This document provides information on clavicle fractures, including: - Epidemiology: Middle third fractures account for 80% and lateral third fractures 15%. - Treatment: Non-displaced fractures are typically treated non-operatively with slings or braces. Displaced or unstable fractures may require open reduction and internal fixation with plates or intramedullary nails. - Complications: Include nonunion, hardware issues, infection, and injuries to nearby structures like blood vessels or the brachial plexus. Floating shoulder injuries involving both the clavicle and scapular neck often require surgical fixation.

1. CLAVICLE FRACTURE
presented by
Dr. P.Harinagendra

2. CONTENTS OF CLAVICLE FRACTURE
• EPIDEMOLOGY
• ANATOMY
• MECHANISM OF INJURY
• ASSOCIATED INJURIES
• CLINICAL FEATURES
• IMAGING MODALITIES
• TREATMENT

3. EPIDEMOLOGY
• Clavicle fractures account for approximately 2.6% of all fractures &
44-66% fractures above the shoulder.
• Middle third fractures account for 80% of all clavicle fractures
whereas lateral third fractures account for 15% ,&medial third 5%.

4. ANATOMY
• S shape
• Subcutaneous bone
• No true medullary canal .
• 1st bone to ossify and last to fuse.
• Form by intra membranous ossification.
• Medial 1/3rd protects neuro vascular structures and superior lung.it is
strongest in axial load.
• Distal clavicle contains coracoclavicular ligament (trapezoid & conoid
ligaments) which provides verticular stability to Acromioclavicular
joint.
• Middle 1/3rd is the vulnerable area to fracture, especially with axial
loading as it lacks reinforcement by muscles/ ligaments distal to
subclavian insertion resulting in additional vulnerability.

7. MECHANISM OF INJURY
• In infants -1.birth injury
2.child abuse
• In children & adults-1.direct trauma in high velocity injuries
2.fall on outstretched hand.
3.compression force from the lateral side.
• Rarely secondary to muscle contraction due to seizures or secondary
to minor trauma due to pathological bone or stress fracture .

9. DEFORMING FORCES ON CLAVICULAR FRACTURE
• Pectoralis &wt of arm – lateral fragment
inferiomedially
• SCM-medial fragment
posteriosuperiorly

10. ASSOCIATED INJURIES
• Most brachial plexus injuries are associated with proximal third
clavicle fractures(tractional injury).
• Lung injuries like pneumothorax/hemothorax.
• Head and chest injuries.
• Vascular injuries.

11. CLINICAL EVALUATION
• HISTORY:
• c/o Pain, swelling, bruising, decreased movement of the affected limb.
• Examination : Tenderness, crepitus, pressure on overlying skin palpable.
• PRESENTATION:
-Arm held across the chest with the opposite limb.
-Tilts the head towards the injured limb .
-Shoulder ptosis with droopy medially driven and shortened shoulder
-Shoulder translates and rotates forward.
-Observe for complications like :
• neurovascular injury of affected arm,
• pneumothorax, subcutaneous emphysema.
• Open fractures

12. CLASSIFICATION

13. CLASSIFICATION

15. LATERAL THIRD CLAVICLE FRACTURE
( NEER CLASSIFICATION)

16. • TYPE 1:
• MINIMAL DISPLACEMENT
• conoid & trapezoid lig intact
• non operative

17. TYPE-2: DIAPLACED SECONDARILY TO FRACTURE
LINE MEDIAL TO CC LIGAMENT
• Type2 A
• Conoid & trapezoid attached(fracture medial to cc lig )

18. TYPE-2B:
• Conoid torn, trapezoid attached(fracture b/w cc lig)
• operative

19. TYPE-3:
• Fracture of articular surface
• conoid& trapezoid lig intact
• Non operative

20. TYPE -4:
• Periosteal sleeve fracture( in children)
• Conoid& trapezoid lig intact
• nonoperative

21. Type -5:
• Comminuted fracture
• Conoid& trapezoid lig
• attached to communited fragment
• operative

22. • Mechanism of injury
• Associated injuries
• Physical examination
• Imaging modalities
• Applied anatomy
• Treatment options
• Management of complications
Contents of clavicle fracture

