07.12.

2013 Clavicle Fractures Treatment & Management

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Clavicle Fractures Treatment & Management
Author: Kevin J Eerkes, MD; Chief Editor: Craig C Young, MD more...

Updated: Sep 9, 2013
Approach Considerations
If all clavicle fractures are considered together, the vast majority heal with nonoperative management, which
includes use of a figure-of-eight brace or a simple shoulder sling. Studies have found, however, that in cases of
specific fracture patterns and locations, not all clavicle fractures behave the same way.
The focus of treatment of middle third fractures remains nonoperative, although evidence is mounting, in support of
operative treatment for displaced midshaft clavicle fractures. Management of medial clavicle fractures also has
remained nonoperative
The incidence of nonunion of displaced distal third fractures is high, and current recommendations are to fix these
injuries surgically.
Consultations
In addition to an orthopedic surgeon if the fracture requires surgical fixation, consultations include the following:
General or thoracic surgeon: If an associated pneumothorax is identified
Vascular surgeon: For a suspected subclavian vessel injury
Surgical Indications
Patients with the following injuries should be sent to a surgeon to determine if operative intervention is necessary:
Complete fracture displacement
[4]
: A literature review showed that 15% of displaced midshaft clavicular
fractures went on to nonunion when treated nonoperatively
[23]
)
Severe displacement causing tenting of the skin with the risk of puncture: This is often seen with type 2
fractures of the distal clavicle.
Fractures with 2 cm of shortening
Comminuted fractures with a displaced transverse "zed" (or z-shaped) fragment
[4]
Neurovascular compromise
Displaced medial clavicular fractures with mediastinal structures at risk
[5]
Polytrauma (with multiple fractures): To expedite rehabilitation
Open fractures
An inability to tolerate closed treatment
Fractures with interposed muscle
Established symptomatic nonunion: Note that many nonunions are asymptomatic, and no treatment is
needed.
Concomitant glenoid neck fracture (floating shoulder)
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Relative indications for open reduction and internal fixation (ORIF) include athletes who require shoulder pads for
sports participation, such as in football and hockey. Surgery in this case would be to avoid skin breakdown over
pronounced callus formation about the fracture site.
Group I Fractures
Nonoperative treatment
The focus of treatment of middle third fractures remains nonoperative. Such treatment can be divided into the
following 2 categories:
Simple support of the extremity - As in a sling or a sling and swath
Reduction and immobilization - Typically with figure-of-eight brace
These treatment options are applicable for almost all middle third clavicle fractures, with the exception of those
that are severely displaced or shortened. The image below illustrates the displacing forces that can affect group I
fractures.
The displacing f orces on a midshaf t clavicle f racture.
The advantage of the figure-of-eight brace is that it gives patients the ability to use both hands. The literature,
however, shows no real difference in outcomes between patients treated with a figure-of-eight splint versus a sling,
so the choice of immobilization should depend on the comfort and functional demands of the patient.
[30]
Healing
time may be as short as 2 weeks for infants, with most adults healing in 4-6 weeks. Immobilization should
continue until repeat radiographs show callus formation and healing across the fracture site.
Stiffness is usually not a problem after nonoperative treatment of clavicle fractures. If the patient does require some
rehabilitation, it should include forward elevation and external rotation. Laborers may return to light lifting after 6
weeks and full duty at 12 weeks. Athletes may return to contact sports after 3 months.
Grassi et al found that patients treated nonoperatively for uncomplicated midclavicle fractures recovered more
quickly than did those who were treated operatively. The investigators examined 40 patients who were treated with
a figure-of-eight brace and 40 patients treated with open reduction and intramedullary fixation with a 2.5-mm
threaded pin.
[31]
Patients who were treated nonoperatively had fewer complications and faster return to normal
daily activities, heavy lifting, and sports.
Overall, however, patients in both groups were satisfied with their results, although 35% of the surgical group had
some adverse events during their recovery, most of which were minor. Nonetheless, 3 patients experienced
refracture after removal of the intramedullary pin. When these patients were then treated with a figure-of-eight
brace, union occurred.
