Fractured Clavicle

Clavicle Fractures 🦴 are very common — especially in children and young adults after sports or falls, and in the elderly with osteoporosis. 👉 Most heal well with conservative management. There is no proven long-term functional benefit to surgical fixation in most cases. 🚨 Surgery is reserved for specific indications (open fracture, neurovascular compromise, severe displacement).

📖 About

• Most frequently fractured bone in childhood 👶.
• High-energy sports injuries, FOOSH, or low-impact falls in elderly.
• Up to 80% involve the middle third of the clavicle.

⚙️ Aetiology

• Fall on an outstretched hand (FOOSH) ✋.
• Direct blow to clavicle (contact sports, road traffic accidents 🚲).
• Indirect trauma via shoulder girdle.

📊 Allman Classification

• Type I (≈80%): Middle third — most common; usually stable.
• Type II (≈15%): Lateral third — often unstable; higher risk of nonunion.
• Type III (≈5%): Medial third — rare, often from major trauma; may involve great vessels or chest injuries.

🔎 Alternative (Neer)

• Further subcategorises lateral third fractures by coracoclavicular ligament involvement → predicts stability and nonunion risk.

🩺 Clinical Features

• Sharp pain over clavicle/shoulder.
• Swelling or deformity over clavicle or anterior chest wall.
• Crepitus/step deformity on palpation.
• Reduced shoulder movement due to pain.
• Systemic response: dizziness, nausea, blurred vision (pain-related).
• Always check for:
  • Skin tenting / open wound
  • Neurovascular compromise (brachial plexus, subclavian vessels)
  • Pneumothorax / haemothorax if medial fracture

🧪 Investigations

• X-ray: AP clavicle ± 15° cephalic tilt view (best for fracture displacement).
• CT chest: Medial fractures with posterior displacement → exclude mediastinal injury.
• MRI/CT: Rarely, for complex or nonunion cases.
• Ultrasound: Radiation-free and useful in children.

⚠️ Complications

• Nonunion (esp. lateral fractures; risk up to 15%).
• Malunion — bony bump/cosmetic, usually asymptomatic.
• Neurovascular injury — brachial plexus, subclavian artery/vein (rare).
• Pneumothorax / Haemothorax — medial/posterior displacement.
• Infection — only if open or post-surgery.

💊 Management

• Initial: Analgesia, wound care, tetanus prophylaxis if open wound. Document neurovascular status.
• Conservative (majority):
  • Broad-arm sling 2–3 weeks until pain allows mobilisation.
  • Figure-of-eight brace no longer preferred (no proven benefit).
  • Early physiotherapy for ROM once pain settles.
  • Children: callus prominence common, remodels with time.
• Surgical Indications (≈5–10%):
  • Open fracture or skin tenting (threatened skin) 🚨
  • Neurovascular compromise
  • Severely displaced/comminuted fracture with >2 cm shortening
  • Unstable lateral third fractures (coracoclavicular ligament disruption)
  • Symptomatic nonunion

📌 OSCE / Exam Pearls

• Always palpate along entire clavicle — ensure no second injury (esp. sternoclavicular joint).
• Lateral third fractures have highest nonunion risk → consider surgery earlier.
• In children, remodelling is excellent; reassure about cosmetic bumps.
• Check for neurovascular compromise (subclavian vessels, brachial plexus) in displaced medial injuries.

📚 References

• Rockwood & Green’s Fractures in Adults, 9th ed.
• British Orthopaedic Association (BOA) guidance on clavicle fractures.
• Robinson CM. Fractures of the clavicle in the adult. J Bone Joint Surg Br. 1998;80(3):476-484.
• NICE Clinical Knowledge Summaries (CKS): Clavicle fracture. 2023.