Introduction
Background
The descriptions of treatment of Fracture union usually progresses regardless of the treatment initiated. In spite of the innocuous appearance of clavicular fractures, the potential difficulty in treatment and possible complications warrant careful attention to this injury.
The clavicle is the first bone in the body to ossify, beginning at the fifth week of gestation.1 Through age 5 years, the growth is primarily through intramembranous ossification. Occasionally, 2 growth centers are found at both ends of the clavicle, and failure of fusion may lead to congenital pseudoarthrosis. The medial epiphysis ossifies late, beginning at age 12-19 years, and may not completely fuse until age 22-25 years. Physeal injuries around this area may be mistaken for fractures, and care should be taken in evaluating injuries. (In patients in the age 22-25 year group, the Salter-Harris classification for physeal injuries can be used, and, often, nonoperative treatment can be initiated.)
For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education article Broken Collarbone.
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Acromioclavicular Injury
Clavicle, Fractures and Dislocations
Fracture, Clavicle
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Clavicle Fractures: Why Surgical Intervention Works
Frequency
United States
The clavicle is the most frequently fractured bone in the body in childhood and accounts for 10-16% of all fractures in this age group.
In adults, clavicular fractures account for 2.6-5% of all fractures and 44% of all shoulder girdle injuries.2, 3, 4 Middle third clavicle fractures account for 69-82% of all fractures of the clavicle, whereas 12% occur in the distal third, and 6% occur in the proximal third.2, 3
Clavicular injuries occur 2.5 times more commonly in males than in females, reflecting a greater involvement of males in contact and violent sports and motor vehicle accidents (MVAs). Clavicular injuries affect 1 in 1000 people per year. Bimodal incidence occurs in men younger than 25 years and older than 55 years. Pneumothorax occurs in 3% of patients.
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Functional Anatomy
The clavicle is a slender, S-shaped bone that acts as a strut between the torso and the upper limb. Proximally, it joins the sternum as the sternoclavicular (SC) joint. Distally, it joins the acromion of the scapula to form the acromioclavicular (AC) joint. Strong ligaments at these joints and between the distal clavicle and coracoid (coracoclavicular ligaments) help stabilize the clavicle and help explain some of the patterns of fracture displacement discussed below (see Workup, Imaging Studies). The junction of the middle and distal thirds of the clavicle is a common site of fracture because this is the thinnest part of the bone, and there is relatively little protection by muscular attachments.
Another function of the clavicle is to help protect the neurovascular bundle that runs behind it. Injury to these structures must be considered when a fracture occurs, particularly at the proximal end of the clavicle.
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Sport-Specific Biomechanics
Clavicle fractures may be caused by direct or indirect trauma. The most common mechanism is an indirect one in which the athlete falls onto the lateral shoulder, causing a compressive force across the clavicle. Examples of a direct mechanism would be a blow from a hockey stick or a direct fall onto the clavicle. At-risk athletes include those in football, hockey, and soccer and those at risk for falling during roller skating, skiing, bicycling, or horseback riding. A very high prevalence is also noted in MVAs. A less common mechanism is a fall onto an outstretched hand (ie, a FOOSH injury).
Clinical
History
- A mechanism of injury as described above (see Sport-Specific Biomechanics)
- Hearing a snapping or cracking sensation at the time of the injury
- Pain, swelling, and possible deformity over the clavicle
Physical
- The athlete may cradle the injured extremity with the uninjured arm.
- The shoulder may appear shortened relative to the opposite side and may droop.
- Swelling, ecchymosis, and tenderness may be noted over the clavicle.
- Abrasion over the clavicle suggests the fracture was from a direct mechanism.
- Crepitus from the fracture ends rubbing against each other may be noted with gentle manipulation.
- A thorough upper extremity examination is necessary, and special attention should be paid to the neurovascular status. Identification of an associated distal nerve dysfunction indicates a brachial plexus injury, and decreased pulses may indicate a subclavian artery injury. Venous stasis, discoloration, and swelling indicate a subclavian venous injury.1, 5
- Difficulty breathing or diminished breath sounds on the affected side may indicate a pulmonary injury, such as a pneumothorax.
- Palpation of the scapula and ribs may reveal a concomitant injury.
- Tenting and blanching of the skin at the fracture site may indicate an impending open fracture, which most often requires surgical stabilization.
Causes
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References
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Huang JI, Toogood P, Chen MR, Wilber JH, Cooperman DR. Clavicular anatomy and the applicability of precontoured plates. J Bone Joint Surg Am. Oct 2007;89(10):2260-5. [Medline].
Checchia SL, Doneux PS, Miyazaki AN, Fregoneze M, Silva LA. Treatment of distal clavicle fractures using an arthroscopic technique. J Shoulder Elbow Surg. May-Jun 2008;17(3):395-8. [Medline].
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Bronstein RD. Taking the trauma out of clavicle fractures. J Musculoskel Med. Oct 2001;485-94.
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Wang SJ, Wong CS. Extra-articular Knowles pin fixation for unstable distal clavicle fractures. J Trauma. Jun 2008;64(6):1522-7. [Medline].
Further Reading
Keywords
clavicular injuries, clavicle fracture, clavicle fractures, clavicle dislocation, shoulder injury, shoulder girdle injury, collar bone fractures, broken collar bone