Given the excellent results obtained with nonoperative treatment of uncomplicated midclavicular fractures, such
therapy, using a figure-of-eight brace or regular support sling, is recommended. Operative treatment is best suited
for more complicated fractures of the middle third of the clavicle.
Surgical studies
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Evidence is mounting, however, in support of operative treatment for displaced midshaft clavicle fractures. A
prospective, multicenter, randomized trial by the Canadian Orthopaedic Trauma Society found that operative repair
for these injuries provided better results than did nonoperative treatment. In the study, involving 132 patients with a
displaced midshaft fracture, outcome and complication rates were compared for nonoperative treatment and plate
fixation.
[32]
The investigators determined that mean time to radiographic union was significantly shorter in the operative group
(16.4 wk vs 28.4 wk). Additionally, functional outcomes were improved at all time points measured in the operative
group. This study provided level I evidence in support of plate fixation for completely displaced midshaft clavicle
fractures in the active adult population.
[32]
Similarly, a study by Smekal et al found better results with another operative procedure, elastic stable
intramedullary nailing (ESIN), than with nonoperative treatment in the repair of fully displaced midshaft clavicle
fractures. Outcomes with regard to the rate of successful bone union, functional outcome, time required for
patients to resume their daily activities, and overall patient satisfaction were superior in the operative group than in
nonoperative patients. There was also significantly less posttraumatic clavicular shortening in the surgical group.
Fracture shortening
Hill et al examined a subset of clavicle fractures in which initial shortening of the fracture was greater than 2 cm
and found a high rate (15%) of nonunion in this population.
[33]
Also, final shortening of more than 2 cm was
associated with unsatisfactory results. Open reduction and internal fixation of these injuries is recommended for
patients with displaced middle third clavicle fractures with greater than 2 cm of shortening.
Wick et al reviewed 39 nonunions of midclavicular fractures treated nonoperatively and found a correlation between
initial fracture shortening of greater than 2 cm and nonunion.
[34]
These patients subsequently underwent open
reduction and internal fixation with subsequent union of the fracture. The major patient complaint for all of these
nonunions was pain, and all patients had complete or near complete resolution of their symptoms. Wick, however,
still recommended a trial of conservative treatment prior to open reduction and internal fixation of these fractures.
Reduction and fixation
When a midshaft clavicle fracture requires surgical fixation, the commonly performed involves open reduction of the
fracture, followed by either insertion of an intramedullary device or fixation with a plate and screws.
[6, 7, 8, 9]
Precontoured plates in the S shape of the clavicle have also become available.
[35]
When using plate-and-screw fixation to treat clavicle fractures, the surgeon must remember that the hardware will
likely be prominent. Proper closure of these incisions is imperative to decrease the risk of painful, prominent
hardware.
Intramedullary fixation
Intramedullary fixation requires a small incision over the fracture site. The incision is carried down sharply to the
clavicle without stripping the periosteum. A Steinman pin is then placed in a retrograde fashion past the fracture
site. It is recommended that the Steinman pin be threaded in the proximal fragment to prevent migration. If a
smooth pin is used, bend the distal tip to prevent migration after crossing the fracture site. Cancellous bone
grafting is indicated in cases of comminution and/or bone loss.
Plate-and-screw fixation
Surgical fixation with a plate and screws is another option for midshaft clavicle fractures.
[36]
An incision is made in
line with the clavicle and carried sharply down to the periosteum, with caution to leave thick skin flaps for closure.
The periosteum is then stripped to expose and reduce the fracture, after which plate-and-screw fixation is
performed using any of a wide variety of plates. Recommendations vary from semitubular plates to dynamic
compression plates, low-contact dynamic compression plates, and double plating. However, fixation of these
fractures with semitubular or reconstruction plates is not as strong biomechanically as fixation with dynamic
compression plating or the newer locking-plate technology.
Obtaining purchase in 6 cortices on either side of the fracture is recommended. Lag screw fixation is also
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appropriate when the fracture pattern allows. Again, cancellous bone grafting is suggested in fractures with
comminution and/or bone loss.
