Clavicle Fractures — Management

Clavicle fractures are among the most common fractures encountered in orthopaedic practice, accounting for approximately 2–5% of all fractures and nearly 35–45% of shoulder girdle injuries. They are particularly common in young active individuals due to sports injuries and road traffic accidents, but also occur in elderly osteoporotic patients following low-energy falls.

The clavicle acts as a strut between the sternum and scapula, maintaining shoulder alignment and allowing effective transmission of forces from the upper limb to the axial skeleton. Fractures of the clavicle may disrupt this biomechanical relationship and can lead to shoulder dysfunction if not appropriately managed.

Most clavicle fractures occur in the middle third due to the bone’s inherent structural weakness at this location, where the curvature changes and ligamentous support is minimal. Advances in fixation techniques have expanded surgical indications in recent years, especially for displaced fractures.

• Only bony connection between upper limb and axial skeleton
• Acts as a strut maintaining scapular position
• Protects neurovascular structures including subclavian vessels and brachial plexus
• Provides attachment for multiple muscles

Muscle attachments significantly influence fracture displacement. The sternocleidomastoid muscle pulls the medial fragment superiorly, while the weight of the arm and pectoralis major pull the lateral fragment inferiorly and medially.

• 2–5% of all fractures
• 35–45% of shoulder girdle fractures
• Most common in young males
• Bimodal age distribution

Clavicle fractures are classified based on anatomical location and fracture pattern.

Distal clavicle fractures are further classified using the Neer classification, which depends on the integrity of the coracoclavicular ligaments.

• Pain and swelling over clavicle
• Visible deformity or step
• Drooping of affected shoulder
• Reduced shoulder movement
• Tenderness along clavicle

The patient often supports the affected arm with the opposite hand. Skin tenting may be present in significantly displaced fractures.

• X-ray clavicle with AP view
• 15° cephalic tilt view
• CT scan in complex fractures

Radiographs help determine fracture location, displacement, comminution, and shortening.

Management depends on fracture location, displacement, patient activity level, and presence of complications.

• Sling immobilization
• Figure of eight bandage (less commonly used)
• Analgesics
• Early pendulum exercises

Most undisplaced or minimally displaced midshaft clavicle fractures heal successfully with conservative treatment.

Surgical fixation is increasingly recommended for displaced fractures with shortening or comminution.

• Open fractures
• Neurovascular compromise
• Significant displacement
• Shortening greater than 2 cm
• Skin tenting
• Floating shoulder injuries

• Nonunion
• Malunion
• Neurovascular injury
• Hardware irritation
• Infection

• Middle third fractures are most common
• Sternocleidomastoid elevates medial fragment
• Weight of arm displaces lateral fragment downward
• Most undisplaced fractures treated conservatively
• Displacement greater than 2 cm increases nonunion risk