Clavicle Fracture

Clavicle fractures are common and are divided according to anatomical location:

Middle third, approximately 70% to 80%
Distal third
Medial third

Most fractures occur after direct impact to the shoulder.

The middle third is most vulnerable because it is narrow, lacks muscular reinforcement and lies between the stabilising ligamentous complexes.

Allman classification

Group I

Middle third fracture.

Group II

Distal third fracture.

Group III

Medial third fracture.

The classification is anatomical but does not adequately describe stability of distal fractures.

Modified Neer classification for distal clavicle fractures

The relationship between the fracture and coracoclavicular ligaments determines stability.

Type I

Fracture lateral to the coracoclavicular ligaments.

Ligaments remain intact.

Usually minimally displaced and stable.

Type IIA

Fracture medial to the coracoclavicular ligaments.

Conoid and trapezoid remain attached to the distal fragment.

The proximal fragment displaces because it has lost coracoclavicular restraint.

Unstable.

Type IIB

Fracture occurs around the coracoclavicular ligament complex with loss of effective conoid restraint.

Unstable and associated with high nonunion risk.

Type III

Fracture extends into the acromioclavicular joint but coracoclavicular ligaments remain intact.

Usually stable.

Type IV

Paediatric physeal injury with intact periosteal sleeve.

Type V

Comminuted distal fracture with an inferior fragment attached to the coracoclavicular ligaments while the medial fragment is displaced.

Unstable.

Types I, III and many IV injuries are usually stable. Types II and V are mechanically unstable and have higher nonunion rates.

Patients present with pain, swelling and visible deformity.

Midshaft fractures commonly produce:

Inferior displacement of the shoulder
Superior displacement of the medial fragment from sternocleidomastoid pull
Inferomedial displacement of the lateral fragment from arm weight

Inspect for:

Skin tenting
Open wound
Neurological deficit
Diminished upper limb pulses

Severe posterior displacement or high energy trauma should prompt assessment of the subclavian vessels and brachial plexus.

Associated injuries include:

Rib fractures
Pneumothorax
Scapular fracture
Acromioclavicular injury
Floating shoulder

Medial clavicle fractures require careful differentiation from sternoclavicular injury.

Nonoperative treatment

Most minimally displaced clavicle fractures are treated with a simple sling.

Early elbow, wrist and hand movement is encouraged.

Begin shoulder pendulum and progressive motion according to pain.

Figure of eight braces do not provide a clear functional advantage over sling treatment and are less comfortable.

Midshaft fracture

Nondisplaced and minimally displaced fractures usually heal reliably without surgery.

Displaced adult midshaft fractures require an individual decision.

Features favouring fixation include:

Open fracture
Threatened skin
Neurovascular injury
Floating shoulder
Marked displacement
Significant comminution
Shortening roughly above 2 cm
High functional demand
Symptomatic nonunion

Operative treatment of displaced adult midshaft fractures produces higher union rates and better early patient reported outcomes than nonoperative care, although long term differences diminish and surgery introduces implant related complications.

Plate fixation

Provides reliable restoration of:

Length
Rotation
Alignment

The plate can be positioned superiorly or anteroinferiorly according to fracture morphology and surgeon preference.

Protect the supraclavicular nerves where possible to minimise postoperative numbness.

Avoid excessive periosteal stripping.

Hardware prominence is common and may lead to later removal.

Intramedullary fixation

An intramedullary clavicle device can provide equivalent long term clinical outcomes to plate fixation in selected simple or wedge midshaft patterns.

It is less suitable for severe comminution requiring precise restoration of length.

Distal clavicle

Stable Neer type I and III fractures are generally treated nonoperatively.

Unstable type II and V fractures have substantially greater nonunion risk and often benefit from operative stabilisation in active patients.

Options include:

Distal clavicle locking plate
Coracoclavicular fixation
Combined plate and ligament stabilisation
Hook plate in selected situations

When the distal fragment is large enough for fixation, a lateral locking plate generally produces fewer implant related problems than a hook plate.

Medial clavicle fracture

Most are treated nonoperatively.

A significantly displaced fracture with posterior displacement threatening mediastinal structures requires specialist surgical assessment.

Paediatric and adolescent fracture

Most clavicle fractures in skeletally immature patients are managed nonoperatively, even with substantial displacement, because remodelling potential is high.

Routine fixation of displaced adolescent midshaft fractures has not demonstrated the same clear benefit seen in adults.

Rehabilitation

Sling use is primarily for comfort rather than rigid immobilisation.

Progress:

Pendulum movement
Assisted range of motion
Active range of motion
Strengthening after clinical and radiological union

Avoid contact sport and heavy loading until union is secure.