Mehmet et al conducted an evaluation of the biomechanical properties and the stability of a locking clavicle plate
(LCP), a dynamic compression plate (DCP), and an external fixator (Ex-fix) and found significant differences
between them. The investigators used an unstable displaced clavicle fracture model under torsional and 3-point
bending loading. For torsion and bending, an overall significant difference was found between the 3 types of fixation
equipment in terms of failure loads; a significant difference was also noted between the LCP and the other 2
models in terms of initial stiffness. The LCP was significantly more stable than the DCP and Ex-fix when subjected
to torsional and bending cyclic loading.
[37]
Group II Fractures
Much controversy exists in the literature regarding the appropriate management of fractures of the distal third of
the clavicle. Incidence of nonunion of these fractures is high, and current recommendations are to fix these injuries
surgically. Neer found that although distal third clavicle fractures are rare, they account for approximately half of all
clavicular nonunions.
[38]
Many different procedures have been described to fix these fractures, and intramedullary
fixation is gaining popularity. However, a problem exists with migration of intramedullary wires.
Many articles have been published focusing on the treatment of distal third clavicle fractures. As mentioned
previously, these injuries account for about 12-15% of all clavicle fractures.
[39]
Type I fractures
Fractures of the distal clavicle are further divided into types I-III. In type I injuries, the coracoclavicular ligaments
are intact and the fracture is usually minimally displaced or nondisplaced. The first image below illustrates
displacing forces; the second image illustrates a type I fracture.
The displacing f orces on a distal clavicle f racture.
Type I f racture of the distal clavicle (group II). The intact ligaments hold the f ragments in place.
Type I fractures, as well as type III fractures (discussed below), are treated symptomatically with ice, analgesics,
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and a sling for support. Early motion with passive shoulder range-of-motion exercises is strongly urged to prevent
the development of degenerative arthritis and to reduce the risk of adhesive capsulitis.
Type II fractures
Type II fractures are at the level of the coracoclavicular ligaments and are further subdivided into IIA and IIB
fractures, as follows:
Type IIA - The conoid and trapezoid ligaments remain intact and the fracture is medial to the ligaments
Type IIB - These involve a disruption of the conoid ligament, with the trapezoid ligament remaining intact
and attached to the distal fracture fragment; included in the IIB fracture is the more rare variant in which
both the conoid and trapezoid are ruptured
Type IIB injuries tend to have significant displacement of the fracture fragments because of the loss of the
downward restraint of the medial fragment by the coracoclavicular ligaments. Type II fractures are depicted in the
images below.
A type II distal clavicle f racture. In type IIA, both conoid and trapezoid ligaments are on the distal segment, while the proximal segment,
without ligamentous attachments, is displaced.
A type IIB f racture of the distal clavicle. The conoid ligament is ruptured, while the trapezoid ligament remains attached to the distal
segment. The proximal f ragment is displaced.
Operative treatment
Many techniques of surgical fixation of distal clavicle fractures have been described in the literature. In general,
surgical fixation is recommended for type II distal clavicle fractures. Treatment of these fractures requires direct
visualization and reduction of the fracture fragments through a vertical incision. After the fracture is visualized and
reduced, the coracoclavicular interval is stabilized.
[40]
Stable fracture fixation can be achieved in many ways, including through combinations of a coracoclavicular screw,
Dacron or Mersilene tape, tension banding, a Kirschner wire (K-wire), and clavicular plates. Regardless of the
exact technique used, the general principles of fracture reduction and fixation and stabilization of the
coracoclavicular interval apply.
Orthopedic consultation before 72 hours is recommended for type IIB clavicle fractures, because these injuries
have a 30% incidence of nonunion and may require surgical repair.
[10]
If surgery is delayed, the results of
treatment may be more problematic.
[41]
Chen et al reported that 10 of 11 patients had good to excellent results with their repair technique for type IIB
fractures. This procedure involves reconstruction of the conoid ligament with Mersilene tape, with the torn ligament
being primarily repaired as well. The fracture is fixed with a number 7 or smaller steel wire. The wire fixation and
the Mersilene tape provide stability for the fracture, allowing the repaired coracoclavicular ligament to heal.
[42]
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All fractures in Chen's study united within 6 months, and 10 of 11 fractures maintained the coracoclavicular
reduction. Nine of the 11 patients had full pain relief and restoration of their full range of motion, and 10 of the
patients were satisfied with the surgery and stated they would undergo the procedure again for treatment of this
fracture.
