Clavicle Fractures

Overview

• 2–5% of all fractures, ~40% of shoulder girdle injuries

• Most common: middle third (~80%)

• Bimodal distribution: young active (sports, traffic) + elderly (falls)

• Mechanism: fall on shoulder, direct blow, FOOSH (less common)

Clinical Presentation

• Local pain, swelling, tenderness

• Visible deformity or step-off in displaced cases

• Reduced shoulder motion due to pain

• Skin tenting → risk of open fracture

• Always check neurovascular status

Imaging

• X-ray: AP + 15° cephalic tilt view (Zanca view)

• CT: distal (AC joint) or medial end (SC joint) fractures

Classification

Allman Classification

I: Middle third (nearly %80)
II: Distal third
III: Medial third

AO/OTA Classification (Clavicle, Distal)

Type A – Nondisplaced, CC ligaments intact

• A1: Extra-articular fracture

• A2: Intra-articular fracture

• Typical management: Nonoperative

Type B – Displaced, CC ligaments intact

• B1: Extra-articular fracture

• B2: Comminuted fracture

• Management: Can be treated nonoperatively or with surgery depending on symptoms and patient factors

Type C – Displaced, CC ligaments disrupted

• C1: Extra-articular fracture

• C2: Intra-articular fracture

• Management: Operative fixation usually required

Neer Classification (distal) :

Type I
Stable fracture pattern, usually managed non-operatively

• Fracture line lies lateral to the coracoclavicular (CC) ligaments

• Trapezoid and/or conoid ligament remains intact

Type IIA
Unstable injury, often requiring surgical fixation

• Fracture is medial to the CC ligaments with significant displacement of the medial fragment

• Conoid ligament preserved

• Trapezoid ligament intact

Type IIB
Unstable fracture, high risk of nonunion, usually surgical

• Fracture occurs between the CC ligaments

• Conoid ligament torn, trapezoid ligament intact

• Medial clavicle fragment displaced

Type III
Stable fracture, generally treated non-operatively

• Intra-articular extension into the acromioclavicular joint

• Both conoid and trapezoid ligaments intact

Type IV
Pediatric pattern, Salter-Harris type I physeal injury, usually stable

• Medial clavicle fragment displaced superiorly

• Periosteal sleeve avulsed from the inferior cortex

• Conoid and trapezoid ligaments intact

Type V
Unstable comminuted fracture, typically surgical

• Medial clavicle fragment displaced

• Inferior fragment remains attached to CC ligaments

• Conoid and trapezoid ligaments intact

Robinson (Edinburgh) Classification:
Considers location (medial, middle, distal), displacement, and comminution
More comprehensive, useful for research/epidemiology

Treatment

• Nonoperative
  Sling or figure-of-eight bandage
  Analgesia, early motion
  Indication: minimally displaced, <2 cm shortening

• Operative Indications
  Open fracture / threatened skin
  Neurovascular compromise
  2 cm shortening or marked displacement
  Comminution in active/high-demand patients
  Symptomatic nonunion

• Techniques
  Plate fixation (superior or anteroinferior)
  Intramedullary devices (elastic nail, pin) for midshaft
  Distal: hook plate, locking plate, CC fixation

Complications

• Nonunion (esp. distal, smokers, comminuted)

• Malunion (cosmetic, functional deficit)

• Hardware irritation, infection

• Rare: neurovascular injury

Key Pearls

• Most middle-third fractures heal well nonoperatively

• Distal type II fractures = higher nonunion risk → surgery often indicated

• 2 cm shortening in young/active = consider fixation

• Look for associated injuries: ribs, pneumothorax, scapula