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Sports Medicine > Shoulder
Clavicular Injuries
Article Last Updated: Aug 18, 2008
AUTHOR AND EDITOR INFORMATION
Section 1 of 11  
Author: Kevin J Eerkes, MD, Clinical Assistant Professor, Department of Medicine, New York University School of Medicine; Medical team physician, New York University athletic teams
Coauthor(s):
Janos P Ertl, MD, Assistant Professor, Department of Orthopedic Surgery, Indiana University School of Medicine; Chief of Orthopaedic Surgery, Wishard hospital;
John B Mitchell, MD, Consulting Staff, Department of Orthopedics, Kaiser Permanente
Editors: Joseph P Garry, MD, Director of Sports Medicine and Sports Medicine Fellowship, Associate Professor of Family Medicine and Exercise and Sport Science, Department of Family Medicine, East Carolina University Brody School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Henry T Goitz, MD, Chief, Sports Medicine, Associate Professor, Department of Orthopaedic Surgery, Medical College of Ohio; Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital; Craig C Young, MD, Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Sports Medicine Fellowship Director, Medical College of Wisconsin
Author and Editor Disclosure
Synonyms and related keywords:
clavicular injuries, clavicle fracture, clavicle fractures, clavicle dislocation, shoulder injury, shoulder girdle injury, collar bone fractures, broken collar bone
Background
The descriptions of treatment of clavicle fractures, date back to Hippocrates. Over time, numerous descriptions have been made of fracture reduction techniques, with the prevalent figure-of-8 bandage described by Lucas Championnière around 1860. The earliest description of a sports-related clavicle fracture dates to 1702, when William III died following an equestrian (riding) accident that led to a false aneurysm of the subclavian artery, evidence of the potentially serious nature of clavicular fractures.
Clavicle fractures are common and easily recognized because of their subcutaneous position. 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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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).
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
See Sport-Specific Biomechanics.
Acromioclavicular Joint Injury
Rotator Cuff Injury
Shoulder Dislocation
Other Problems to Be Considered
Hemothorax
Neurovascular injury (especially the ulnar nerve)
Pneumothorax
Rib fracture
Scapular fracture
Sternoclavicular joint injury
Lab Studies
- Laboratory studies are ordered depending on the severity of trauma. With suspected vascular injury, obtain a complete blood cell (CBC) count to check the hemoglobin and hematocrit values. If a pulmonary injury is suspected or identified, perform an arterial blood gas (ABG) determination, and obtain an expiration posteroanterior (PA) chest film.
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Imaging Studies
- Clavicular radiographs
- Two views are standard for the initial radiography evaluation: An anteroposterior (AP) view and a 45° cephalic tilt view. These will delineate the fracture displacement, as well as medial clavicle and possible first rib fractures.
- The proximal humerus and scapula should be looked at for possible associated fractures.
- With regard to fracture patterns, most low-energy fractures that occur in sports result in a minimally displaced oblique fracture at the mid shaft.1, 2, 3, 4, 6 As the energy of the lateral force is increased, the fracture tends to be comminuted with a butterfly fragment and shortened. The typical appearance is inferior and medial displacement of the distal fragment, owing to the weight of the upper extremity and medial pull of the pectoralis. The proximal clavicle is pulled in a superior direction by the sternocleidomastoid muscle (see Image 1).
- A roentgenographic classification of distal clavicle fractures was developed by Neer7 and Rockwood and Jenson.8 They divided the fractures into 3 types, as follows:
- Type 1 fractures are minimally displaced and occur lateral to an intact coracoclavicular ligament complex. These fractures may be treated nonoperatively and symptomatically.
- Type 2 fractures occur when the medial fragment is separated from the coracoclavicular ligament complex. The medial fragment is displaced cephalad by the pull of the sternocleidomastoid muscle, and the distal fragment is displaced caudally by the weight of the upper extremity, with the intact coracoclavicular ligament complex. The resulting deformity leads to marked displacement of the fracture ends, predisposing this fracture type to a higher prevalence (up to 30%) of nonunion (see Image 2).
- Type 3 fractures are nondisplaced and extend into the AC joint. As with type 1 fractures, these injuries can be treated symptomatically. The development of late AC degenerative changes can be treated with distal clavicular excision.
- Computed tomography (CT) scanning with 3-dimensional (3-D) reconstruction: This imaging study may be obtained to further evaluate displaced fractures. In the case of proximal clavicle fractures, CT scans can show any evidence of posterior displacement of the fracture and injury to the neurovascular structures.
- Chest radiography: This study may be necessary to evaluate for pneumothorax, hemothorax, and rib fractures and is especially helpful in polytrauma or patients who are comatose.
- Arteriography: Perform arteriography if a vascular injury is suspected.
- Shoulder series: These radiographs may be required to rule out additional injuries or fractures (eg, to the scapula or proximal humerus).
