IntroductionEpidemiologyincidenceclavicle fractures make up 5-10% of all fracturesdemographicsoften seen in young active patientsPathophysiologymechanismdirect blow to lateral aspect of shoulderfall on an outstretched arm or direct traumapathoanatomyin displaced fractures SCM and trapezius muscles pull the medial fragment posterosuperiorly, while pectoralis major and weight of arm pull the lateral fragment inferomedially open fractures buttonhole through platysmaAssociated injuriesare rare but includeipsilateral scapula fracturescapulothoracic dissociationshould be considered with significantly displaced fracturesrib fracturepneumothoraxneurovascular injuryPediatric Clavicle fracturesfracture patterns includemedial/middle/lateral fractures (listed below)medial clavicle physeal injury distal clavicle physeal injury treatmentpediatric distal clavicle fractures are typically treated non-operatively because of the great osteogenic capacity of the intact inferior periosteum. Relevant AnatomyAcromioclavicular Joint Anatomy AC joint stability acromioclavicular ligamentprovides anterior/posterior stabilityhas superior, inferior, anterior, and posterior componentssuperior ligament is strongest, followed by posteriorcoracoclavicular ligaments (trapezoid and conoid)provides superior/inferior stabilitytrapezoid ligament inserts 3 cm from end of clavicleconoid ligament inserts 4.5 cm from end of clavicle in the posterior borderconoid ligament is strongestcapsule, deltoid and trapezius act as additional stabilizers

Classification

Group I - Middle third (80-85%)NondisplacedLess than 100% displacementNonoperative

DisplacedGreater than 100% displacementNonunion rate of 4.5%Operative

Group II - Neer Classification of Lateral third (10-15%)Type IFracture occurs lateral to coracoclavicular ligaments (trapezoid, conoid) or interligamentousUsually minimally displacedStable because conoid and trapezoid ligaments remain intactNonoperative

Type IIAFracture occurs medial to intact conoid and trapezoid ligamentMedial clavicle unstableUp to 56% nonunion rate with nonoperative managementOperative

Type IIBFracture occurs either between ruptured conoid and intact trapezoid ligament or lateral to both ligaments tornMedial clavicle unstableUp to 30-45% nonunion rate with nonoperative managementOperative

Type IIIIntraarticular fracture extending into AC jointConoid and trapezoid intact therefore stable injuryPatients may develop posttraumatic AC arthritisNonoperativexType IVA physeal fracture that occurs in the skeletally immatureDisplacement of lateral clavicle occurs superiorly through a tear in the thick periosteumClavicle pulls out of periosteal sleeveConoid and trapezoid ligaments remain attached to periosteum and overall the fracture pattern is stableNonoperativexType VComminuted fractureConoid and trapezoid ligaments remain attached to comminuted fragmentMedial clavicle unstableOperativexGroup III - Medial third (5-8%)Anterior displacement

Most often non-operativeRarely symptomaticNonoperative

Posterior displacementRare injury (2-3%)Often physeal fracture-dislocation (age < 25)Stability dependent on costoclavicular ligamentsMust assess airway and great vessel compromiseSerendipity radiographs and CT scan to evaluateSurgical management with thoracic surgeon on standbyOperative

PresentationSymptomsshoulder painPhysical examdeformityperform careful neurovascular examexamine skinImagingRadiographsstandard AP view45 cephalic tilt determine superior/inferior displacement45 caudal tilt determines AP displacementCTmay help evaluate displacement, shortening, comminution, articular extension, and nonunionuseful for medial physeal fractures and sternoclavicular injuriesTreatmentNonoperative sling immobilization with gentle ROM exercises at 2-4 weeksindicationsnondisplaced Group I (middle third)stable Group II fractures (Type I, III, IV)nondisplaced Group III (medial third)pediatric distal clavicle fractures (skeletally immature)outcomesnonunion (1-5%) risk factors for nonunionGroup II (up to 56%)comminutionfracture displacement & shortening (>2 cm)advanced age and female genderdecreased shoulder strength and endurance seen with displaced midshaft clavicle fracture healed with > 2 cm of shorteningOperativeopen reduction internal fixationindications absoluteunstable Group II fractures (Type IIA, Type IIB, Type V)open fxsdisplaced fracture with skin tenting subclavian artery or vein injuryfloating shoulder (clavicle and scapula neck fx)symptomatic nonunionposteriorly displaced Group III fxsdisplaced Group I (middle third) with >2cm shortening relative and controversial indicationsbrachial plexus injury (questionable b/c 66% have spontaneous return)closed head injuryseizure disorderpolytrauma patientoutcomesimproved results with ORIF for clavicle fractures with >2cm shortening and 100% displacementoutcome results improved functional outcome / less pain with overhead activity faster time to uniondecreased symptomatic malunion rate improved cosmetic satisfactionimproved overall shoulder satisfactionincreased shoulder strength and enduranceincreased risk of need for future proceduresimplant removaldebridement for infectioncoracoclavicular ligament repair vs reconstructionindicationindicated in group IIb and group III fractures with ligamentous injuryTechniquesSling Immobilizationtechniquesling or figure-of-eight (prospective studies have not shown difference between sling and figure-of-eight braces) after 2-4 weeks begin gentle range of motion exercisesno attempt at reduction should be madecomplications of nonoperative treatmentnonunion (1-5%)treatment of nonunionif asymptomatic, no treatment necessaryif symptomatic, ORIF with plate and bone graft (particularly atrophic nonunion) Open Reduction Internal Fixationsurgical techniqueplate and screw fixationsuperior vs anterior plating superior plating biomechanically higher load to failure and bendingsuperior plating better for inferior bony comminutionsuperior plating has higher risk of neurovascular injury during drillinglimited contact dynamic compression plate3.5mm reconstruction plate locking plates precontoured anatomic plates lower profile needing less chance for removal surgeryintramedullary screw or nail fixation higher complication rate including hardware migrationhook plate AC joint spanning fixationpostoperative rehabilitationsling for 7-10 days followed by active motionstrengthening at ~ 6 weeks when pain free motion and radiographic evidence of unionfull activity including sports at ~ 3 monthscomplications (~10% to 30%)hardware complications~30% of patient request plate removalsuperior plates associated with increased irritationneurovascular injury (3%)superior plates associated with increased risk of subclavian artery or vein penetrationadhesive capsulitis4% in surgical group develop adhesive capsulitis requiring surgical intervention nonunion (1-5%)infection (~4.8%)mechanical failure (~1.4%)Coracoclavicular ligament repair vs reconstructiontechniqueprimary repair can be donemost add supplementary suture (mersilene tape, fiberwire, ethibond) tied around coracoid and either into or around clavicle