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 login to view 1 more bullet prevalence login to view 1 more bullet 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 login to view 1 more bullet only area not protected by or reinforced with muscle and ligamentous attachments displaced fractures login to view 2 more bullets 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 login to view 4 more bullets rib fracture neurovascular injury ANATOMY Osteology Shape S-shaped bone flat laterally, tubular centrally, and prismatic medially Articulations sternoclavicular joint four primary stabilizers login to view 4 more bullets acromioclavicular joint two primary stabilizers login to view 2 more bullets 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 login to view 1 more bullet 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 Ligaments coracoclavicular (CC) ligaments provide superior/inferior stability to AC joint two components login to view 4 more bullets Blood Supply 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 Nervous System supraclavicular nerves cutaneous nerves that run vertically over clavicle and supply superior chest wall 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 login to view 4 more bullets shoulder series login to view 1 more bullet optional views upright chest x-ray login to view 2 more bullets findings superior displacement of medial fragment inferior displacement of lateral fragment shortening measurements shortening login to view 4 more bullets displacement login to view 2 more bullets CT indications assess fracture pattern for preop planning login to view 1 more bullet 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 sling immobilization indications login to view 4 more bullets techniques login to view 3 more bullets outcomes login to view 2 more bullets Operative open reduction internal fixation (ORIF) indications login to view 12 more bullets techniques login to view 2 more bullets outcomes login to view 3 more bullets Techniques Sling Immobilization technique immobilize using sling or figure-of-eight brace login to view 1 more bullet rehab login to view 3 more bullets advantage overall good outcomes avoid surgical/hardware complications disadvantage higher nonunion rate compared to operative management slower time to union complications nonunion (10-15%) malunion poor cosmesis decreased shoulder strength and endurance login to view 1 more bullet Plate Fixation approach beach chair vs. supine direct superior vs. anterior incision technique plate configuration login to view 9 more bullets plate options login to view 3 more bullets 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 login to view 2 more bullets complications hardware irritation infection neurovascular injury supraclavicular nerve injury hardware failure pneumothorax postoperative Rehabilitation early login to view 1 more bullet late login to view 2 more bullets Intramedullary Fixation (IMN) technique positioning login to view 1 more bullet approach login to view 1 more bullet implant choices login to view 5 more bullets advantages smaller incision less soft-tissue disruption avoids supraclavicular nerves that are commonly injured with plating best for simple patterns disadvantages higher complication rate login to view 1 more bullet 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 login to view 5 more bullets predictors at 6 week login to view 3 more bullets treatment login to view 2 more bullets malunion (~20%) definition login to view 3 more bullets presentation login to view 4 more bullets treatment login to view 1 more bullet 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 login to view 2 more bullets nonunion (1-5%) infection (~4.8%) risk factors login to view 3 more bullets mechanical failure (~1.4%) pneumothorax adhesive capsulitis 4% in surgical group develop adhesive capsulitis requiring surgical intervention