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Acute Phase
Medical Issues/Complications
Icing, rest, and medication (see the Medication section) are used for pain relief. The vast majority of clavicle fractures heal uneventfully no matter which treatment is instituted.9, 10 A sling to support the weight of the upper extremity is recommended for nondisplaced or minimally displaced fractures for 2-6 weeks' duration, depending on the patient’s pain. Types 1 and 3 fractures of the distal clavicle can also be treated with a sling.
A figure-of-8 bandage has been used in attempt to bring displaced fracture fragments into better opposition, however, no evidence exists that a figure-of-8 bandage can hold a fracture in reduction. In order for it to effectively reduce the fracture, the splint would have to be so tight that skin breakdown, increased pain, and nerve injury could result. No improvement in the healing rate or fracture alignment with the figure-of-8 bandage has been found.11 The general consensus is that changing the amount of displacement observed on the initial radiographs is not possible without surgery. Fortunately, the fracture healing with a modest amount of angulation does not usually result in significant functional limitations.
Surgical Intervention
Patients with the following injuries should be sent to a surgeon to determine if operative intervention is necessary:
- Severe fracture displacement (>100% displacement or fracture ends are >1.5 cm apart)
- Tenting of the skin with the risk of puncture: This is often seen with type 2 fractures of the distal clavicle.
- Fractures with 2 cm of shortening
- Neurovascular compromise
- Polytrauma, (with multiple fractures) to expedite rehabilitation
- Open fractures
- An inability to tolerate closed treatment
- Fractures with interposed muscle
- Established symptomatic nonunion: Note that many nonunions are asymptomatic, and no treatment is needed.
- Concomitant glenoid neck fracture (floating shoulder)
Relative indications for open reduction and internal fixation (ORIF) include athletes who require shoulder pads for sports participation, such as in football and hockey. Surgery in this case would be to avoid skin breakdown over pronounced callus formation about the fracture site.
The surgical procedure performed is either plate-and-screw fixation or placement of a intramedullary device.6, 12 Precontoured plates in an S-shape of the clavicle have also become available.13
Checchia et al reported a new arthroscopic technique to treat distal clavicle fractures in 7 patients with a mean age of 46 years.14 The investigators identified the coracoid through the rotator interval, and using a special needle, a double #5 suture was passed around the coracoid. A hole was then created at the clavicle and, through another guide wire, was sent to the anterior portal. The double #5 suture was transported to the clavicle. Following the fracture reduction, the sutures were tightened. Checchia et al noted that all 7 cases healed without complication. The investigators believe that, with the aid of arthroscopy, the morbidity of surgical treatment of clavicle fractures can be decreased.13
Complication rates with acute surgical treatment have been reported to be as high as 20%. Complications can include infection, failure of fixation, prominent scarring, and nonunion.
Consultations
Recovery Phase
Rehabilitation Program
Physical Therapy
Once the fracture pain begins to subside and the athlete is weaning off the pain medications, begin range-of-motion exercises with the shoulder and elbow out of the sling to prevent stiffening of these joints. Exercises should be performed within the limits of comfort.
As pain continues to improve, isometric exercises of the shoulder girdle and arm musculature can begin. This can be performed under the supervision of a physical therapist or by the athlete on his or her own, with an instructional handout for guidance.
The sling can be used as needed for comfort for up to 2-4 weeks after the injury. As fracture healing progresses based on clinical and radiographic examination findings, isotonic exercises can begin using light weights or elastic bands for resistance.
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Maintenance Phase
Rehabilitation Program
Physical Therapy
Therapy includes progressive range-of-motion exercises and strengthening exercises. Functional and sports-specific exercises can be added depending on the athlete’s goals.
Fractures are very painful. Pain medications are used until the pain is under control or tolerable.
Drug Category: Analgesic, Narcotic
Pain control is essential to quality patient care. Analgesics can reduce patient discomfort and narcotic analgesics often have a sedative effect, which are beneficial for patients who have sustained trauma or who have sustained injuries.
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| Drug Name | Acetaminophen and codeine (Tylenol #3) |
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| Description | Indicated for the treatment of mild to moderate pain. |
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| Adult Dose | 30-60 mg/dose based on codeine PO q4-6h; not to exceed 12 tab/24 h |
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| Pediatric Dose | Codeine dose is 0.5-1 mg/kg/dose, acetaminophen 10-15 mg/kg/dose q4-6h |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Toxicity increases when administered concurrently with CNS depressants. |
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| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
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| Precautions | Administer with caution in patients who are dependent on opiates because this substitution may result in acute opiate withdrawal symptoms; exercise caution when patients have severe renal or hepatic dysfunction. |
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Drug Category: Analgesic, Nonsteroidal Anti-inflammatory Drug
NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. The mechanism of action of these agents is not known, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation and various cell membrane functions. Many NSAIDs are currently on the market. In general, the mechanism of action of these agents is the same. No evidence exists that one NSAID is more efficacious than another; however, individual response may differ.
