The clavicle is an s-shaped bone that ties the appendicular skeleton to the axial skeleton. It serves as the only direct bony attachment of the arm to the trunk. Embryonically, the central clavicle ossifies first, providing most of the linear growth for the first 5 years of life. After 5 years of age, the medial and lateral physeal plates develop. The medial physeal plate is responsible for the majority of the remaining clavicle growth until adulthood. The medial physis eventually closes by 25 years of age.
Clavicle fractures are common injuries for active adults and children. Determination of a clavicle fracture is often not difficult when an appropriate history and examination is completed. X-rays, often are used only as a validation of the initial, history-based diagnosis. Most clavicular fractures heal very well with appropriate bracing and do not require surgical intervention.
Clavicle fractures account for approximately 5% of all fracture types. The incidence of clavicle fractures seems to be increasing; this may be due to increasing participation in contact sports and/or increasing motor vehicle accidents.
The most common mechanism of injury for a clavicle fracture is falling on the tip of the shoulder or a direct blow to the front of the shoulder. Additionally, a fall on the outstretched arm may result in a clavicle fracture. Studies have also shown that the mechanism of injury does not correlate to the location of the fracture.
Clavicle fractures were first classified by Dr. FL Allman in 1967. The fractures are classified relative to where the injury has occurred. This graphic shows the Allman classification of clavicle fractures. Group 1 fractures account for approximately 80% of all fractures. Group 2 fractures represent 12% - 15%. And, Group 3 fractures are the least common, accounting for approximately 5% - 7% of clavicle fractures.
The athlete will present with a history of a fall or a blow to the shoulder. The athlete may have heard or felt a “pop”, “snap”, or “crack” during the injury. The athlete then describes the mechanism of injury followed by localized pain, swelling, crepitus with movement and an increasing loss of shoulder motion.
The athlete will hold the arm hanging “pinned against the side” or will support the elbow and forearm with the opposite hand. Visually, there may be a deformity noticed along the clavicle. Palpation of the deformity will elicit focal pain, crepitus, and occasionally motion. The skin may be “tented” if the fracture is displaced. Rarely is an open clavicle fracture seen.
If the fracture is nondisplaced, a bump or deformity may not be present. However, palpation of the fracture site and active shoulder motion should still produce focal pain at the fracture site.
Neurological damage is rare with clavicle fractures. However, if the fracture is severely displaced, damage can occur to the medial cord of the brachial plexus. Due to this possibility, a neurological examination should be performed to rule out Ulnar nerve dysthesia.
Plain film radiographs are used to confirm the history based diagnosis, evaluate fracture position and alignment, classify the fracture, and to follow healing on follow-up visits. Most physicians will order a standard shoulder series consisting of: an anteroposterior (AP) view with the humerus in internal rotation, an AP view with the humerus in external rotation, an axillary lateral view, and a scapulolateral view.
The AP view will best visualize the fractured clavicle. As seen in the x-rays, the clavicle fracture is easily visualized. This is an example of a displaced Group 1 fracture.
Treatment of most clavicle fractures is very straight forward. The athlete is placed in a sling and swath or a figure 8 brace to immobilize the arm. If the fracture is not displaced significantly, a simple sling (with or without a swath) provides ample protection of the fracture to allow for healing.
The treating physician may use a figure 8 brace with a displaced fracture. The figure 8 brace holds the shoulders in a retracted position. This pulls the clavicle into a “normal” alignment to help reduce the displaced fracture. The figure 8 brace should be tightened periodically during the day to maintain traction. Excessive tightening of the brace can lead to skin lesions, edema from venous obstruction and brachial plexus palsy.
Rehabilitation begins immediately after the injury. Early rehab should focus on pain reduction, swelling reduction, range of motion exercises, and gentile strengthening. All of the rehabilitation exercises should follow the adage “use pain as your guide.”
During the acute phase of the healing process strength and ROM activities should be performed for the fingers, wrist, and elbow. Gripping exercises, wrist curls, and elbow flexion and extension will help to reduce swelling in the lower arm that results from the injury and use of a sling.
As pain in the shoulder declines and healing is demonstrated on x-ray (usually 2 to 3 weeks post injury), shoulder exercises for ROM may begin. As the healing progresses and pain decreases the rehabilitation advances to strength building exercises.
Athletes who suffer clavicle fractures will return to full athletic participation with little morbidity. Full return in children is expected in 6 weeks. Full return for adolescents and adults is usually 6 to 12 weeks.
©2000 - 2009 David Edell
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Last Update for AthleticAdvisor.com: 10/24/2009 12:09:35 AM