by Stacy Snow
Description
Clavicle fractures are relatively common injuries that most often occur in young active males and in elderly individuals. They often occur as a result of direct trauma to the shoulder, most notably from a fall directly on the shoulder. The force then is transmitted through the clavicle from the acromioclavicular joint to the sternoclavicular joint[1].
(http://www.mayoclinic.com/images/image_popup/ans7_broken_collarbone.jpg)
Anatomy
The clavicle is an ‘S-shaped’ bone that forms the only bony connection between the upper extremity and the axial skeleton. Due to its anatomical location, it lies over and creates a protective barrier for the brachial plexus and the subclavian vessels of the upper extremity. The clavicle is also an important component in the motion and stability of the upper extremity[2][3].The clavicle attaches distally to the acromion forming the acromioclavicular (AC) joint and proximally to the sternum, forming the sternoclavicular (SC) joint. The clavicle is an important, but often overlooked component of normal shoulder motion. During shoulder flexion and abduction, the clavicle must elevate or rotate in order to allow full movement[8]. Therefore an injury to the clavicle, especially involving displacement, will create limitations in shoulder motion that will need to be addressed during the course of treatment.
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(http://img.webmd.com/dtmcms/live/webmd/consumer_assets/site_images/articles/image_article_collections/anatomy_pages/shoulder.jpg)
There are many muscles involved in the shoulder complex, but there are 6 muscles that attach directly to the clavicle. These include[4][9]:
- Pectoralis Major
- Upper trapezius (distal end)
- Anterior deltoid
- Sternocleidomastoid (SCM)
- Subclavius
Innervation
The nerves supplying the shoulder complex and the upper extremity receive their innervation primarily through the brachial plexus, 'a consolidation of ventral rami from the C5-T1 nerve roots[9].' This bundle of nerves travels underneath the clavicle to enter the upper extremity and is therefore vulnerable to injury with clavicle fractures.
(https://encrypted-tbn1.google.com/images?q=tbn:ANd9GcQhX0EVa1iTvv9AfM64vucJa2pC0QgUkUvHpINDbPjDCXZNJWs7)
Clavicle Fracture Classifications
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The Allman classification describes the anatomical site of the fracture by dividing the clavicle into thirds. [3]
- Group I (Midshaft): Occur on the middle 1/3 of the clavicle
- Group II (Lateral/Distal): Occur on the lateral or distal 1/3 of the clavicle (Closest to the acromion)
- Group III (Medial/Proximal): Occur on the medial or proximal 1/3 of the clavicle (Closest to the sternum)
(http://eorif.com/Shoulderarm/Images/Clavicle-classfc.jpg)
Incidence & Prevalence
Clavicle fractures represent 5-10% of all fractures [3]and 33-45% of all injuries involving the shoulder girdle. The midshaft portion is the most frequently fractured area of the clavicle. The bone at this section is thinner and weaker and is therefore more susceptible to fracture. Midshaft fractures account for 69-82% of all clavicle fractures, and most of these fractures are displaced.[1].
Clinical Presentation
Patients with a fracture of the clavicle typically present with:
- Focal tenderness, ecchymosis, crepitation on palpation over the clavicle and edema[3]
- Patients with clavicle fractures typically hold the injured arm close to the body, often using the opposite hand to support the affected arm[3]
- The fractured section of the bone may often be visualized or detected with palpation [3]
- With displaced fractures, a deformity may be visible. This occurs when the weight of the shoulder displaces the lateral fragment downward and the sternocleidomastoid displaces the medial fragment upward creating a visible 'bump' on the clavicle[1][4] as illustrated below
(http://www.aafp.org/afp/2008/0101/afp20080101p65-f4.gif)
- When the fracture is displaced, this abnormality will easily be seen when looking at the patient from the front
Potential Etiologies
The most frequent mechanism of injury for clavicle fractures is a direct fall on the shoulder with the arm at the side. In rare cases, these fractures may occur from a fall on an outstretched hand (FOOSH injury) or from a direct blow[3] as sustained in contact sports or in a motor vehicle accident.
Diagnostic Tests
Clavicular fractures are usually determined with a routine anteroposterior (AP) radiographic view. Because non-displaced fractures may be difficult to detect with this view, a 20-degree (Zanca view) or 45-degree cephalic tilt view will usually demonstrate the fracture[2].
(http://cdn0.sbnation.com/legacy_images/conquestchronicles/images/admin/XRAY_Clavicle.jpg)
Evaluation & Special Orthopedic Tests
After an injury to the clavicle, especially with a displaced fracture, it is important to rule out lesions involving the brachial plexus, subclavian vessels, and associated chest injuries such as 'pneumothorax or hemothorax which reportedly occurs at rates of us to 3%[1]. Although rare, these injuries can have serious consequences if undetected.
Physical Therapy Management of Clavicle Fracture
Conservative Treatment
In non-displaced mid-shaft clavicle fractures, the most common treatment approach continues to be nonoperative management. In fact, 'there is complete agreement in the literature on the indication for conservative treatment in undisplaced, uncomplicated fractures of the middle third of the clavicle…and the vast majority are found to have excellent results[3][5][6].' The most commonly used conservative management consists of immobilization in a sling or figure-of-eight dressing.
Even figure-of-eight dressing is still widely used, several studies utilizing a simple arm sling have demonstrated similar union rates and increased satisfaction in patients. Immobilization is generally maintained for 1-2 weeks to maintain a position of comfort[3]. While the sling is worn, the patient may begin active ROM of the elbow, wrist and hand and may begin pendulum exercises as soon as pain allows[6]. The patient may begin to gradually progress to active ROM and strengthening of the shoulder over the 4-8 week period following the fracture.[3].
Simple arm sling
Figure-of-Eight sling
Clavicle fractures in children
Midshaft clavicle fracture in children tend to heal well. This is primarily because children have 'great periosteal regenerative potential,' and healing of these fractures generally occurs within 4-6 weeks. [3].
Surgery & Post-Op Treatment
Midshaft clavicle fractures that are displaced tend to have higher rates of nonunion and a greater risk of long-term complications. Because of this, these fractures are generally considered for surgical reduction to correct. Common options for surgical reduction include open or closed reduction with plate fixation or intramedullary fixation which is generally less common[3].
Plate and Screw Fixation
(http://www.shoulderdoc.co.uk/images/uploaded/clavicle_plate02.jpg)
Intermedullary Fixation for Clavicle Fracture
Post-Op Management
After surgery, the affected arm is kept in a sling for one week. Discharge the next day is typical for patients with isolated fractures. Patients are restricted from heavy lifting, raising the arm overhead and driving until bony union is apparent by Xray. Xrays are taken every two weeks until bony union is detected and then again at six months before the screw/screws are removed[7].
Additional Web Resources
Anatomy: http://www.theodora.com/anatomy/the_clavicle.html
General info: http://orthoinfo.aaos.org/topic.cfm?topic=a00072
General surgery info: http://my.clevelandclinic.org/disorders/clavical_fracture/or_overview.aspx
Clavicle Fracture in Pediatrics: http://www.aaos.org/news/aaosnow/aug09/clinical1.asp
Clavicle Fracture in the Newborn: http://web.jbjs.org.uk/cgi/reprint/85-B/1/115
Clavicle Fracture Rehab: http://sportsmedicine.about.com/od/surgeryrehab/qt/Clavicle-Rehab.htm
Surgical Options: http://www.orthosupersite.com/view.aspx?rid=21065
Medical Disability Guidelines: http://www.mdguidelines.com/fracture-clavicle
Surgical Repair Videos: (*Caution: Second video contains graphic images*)
