You are called by A+E to assess a 22 year old male who was playing rugby and has sustained the following injury. He has no past medical history.
This is an AP and clavicular view plane film radiograph of an patient left clavicle. There are no patient identifiers, the patient appears to be skeletally mature. The X-Ray was taken on an unknown date at an unknown time. There is a completely displaced middle 1/3rd (Allman 1) clavicular fracture. There is shortening >2cm (pectoralis and latissimus dorsi). The lateral fragment is displaced inferiorly (weight of arm via coracoclavicular ligaments). The medial fragment is displaced superiorly (sternocleidomastoid).
Proximal (medial fragment)
- Superior pull – Sternocleidomastoid
- Medial pull – Sternoclavicular ligaments
Distal (Lateral fragment)
- Medial pull (shortening) – pectoralis and latissimus muscle
- Inferior – weight of arm
- Shortening – trapezius
I would assess this patient using ATLS principles.
I would ensure there are no life threating injuries by securing the patient’s cervical spine and assessing the patients’ airway, breathing, circulation, disability. Following this I would examine the patient from head to toe to rule out any other injuries.
I would then examine the clavicle looking for any skin tenting/compromise, double checking there are no signs of pneumothorax and checking the neurovascular status of the limb.
I would take a full history including: hand dominance, mechanism of injury, occupation and smoking.
I would place the patient into a broad arm sling, provide analgesia and discuss the patient in the trauma meeting.
- Neurovascular damage (subclavian artery/vein and brachial plexus)
- Lung – pneumothorax
- Scapular fracture
- Rib fracture
- Open/impending open fractures
- Subclavian artery or venous injury
- Floating shoulder
- Symptomatic non/mal-union
- >2cm shortening
- Heavy comminution
- Polytrauma patient
Middle 1/3rd 80% (thinnest part of the bone and has no ligamentous attachments)
Lateral 1/3rd 15%
Medial 1/3rd 5%
- Hardware irritation
- NV injury – supraclavicular nerve
- Adhesive capsulitis
- Non union
Middle third (80%)
Lateral third (15%)
Medial third (5%)
Neer’s classification for Allman 2 or Lateral 1/3rd clavicle fractures
Stable. Minimally displaced and sits lateral to the coracoclavicular ligaments.
Unstable. Sits medial to the coracoclavicular ligaments. Conoid and trapezoid ligaments intact.
Unstable. The fracture occurs between the coracoclavicular ligament resulting in the conoid ligament torn and trapezoid ligament intact.
Stable. Intra-articular distal clavicular fracture extending into the acromioclavicular joint.
Stable. Physeal fracture in skeletally immature patients.
Unstable. Comminuted fracture.
- Lower rates of symptomatic mal-union
- Faster return to activity
- Cosmetic satisfaction
- Less pain with overhead activities
- Increased shoulder strength/endurance
- Improved shoulder satisfaction
Concurrent clavicle and scapular neck fracture
Canadian Operative Trauma Society (2007 BJJ) conducted a RCT with 132 patients looking a nonoperative vs operative management of midshaft clavicle fractures. The operative group had fewer non-unions (2% vs 15%), fewer mal-unions, and quicker time to union and more satisfaction at 1 year.
Patient included in the study were:
- Aged between 16 and 60
- Had completely displaced mid (middle third) clavicular fractures
- No contraindications to a GA
Skin sensation over the upper chest and shoulder.
- 7-10 days sling
- Pendulum exercises
- Strengthening at 6 weeks (pain free motion and evidence of union)
- Return to sports including at 3 month