Kao et al reported on an operative technique with which 11 of 12 fractures formed bony unions, with these patients
experiencing pain-free range of motion. The study included 7 patients with displaced type IIA fractures and 3
patients with type IIB fractures; all of them underwent open reduction and internal fixation with Kirschner wires (K-
wires) and a tension band.
[43]
Also included were 2 patients with comminuted distal clavicle fractures. Kao et al's
technique spared the soft tissue around the fracture site, including the AC joint, with dissection limited only to the
fracture site.
Another surgical option for distal clavicle fractures involves using a Dacron arterial graft as a sling around the
medial fracture fragment and the coracoid. This acts to stabilize the medial fragment in a reduced position in the
superior/inferior plane. This procedure was performed on 11 acute distal clavicle fractures, all of which united with
full range of motion.
Four other patients included in this study were previously diagnosed as having established nonunions. These
patients underwent fixation of the nonunion with a lag screw, iliac crest bone grafting, and stabilization with a
Dacron sling. All of the patients subsequently developed bony union of the fracture site with full range of motion. Of
note, the Dacron sling did cause some slight erosion of the clavicle that was in contact with the sling; however,
this did not progress and did not cause any problems for the patients. The sling is also thought to allow for the
return of function of the coracoclavicular ligaments. Once the coracoclavicular ligaments reconstitute, the Dacron
sling becomes redundant.
The use of Wolter clavicular plates for unstable, comminuted distal clavicle fractures was reported to result in good
bony union and range of motion in all 16 patients in a series by Mizue et al.
[44]
This procedure, however, requires a
second operation for removal of the plate and is recommended only for injuries that are severely comminuted and
unstable.
Type III fractures
Type III injuries are distal to the coracoclavicular ligaments and involve the acromioclavicular (AC) joint. These
fractures are usually minimally displaced or nondisplaced and are treated nonoperatively, as previously described.
Group III Fractures
Current management of medial clavicle fractures remains nonoperative, including with ice, analgesics, and a sling
for support, and the treatment results have been consistently good. Significant displacement is rare because of the
extensive ligamentous attachments. However, if significant displacement occurs with this fracture, further imaging
studies are warranted. A CT scan should help to define the nature of the fracture displacement and the status of
the nearby neurovascular structures.
Group III fractures may be associated with intrathoracic injuries or the development of late complications, such as
arthritis.
[45]
Physical Therapy
Once the fracture pain begins to subside and the patient is weaning off pain medications, begin range-of-motion
exercises with the shoulder and elbow out of the sling to prevent stiffening of these joints. Exercises should be
performed within the limits of comfort.
As pain continues to improve, isometric exercises of the shoulder girdle and arm musculature can begin. These
can be performed under the supervision of a physical therapist or by the patient on his or her own, with an
instructional handout for guidance.
As fracture healing progresses, based on clinical and radiographic examination findings, isotonic exercises can
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begin using light weights or elastic bands for resistance.
Activity
For athletes, return to play depends on the location and severity of the clavicle fracture, the degree of clinical and
radiographic healing, and the sport played.
Noncontact sports
Return to noncontact sports is allowed when (1) the clavicle fracture is healed (ie, no tenderness is present, and
radiographs show callus formation) and (2) the patient has full, painless range of motion and has regained near-
normal strength. These milestones are usually reached at about 6 weeks from the time of the injury.
Contact sports
Return to contact sports takes much longer because the risk of refracture is high. The return to play should be
delayed until the fracture union is solid, which can take from 2-6 months from the time of the injury or 4-6 weeks
after clinical and radiographic union. A donut pad or fiberglass shoulder shell may be used for extra protection.
Maintenance Phase
Rehabilitation Program

Contributor Information and Disclosures
Author
Kevin J Eerkes, MD Clinical Assistant Professor, Department of Medicine, New York University School of
Medicine; Medical Team Physician, New York University Athletics
Disclosure: Nothing to disclose.
Coauthor(s)
Janos P Ertl, MD Assistant Professor, Department of Orthopedic Surgery, Indiana University School of
Medicine; Chief of Orthopedic Surgery, Wishard HospitalChief, Sports Medicine and Arthroscopy, Indiana
University School of Medicine
Janos P Ertl, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons,
American Orthopaedic Association, Hungarian Medical Association of America, and Sierra Sacramento Valley
Medical Society
Disclosure: Nothing to disclose.
