Musculoskeletal · Trauma/Orthopedics
The facts most likely to be tested
The middle third (midshaft) is the most common location for a clavicle fracture due to the transition from the convex to concave shape of the bone.
Physical examination typically reveals tenderness, crepitus, and a palpable deformity over the clavicle with the patient holding the arm in an adducted position.
The sternocleidomastoid muscle pulls the proximal fragment superiorly and posteriorly, while the weight of the arm causes the distal fragment to displace inferiorly.
Initial management for the vast majority of non-displaced or minimally displaced midshaft fractures is non-operative treatment with a simple sling or figure-of-eight bandage for comfort.
Neurovascular compromise (brachial plexus injury or subclavian vessel injury) is a rare but critical complication that requires immediate vascular surgery consultation.
Surgical fixation (ORIF) is indicated for open fractures, neurovascular compromise, tenting of the skin (impending skin breakdown), or severely displaced fractures with significant shortening.
Delayed union or nonunion is more common in patients with significant fracture displacement, comminution, or advanced age.
Vignette unlocked
A 22-year-old male presents to the emergency department after falling onto his outstretched right shoulder during a rugby match. On physical exam, he is holding his right arm against his chest with his left hand. There is obvious deformity and point tenderness over the mid-portion of the right clavicle. Crepitus is noted upon palpation. Distal pulses are 2+ and symmetric, and there are no sensory or motor deficits in the upper extremity.
What is the most appropriate initial management for this patient?
Simple sling immobilization
This patient has a standard midshaft clavicle fracture without neurovascular compromise or skin tenting, which is best managed non-operatively with a sling.
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Etiology / Epidemiology
Most common fracture in children and neonates (birth trauma). Usually results from direct blow or fall on outstretched hand (FOOSH).
Clinical Manifestations
Patient presents with arm held in adducted position and step-off deformity. Crepitus and localized tenderness are pathognomonic.
Diagnosis
Radiography (AP view) is the gold standard. Always assess for neurovascular compromise.
Treatment
Mid-shaft fractures require sling immobilization for 4-6 weeks. Surgery is indicated for open fractures or neurovascular compromise.
Prognosis
Excellent healing in most cases. Nonunion is rare but higher in proximal third fractures.
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Epidemiology & Etiology
Common in active populations due to high-impact sports or motor vehicle accidents. In neonates, it is the most common birth injury associated with shoulder dystocia. Direct trauma to the lateral aspect of the shoulder is the most frequent mechanism.
Pertinent Anatomy
The clavicle is the only bony attachment between the trunk and the upper extremity. The middle third (junction of medial 2/3 and lateral 1/3) is the weakest point and most common site of fracture. The brachial plexus and subclavian vessels lie directly posterior to the bone.
Pathophysiology
Fracture displacement is driven by muscle forces: the sternocleidomastoid pulls the proximal fragment superiorly, while the weight of the arm and the pectoralis major pull the distal fragment inferiorly and medially. This creates the classic Z-deformity. High-energy trauma may cause comminuted fractures or injury to underlying structures.
Clinical Manifestations
Patients present with pain, swelling, and a palpable step-off deformity. The patient will often support the affected arm with the contralateral hand to reduce tension. Red flags include diminished distal pulses, brachial plexus paresthesias, or skin tenting indicating impending open fracture.
Diagnosis
Standard AP Radiography confirms the diagnosis and identifies the fracture location. If the fracture is comminuted or involves the medial/lateral ends, a CT scan may be required to rule out intra-articular involvement. Always perform a thorough neurovascular exam to document baseline status.
Treatment
Non-operative management with a simple sling or figure-of-eight brace is standard for mid-shaft fractures. Surgical fixation (ORIF) is mandatory for open fractures, symptomatic nonunion, or significant neurovascular compromise. Early range-of-motion exercises are initiated once pain subsides to prevent adhesive capsulitis.
Prognosis
Most fractures heal within 6-12 weeks with excellent functional outcomes. Nonunion occurs in <5% of cases, typically associated with high-energy trauma or inadequate immobilization. Monitor for malunion which may cause cosmetic deformity or chronic shoulder pain.
Differential Diagnosis
Acromioclavicular (AC) joint separation: tenderness localized to the distal clavicle/AC joint
Proximal humerus fracture: pain with shoulder rotation rather than direct clavicular palpation
Scapular fracture: associated with high-energy chest trauma and rib fractures
Sternoclavicular dislocation: pain and deformity at the medial clavicular head
Brachial plexus injury: isolated neurological deficits without bony deformity