Complications include:

Nonunion
Symptomatic malunion
Neurovascular injury
Pneumothorax in high energy trauma
Hardware irritation
Supraclavicular sensory numbness
Refracture after implant removal

Persistent pain with movement several months after fracture should prompt investigation for nonunion rather than indefinite reassurance.

Clinical toolsCalculators

BMI GCS EDD Parkland Formula

Corrected Sodium Corrected Calcium Anion Gap Creatinine Clearance Insulin Calculations qSOFA Wells PE Wells DVT CHA₂DS₂-VASc HAS-BLED CURB-65 Centor/McIsaac

Olecranon Fracture

An olecranon fracture is an intra articular fracture of the proximal ulna involving the trochlear notch and insertion of the triceps mechanism.

The olecranon performs three major functions:

Forms the proximal trochlear articulation
Provides a posterior buttress preventing anterior translation of the ulna
Serves as the insertion of the triceps tendon

Treatment therefore depends on both articular congruity and integrity of the extensor mechanism.

Mechanisms include:

Direct impact onto the posterior elbow, commonly producing comminution
Indirect injury from sudden triceps contraction, commonly producing a transverse fracture
High energy fracture dislocation

Mayo classification

The Mayo classification is based on displacement, comminution and ulnohumeral stability.

Type I: Nondisplaced

Displacement below approximately 2 to 3 mm and a stable elbow.

Nondisplaced, noncomminuted.

Nondisplaced, comminuted.

Type II: Displaced but stable

The fracture is displaced, but the ulnohumeral articulation remains stable.

IIA

Displaced, noncomminuted.

IIB

Displaced and comminuted.

Type III: Displaced and unstable

The fracture is associated with ulnohumeral instability or fracture dislocation.

IIIA

Unstable, noncomminuted.

IIIB

Unstable and comminuted.

Mayo IIA is the classical simple displaced transverse fracture suitable for compression or tension band principles, whereas IIB and III injuries generally require plate fixation.

Associated injuries

Look for:

Radial head fracture
Coronoid fracture
Monteggia type injury
Elbow dislocation
Collateral ligament injury

A transolecranon fracture dislocation is different from a Monteggia injury. The proximal radioulnar relationship remains intact, but the forearm translates through the comminuted trochlear notch.

Patients present with posterior elbow pain, swelling and haemarthrosis.

A palpable gap may be present.

Assess active elbow extension.

Loss of active extension suggests disruption of the extensor mechanism, although pain can make examination unreliable.

Inspect carefully for an open wound because the olecranon has minimal posterior soft tissue coverage.

Document:

Ulnar nerve function
Median nerve function
Radial nerve function
Radial and ulnar pulses

Nonoperative treatment

Appropriate for:

Mayo type I fractures
Intact extensor mechanism
Stable elbow

Selected frail, low demand older patients with displaced but stable fractures may also be treated nonoperatively when the morbidity of fixation outweighs the benefit. Functional outcomes can remain acceptable despite a fibrous nonunion.

Use brief posterior splint immobilisation followed by early range of motion.

Avoid prolonged immobilisation because the elbow develops stiffness rapidly.

Operative indications

Operate for:

Displaced fracture in an active patient
Loss of active extension
Articular incongruity
Unstable fracture
Open fracture
Fracture dislocation
Failure of nonoperative treatment

Simple transverse fracture

Mayo IIA fractures can be treated with:

Tension band fixation
Intramedullary screw with tension band augmentation
Plate fixation

Tension band constructs rely on an intact anterior cortex and a simple fracture that can be compressed.

Do not use tension band wiring for severe comminution, distal extension or unstable fracture dislocation.

Classic K wire tension bands are effective but frequently produce symptomatic posterior metalwork. Plate fixation has lower rates of hardware related reoperation in several comparative series.

Comminuted fracture

Mayo IIB and most type III fractures require precontoured proximal ulna plate fixation.

Reconstruct:

Trochlear notch
Olecranon length
Proximal ulna alignment
Coronoid where involved

Avoid narrowing or distortion of the trochlear notch.

Small depressed articular fragments may require elevation and support.

Fragment excision

Excision of the proximal fragment with triceps advancement has a limited role.

Consider only when:

Elderly low demand patient
Severe osteoporotic comminution cannot be reconstructed
Less than approximately 50% of the olecranon articular surface would be removed
Elbow remains stable

Avoid this strategy in young or active patients and in fracture dislocations because removal reduces posterior elbow stability.

Postoperative care

Stable fixation should permit early elbow motion.

Protect active resisted extension initially while the fracture heals.

Major complications include:

Symptomatic hardware
Elbow stiffness
Loss of extension
Ulnar nerve symptoms
Post traumatic arthritis
Infection
Nonunion
Fixation failure

Clavicle Fracture

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management