Summary

Clavicle fractures are the most common fracture of the shoulder girdle (4% of all adult fractures). The vast majority (80%) occur in the Middle Third (Allman Type I). Management has evolved significantly following the COTS Trial, which showed that while plating reduces non-union rates in displaced fractures, it comes with a high re-operation rate for hardware removal. Currently, surgery is recommended for shortening >2cm, displacement >100%, or "Floating Shoulder". Lateral end fractures (Neer Type II) are inherently unstable due to coracoclavicular ligament disruption and require fixation (Hook Plate or Button). [1,2,3]

Key Facts

• Most Common Mechanism: Direct blow to the shoulder (87%). Not FOOSH.
• Deforming Forces:
  • Medial Fragment: Pulled UP by Sternocleidomastoid (SCM).
  • Lateral Fragment: Pulled DOWN and IN by Pectoralis Major + weight of arm.
• Emergency: Skin Tenting. If the bone spikes the skin and blanches it white, it will necrose and become an Open Fracture within hours. Immediate reduction is required.

Clinical Pearls

"Check the Chest": The clavicle protects the apex of the lung and the subclavian vessels. Always auscultate the chest for a pneumothorax and palpate the distal pulses.

"The Z Deformity": In midshaft fractures, the fragments overlap, creating a Z-shape. The shortening pulls the shoulder girdle forward and seemingly shortens the chest width.

"Hook Plates Hurt": If you put a Hook Plate in for a Lateral fracture, tell the patient DAY ONE that it must come out in 3-4 months. It impinges on the rotator cuff and acromion during abduction.

                 CLAVICLE FRACTURE
                        ↓
            TENTING? OPEN? NV INJURY?
            ┌───────────┴───────────┐
           YES                      NO
            ↓                       ↓
         EMERGENCY               LOCATION?
          SURGERY               ┌────┴─────┐
                             MIDSHAFT    LATERAL
                                ↓          ↓
                            DISPLACED?   NEER TYPE?
                            ┌───┴───┐    ┌───┴────┐
                           NO      YES   I       II (Unstable)
                           ↓        ↓    ↓        ↓
                         SLING    SHORTENING    SURGERY
                                    >2cm?     (Hook Plate)
                                  ┌───┴───┐
                                 NO      YES
                                 ↓        ↓
                               SLING   DISCUSS
                                       SURGERY

1. Conservative (Sling)

• Indication: Undisplaced fractures. Displaced midshaft with <2cm shortening. Neer I lateral fractures.
• Device: Simple Broad Arm Sling or Polysling. "Figure-of-8" bandages are abandoned (cause nerve palsy, uncomfortable, no better union rate).
• Protocol:
  • 0-2 Weeks: Sling full time. Elbow ROM.
  • 2-6 Weeks: Wean sling. Active Assist (Pendulum).
  • 6 Weeks: X-ray. If callus -> Full ROM.
  • 3 Months: Contact sports / Heavy lifting.

2. Surgical Fixation (Plate)

• Indications:
  • Absolute: Open, Tenting, NV injury.
  • Relative (The "Grey Zone"): Shortening >2cm, 100% Displacement, Floating Shoulder, Seizure disorder, Polytrauma.
• Technique:
  • Superior Plate: Stronger (tension band side). Prominent (can feel it).
  • Anterior Plate: Less prominent. Safer drilling trajectory (away from lung).
• Outcomes: Faster return to function. Lower non-union rate (2% vs 15%). Plate removal rate 20-50%.

3. Hook Plate (Lateral End)

• Indication: Unstable Lateral (Neer II) fractures where distal fragment is too small for screws.
• Technique: Plate has a hook that goes under the acromion, levering the clavicle down.
• Requirement: Must be removed at 3-6 months.

The COTS Trial (Canadian Orthopaedic Trauma Society, 2007)

• Comparison: Plate vs Sling for Displaced Midshaft Fractures.
• Key Finding 1: Surgery = Better function (DASH Score) at 3, 6, 12 months.
• Key Finding 2: Surgery = Much lower non-union rate (3% vs 24%).
• Key Finding 3: No difference in function at 2 years.
• Conclusion: Surgery speeds up recovery and ensures union, but introduces surgical risks. Offer to active patients.

Robinson (1998)

• Classified 1000 fractures. Showed that non-union is rare (<1%) in undisplaced fractures but significant in displaced ones.

Broken Collarbone

You have snapped the strut that holds your shoulder out.

Do I need surgery?

• The Sling Option: Most heal fine. You will have a permanent bump. Your shoulder might be a bit narrower. There is a 1 in 7 chance it doesn't join (Non-union) and needs surgery later.
• The Surgery Option: We put a metal plate in. The bone is straight immediately. You can move it sooner. But, you have a scar, a numb patch on your chest, and a risk of infection. The plate might annoy you (like a backpack strap rubbing) and need removing later.

What is "Tenting"?

(If applicable) The sharp bone end is pushing against your skin, turning it white. We need to operate TONIGHT to pull it back, otherwise it will poke through the skin and cause a bone infection.

Recovery

No heavy lifting or contact sports for 3 months, regardless of treatment. The bone needs time to turn from "soft glue" into hard bone.

Q1: What are the absolute indications for surgery in a clavicle fracture? A: Open fracture, Skin Tenting (impending open), Neurovascular injury (subclavian vessels/brachial plexus), Floating Shoulder (with displaced scapular neck fracture).

Q2: Describe the Neer Classification for Lateral Clavicle fractures. A: Based on the integrity of the Coracoclavicular (CC) ligaments.

• Type I: Fracture lateral to intact ligaments. Stable.
• Type II: Fracture medial to ligaments (IIA) or between ligaments with Conoid tear (IIB). Unstable (medial fragment elevates). High non-union rate.
• Type III: Intra-articular extension.

Q3: Why is the "Figure of 8" bandage no longer recommended? A: Studies have shown it does not improve alignment or union rates compared to a simple sling, but causes significantly more discomfort and can cause temporary brachial plexus palsies due to axillary compression.

(End of Topic)