NSAIDs are discouraged beyond 5 days from the injury. It is thought that they may interfere with fracture healing.
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| Drug Name | Ibuprofen (Ibuprin, Advil, Motrin) |
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| Description | Member of the propionic acid group of NSAIDs. Available in low-dose form as an over-the-counter medication. Highly protein bound, metabolized in liver, and eliminated primarily in urine. May reversibly inhibit platelet function. |
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| Adult Dose | 600-800 mg PO tid/qid |
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| Pediatric Dose | 40 mg/kg PO divided tid/qid (recommended maximum daily dose) |
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| Contraindications | Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding |
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| Interactions | Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; monitor PT duration closely (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently |
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| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
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| Precautions | Caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of anticoagulation abnormalities or during anticoagulant therapy |
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Return to Play
Return to play depends on the location and severity of the clavicle fracture, the degree of clinical and radiographic healing, and the sport played. Noncontact sports Return to noncontact sports is allowed when (1) the clavicle fracture is healed (ie, no tenderness is present, and radiographs show callus formation), and (2) the patient has full, painless range of motion and has regained near-normal strength. These milestones have usually been reached at about 6 weeks from the time of the injury. Contact sports Return to contact sports takes much longer because the risk of refracture is high. The return to play should be delayed until the fracture union is solid, which can take from 2-6 months from the time of the injury or 4-6 weeks after after clinical and radiographic union. A donut pad or fiberglass shoulder shell may be used for extra protection.
Complications
Nonunion Nonunion is a failure to show clinical or radiographic progression of healing after 4-6 months. The following are risk factors for nonunion: - Fracture comminution
- Significant fracture displacement or shortening
- Type 2 fractures of the distal third of the clavicle
- Refracture
- Female sex
- Advanced age
The nonunion rate for all midclavicle fractures treated nonoperatively is 6%. The nonunion rate for displaced midclavicle fractures treated nonoperatively is 15%. Note that many nonunions are asymptomatic, and no treatment is needed. Symptoms of nonunion can be pain, motion, or loss of function. Refer patients with symptomatic nonunion to an orthopedic surgeon to discuss surgical options. In some situations, a bone stimulator to help promote bone healing can be tried before surgery. Malunion Malunion is when the fracture heals with significant angulation, shortening, and a poor appearance. Mild malunion is common after clavicle fractures, but it is usually not clinically significant. Occasionally, the patient can have pain or a mild limitation of motion or strength. Symptoms from nerve impingement may occur but are uncommon. Surgeries for malunion attempt to restore the clavicular length and correct any angular deformity of the clavicle. A spike of bone can form subcutaneously after angulated fractures heal. This can be symptomatic for athletes who wear shoulder pads or for backpackers. If a donut pad is not sufficient to relieve symptoms, surgical excision can be considered. Other Neurovascular compromise can develop from exuberant callus formation or from malunion. The medial cord and ulnar nerve are affected most often. Treatment is surgical in nature. Posttraumatic arthritis can develop if the fracture enters the AC or SC joints.
Medical/Legal Pitfalls
At the initial visit, discuss the following with the athlete who has a clavicular injury:
- A visible prominence may remain at the fracture site after it heals. This may be more evident in thin individuals.
- Fracture nonunion is possible, and surgery may be necessary.
- Refracture is also a possibility when returning to contact sports, particularly if the athlete returns to play too soon.
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| Media file 1:
Anteroposterior view of middle third clavicular fracture illustrating a more typical fracture pattern. |
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Media type: X-RAY
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| Media file 2:
Anteroposterior view of distal clavicular fracture, type 2, showing wide displacement. |
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Media type: X-RAY
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| Media file 3:
Comminuted fracture in a hockey player (same patient in Images 3-5). Note the medial fragment tenting the skin. |
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Media type: X-RAY
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| Media file 4:
Additional view of fracture displacement and comminution in a hockey player (same patient in Images 3-5). The sternocleidomastoid is the deforming force of the medial fragment. |
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Media type: X-RAY
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| Media file 5:
Radiographs after open reduction and internal fixation of a comminuted fracture in a hockey player (same patient in Images 3-5). |
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Media type: X-RAY
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| Media file 6:
A posterior view demonstrating a closed clavicle fracture tenting the skin (arrow) (same patient in Images 6-8), which can potentially lead to an open fracture. |
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Media type: Photo
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| Media file 7:
Comparison of both clavicles, with the left tenting the skin (wide arrow) (same patient in Images 6-8). |
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| Media file 8:
Close-up view of clavicle tenting the skin (arrow) (same patient in Images 6-8). |
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Media type: Photo
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Clavicular Injuries excerpt Article Last Updated: Aug 18, 2008
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