Clavicular fracture
Updates to Article Attributes
Clavicular fractures are common and account for 2.6-10% of all fractures 2-3. They usually require minimal treatment, which relies on analgesia and a collar-and-cuff. However, in some cases open reduction and internal fixation is required.
Mechanism
Fractures can occur at any part of the clavicle. However, the vast majority (69-82%) occur in the midshaft, at or near the junction of the middle and outer third. This is due two factors: firstly this is the thinnest part of the bone, and secondly, it is the only part of the bone not reinforced by attached musculature and ligaments 3.
Typically, fractured clavicles occur as the result of a fall onto an outstretched arm on onto the point of the shoulder. They are common in very young and very old patients.
Radiographic Features
Plain film
While it is not unusual for only a single AP film to be obtained, ideally, as with any trauma situation, two views are better than one. In most trauma situations, orthoginal views of obtained of the affected bone or joint. Since this is not possible with the clavicle, AP and oblique views are obtained:
- frontal (AP)
- cephalic tilt (15-45 degree)
In most instances, the fracture is evident clinically and easily identified on radiographs. It is common for significant displacement and overlap to be present, accentuated by the distal downward pull of the upper limp and the proximal upward forces exerted by sternocleidomastoid medially.
It is important to note that occult fractures may be present in the apparently normal radiograph; this is relatively common in children and also occasionally seen in adults 2.
Report checklist
Radiology reports should not only include whether or not a fracture is present but also comment on:
- fracture
- location of the fracture along the shaft
- angulation and fracture end displacement (including direction)
- comminution
- degree of overlap (measurement is useful)
- associated findings and relevant negatives
- acromioclavicular joint and sternoclavicular joint alignment
- coracoclavicular distance
- glenohumeral joint
Treatment and prognosis
In cases where the clavicle is thought to be fractured clinically, but where the radiograph is normal, it is advisable to treat patients as if a fracture is present; this is especially the case in children 2.
Traditionally midshaft fractures of the clavicle have been treated with immobilisation and a sling or figure-of-8 dressing, and in most cases results are said to be excellent with low non-union rates and minimal functional impairment 3. This has been challenged by some authors, who have found non-union rates of up to 15% and high rates of suboptimal outcome, e.g. ongoing local pain, brachial plexus irritation, cosmetic deformity 5.
In cases where these is significant displacement, angulation, shortening (>2 cm) or comminution, internal fixation either with plate-and-screw fixation or with an medullary device (e.g. intramedullary titanium elastic nail) have been shown to result in better cosmetic outcome and higher rates of union. Internal fixation is thus probably advisable in such cases and in patients who are at risk of non-union (e.g. elderly) 3-5.
Additionally cosmetic concerns may be an indication for internal fixation to avoid unsightly deformity.
See also
-<li>acromioclavicular joint and sternoclavicular joint alignment</li>- +<li>
- +<a title="Acromioclavicular joint" href="/articles/acromioclavicular-joint-1">acromioclavicular joint</a> and <a title="Sternoclavicular joint" href="/articles/sternoclavicular-joint">sternoclavicular joint </a>alignment</li>
-</ul><h4>Treatment and prognosis</h4><p>In cases where the clavicle is thought to be fractured clinically, but where the radiograph is normal, it is advisable to treat patients as if a fracture is present; this is especially the case in children <sup>2</sup>. </p><p>Traditionally midshaft fractures of the clavicle have been treated with immobilisation and a sling or figure-of-8 dressing, and in most cases results are said to be excellent with low non-union rates and minimal functional impairment <sup>3</sup>. This has been challenged by some authors, who have found non-union rates of up to 15% and high rates of suboptimal outcome, e.g. ongoing local pain, brachial plexus irritation, cosmetic deformity <sup>5</sup>. </p><p>In cases where these is significant displacement, angulation, shortening (>2 cm) or comminution, internal fixation either with plate-and-screw fixation or with an medullary device (e.g. intramedullary titanium elastic nail) have been shown to result in better cosmetic outcome and higher rates of union. Internal fixation is thus probably advisable in such cases and in patients who are at risk of non-union (e.g. elderly) <sup>3-5</sup>.</p><p>Additionally cosmetic concerns may be an indication for internal fixation to avoid unsightly deformity. </p><h4>See also</h4><ul><li><a href="/articles/upper-extremity-fractures">upper extremity fractures</a></li></ul><p> </p>- +</ul><h4>Treatment and prognosis</h4><p>In cases where the clavicle is thought to be fractured clinically, but where the radiograph is normal, it is advisable to treat patients as if a fracture is present; this is especially the case in children <sup>2</sup>. </p><p>Traditionally midshaft fractures of the clavicle have been treated with immobilisation and a sling or figure-of-8 dressing, and in most cases results are said to be excellent with low non-union rates and minimal functional impairment <sup>3</sup>. This has been challenged by some authors, who have found non-union rates of up to 15% and high rates of suboptimal outcome, e.g. ongoing local pain, <a title="Brachial plexus" href="/articles/brachial-plexus">brachial plexus</a> irritation, cosmetic deformity <sup>5</sup>. </p><p>In cases where these is significant displacement, angulation, shortening (>2 cm) or comminution, internal fixation either with plate-and-screw fixation or with an medullary device (e.g. intramedullary titanium elastic nail) have been shown to result in better cosmetic outcome and higher rates of union. Internal fixation is thus probably advisable in such cases and in patients who are at risk of non-union (e.g. elderly) <sup>3-5</sup>.</p><p>Additionally cosmetic concerns may be an indication for internal fixation to avoid unsightly deformity. </p><h4>See also</h4><ul><li><a href="/articles/upper-extremity-fractures">upper extremity fractures</a></li></ul>
Image 4 X-ray ( update )
Image 5 X-ray ( update )
Image 7 X-ray (Frontal) ( update )
Image 9 CT (bone window) ( update )
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