John B Mitchell, MD Consulting Staff, Department of Orthopedics, Kaiser Permanente
Disclosure: Nothing to disclose.
Chief Editor
Craig C Young, MD Professor, Departments of Orthopedic Surgery and Community and Family Medicine,
Medical Director of Sports Medicine, Director of Primary Care Sports Medicine Fellowship, Medical College of
Wisconsin
Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians,
American College of Sports Medicine, American Medical Society for Sports Medicine, and Phi Beta Kappa
Disclosure: Nothing to disclose.
Additional Contributors
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Lawrence C Brilliant, MD Clinical Assistant Professor, Department of Primary Care and Community Services,
MCP Hahnemann University; Attending Physician, Department of Emergency Medicine, Doylestown Hospital
Lawrence C Brilliant, MD is a member of the following medical societies: American College of Emergency
Physicians
Disclosure: Nothing to disclose.
Francis Counselman, MD, FACEP Chair, Professor, Department of Emergency Medicine, Eastern Virginia
Medical School
Francis Counselman, MD, FACEP is a member of the following medical societies: Alpha Omega Alpha,
American College of Emergency Physicians, Association of Academic Chairs of Emergency Medicine
(AACEM), Norfolk Academy of Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Amir Estephan, MD Resident Physician, Department of Emergency Medicine, Kings County Hospital Center,
Brooklyn
Amir Estephan, MD, is a member of the following medical societies: Alpha Omega Alpha, American College of
Emergency Physicians, and Emergency Medicine Residents Association
Disclosure: Nothing to disclose.
Joseph P Garry, MD, FACSM, FAAFP Associate Professor, Department of Family and Community Medicine,
University of Minnesota Medical School
Joseph P Garry, MD, FACSM, FAAFP is a member of the following medical societies: American Academy of
Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, and
Minnesota Medical Association
Disclosure: Nothing to disclose.
Henry T Goitz, MD Academic Chair and Associate Director, Detroit Medical Center Sports Medicine Institute;
Director, Education, Research, and Injury Prevention Center; Co-Director, Orthopaedic Sports Medicine
Fellowship
Henry T Goitz, MD is a member of the following medical societies: American Academy of Orthopaedic
Surgeons and American Orthopaedic Society for Sports Medicine
Disclosure: Nothing to disclose.
Robert J Gore, MD Clinical Assistant Professor, Attending Physician, Assistant Residency Director,
Department of Emergency Medicine, Kings County/State University of New York Downstate Hospital
Robert J Gore, MD is a member of the following medical societies: American College of Emergency Physicians,
National Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Benjamin P Kleinhenz, MD Resident Physician, Department of Orthopedic Surgery, Wright State University
Boonshoft School of Medicine
Benjamin P Kleinhenz, MD is a member of the following medical societies: American Academy of Orthopaedic
Surgeons and American Medical Association
Disclosure: Nothing to disclose.
Matthew W Lawless, MD Assistant Professor of Orthopedic Surgery, Wright State University School of
Medicine; Consulting Surgeon, Department of Orthopedic Surgery, Miami Valley Hospital and Dayton Veterans
Affairs Medical Center
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Matthew W Lawless, MD is a member of the following medical societies: American Academy of Orthopaedic
Surgeons
Disclosure: Nothing to disclose.
Pekka A Mooar, MD Professor, Department of Orthopedic Surgery, Temple University School of Medicine
Pekka A Mooar, MD is a member of the following medical societies: American Academy of Orthopaedic
Surgeons
Disclosure: Nothing to disclose.
L Joseph Rubino, MD Assistant Professor, Department of Orthopedic Surgery, Wright State University
L Joseph Rubino, MD is a member of the following medical societies: Alpha Omega Alpha, American
Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, and Mid-America
Orthopaedic Association
Disclosure: Nothing to disclose.
Tom Scaletta, MD Chair, Department of Emergency Medicine, Edward Hospital; Past-President, American
Academy of Emergency Medicine
Tom Scaletta, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center
College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Medscape Salary Employment
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