Patients will present with sudden-onset localised severe pain, made worse on active movement of the arm, nearly always following trauma. The medial fragment will often displace superiorly, due to the pull of the sternocleidomastoid muscle, whilst the lateral fragment will displace inferiorly from the weight of the arm. Figure 1 - the inferior surface of the clavicle PathophysiologyĬlavicle fractures will occur through either a direct (trauma directly onto the clavicle) or indirect (such as a fall onto the shoulder) mechanism of injury. Where fractures have failed to unite, an open-reduction internal-fixation (ORIF) will be necessary, which is usually performed at 2-3 months post-injury. It is also typically performed if the patient has bilateral fractures, to permit weight bearing. It is usually reserved for very comminuted fractures or those that are very shortened. However, surgical management for the remainder of clavicle fractures remains contentious. Surgical ManagementĪll open fractures will need surgical intervention. *Patients should be given the option of operative management (in appropriate cases) because a potential shorter time to union may be worth the risks of surgery in certain patients (e.g. The sling is generally kept on until the patient regains pain-free movement of the shoulder.įractures of the proximal clavicle will also need to be considered in the wider context of associated injury, such as traumatic pneumothorax, and managed accordingly. Early movement of the shoulder joint is recommended, to prevent the development of frozen shoulder in these patients. Initial treatment is with a sling, which should be properly applied so that the elbow is well supported and improves the deformity. As the clavicle is subcutaneous, metalwork is often prominent and therefore may require removal after fracture union too Most clavicle fractures can be treated conservatively, even those with significant deformity, as evidence has shown no long-term benefit to surgical management over a conservative approach, with >90% uniting despite displacement*. As the mediastinum sits directly behind the medial aspect of the clavicle, they can be associated with neurovascular compromise, pneumothorax, or haemothorax.Type III – remaining 5% occur in the medial third of the clavicle, commonly associated with multi-system polytrauma.When displaced, this type are often unstable.Type II – fractures involving the lateral third of the clavicle and constituting around 20% of all clavicular fractures.They are generally stable, although significant deformity is usually present. Type I – fracture of the middle third of the clavicle, constituting 75% clavicular fractures (as the middle third is the weakest segment).They most commonly occur in adolescents and young adults, however a second peak in incidence also occurs over the age of 60, associated with the onset of osteoporosis.Ĭlavicular fractures can be classified by the Allman classification system, determined by the anatomical location of the fracture along the clavicle: Clavicle fractures are common injuries, accounting for around 3% of all fractures.
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