tibial plateau fractures as well as the clavicle fracture shown in Figure A. What is the most appropriate management of the clavicular injury?

QID: 554
FIGURES:

Closed reduction and figure of 8 splinting

1%

(23/2668)

Open reduction and plate fixation

96%

(2556/2668)

Open reduction and percutaneous pinning

0%

(4/2668)

Simple sling to involved side

2%

(64/2668)

Sling with abduction pillow to involved side

0%

(7/2668)

L 1 C

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(OBQ08.54) Which of the following factors increase the risk of nonunion in midshaft clavicle fractures when treated nonoperatively?

QID: 440

Sling immobilization

0%

(11/2479)

Displacement and comminution

92%

(2293/2479)

Age less than 40 years old

0%

(12/2479)

Immediate motion exercises

5%

(127/2479)

Male

1%

(23/2479)

L 2 A

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(OBQ07.1) A 45-year-old male falls onto his left shoulder while biking and an injury radiograph is shown in Figure A. He elects for nonoperative treatment. What is the most likely clinical outcome at one year after injury?

QID: 662
FIGURES:

Symmetric cosmesis of shoulders

6%

(89/1575)

Decreased shoulder motion

6%

(88/1575)

Symptomatic nonunion

15%

(241/1575)

Shoulder instability

0%

(2/1575)

Decreased shoulder strength and endurance

73%

(1148/1575)

L 2 C

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(OBQ07.275) Which of the following factors is associated with the highest rate of nonunion of a midshaft clavicle fracture?

QID: 936

younger patients

7%

(85/1280)

female gender

55%

(703/1280)

simple fracture pattern

9%

(116/1280)

sling immobilization

6%

(78/1280)

early range-of-motion

23%

(290/1280)

L 4 B

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(OBQ07.25) A 31-year-old male sustains the injury shown in Figure A. As compared to treatment with a simple sling, what is the primary advantage of treatment with a figure-of-eight brace?

QID: 686
FIGURES:

Decreased sleep disturbance

2%

(25/1291)

Decreased personal care and hygiene impairment

3%

(35/1291)

Decreased rates of malunion

3%

(35/1291)

Improved long-term clinical outcomes

1%

(8/1291)

No advantage, equivalent result between a simple sling and figure-of-eight brace

92%

(1182/1291)

L 2 D

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