23. • In infants
• 1) Birth injury
• 2) child abuse
• In children and Adults
• 1) Direct trauma in high velocity injuries
• 2) fall on out streched hand
• 3) compression force from lateral side
• Non traumatic / simple injures
Mechanism of injuries

24. • Head and chest injuries
• Ipsilateral upper limb injuries
• Lower limb injuries – mobilization
• Lung injuries – pneumo/haemothrax
• Vascular injuries (subclavian)
• Floating shoulder (glenoid neck fractures)
Associated injuries

25. Physical examination
History
Type of injury
1) Simple
- pathologic
- metabolic
2)Direct fall on shoulder
3)Traction injury(dockyard,
industrial injury –scapulothoracic dissociation)
4) Stress fractures

26. • In standing position – deformity
• Clavicle length measurement
• Vascular and neurological examination
• Patient tilts head towards injury to relax pull of trapezius
• Patient holds involved hand close to chest
• Asymmentric moro reflex
• Baby does not feed from one breast
Physical examination

27. Completely displaced mid shaft fracture
• Shoulder “ptosis,” with a droopy, medially driven, and shortened
shoulder
• In addition, the shoulder translates and rotates forward:

28. • Simple ap chest x ray – emergency
Medial clavicle fracture
• Serendipity view -Medial clavicle fracture with dislocation
• Ct scan
• Lateral clavicle fracture
Stress view – for coracoclavicuar integrity
Zanca’s view – for removing thoracic cage overlap
Imaging modalities

29. Serendipity view

31. • Bone anatomy
• The relatively thin diaphysis is typically hard cortical
bone best suited for cortical screws
• whereas the medial and lateral expansions are softer
cancellous bone where larger pitch cancellous screws
can be inserted without tapping.
Applied anatomy

32. • Medial
• Sc capsule- thick posteriorly , prevent to anterior or
posterior translation of the medial clavicle
• Interclavicular ligament- tension wire :
prevents inferior angulation
• Stout ligaments-primarily resist translation of the
medial clavicle
Ligamentous anatomy

33. • Ac capsule joint
• Thickened superiorly prevent AP displacement
• Cc ligaments
• Trapezoid(lateral)
• Conoid (medial) , prevent superior displacement
Lateral ligaments

34. • Deformity is due to muscle pull and gravity effect
• Medial fragment is elevated by sternocleidomastoid
• lateral fragment is held inferiorly by deltoid and
medially by pectoralis major
Muscle anatomy

35. • supraclavicular nerves originate from cervical roots C3 and C4 and
exit from a common trunk behind the posterior border of the
sternocleidomastoid muscle
• Numbness postoperatively
• Neuroma formation
• Vascular structures at risk
- subclavian vessels
Neurovascular anatomy

36. • Medial – opposed to posterior cortex
• Middle – mean distance of 17 and 13 mm
• Lateral – mean distance of 63 and 76 mm

37. • Non operative
 Hippocrates “Edwin smith papyrus’’
 Figure of 8 bandage
- temporary lower trunk injury of brachial plexus injury
 Arm sling
Treatment options

38. • Very rare
• Can be managed non operatively unless posterior
dislocation
• May dislocate
•anterior (more common)
•posterior (mediastinal structures at risk)
•important to distinguish from medial
clavicle physeal fracture (physis doesn't fuse until
age 20-25)
•MECHANISM
•usually high energy injury (MVA, contact sports)
Medial clavicle injuries

39. •Symptoms
•anterior dislocation
•deformity with palpable bump
•posterior dislocations
•dyspnea or dysphagia
•tachypnea and stridor worse when supine
•provocative maneuvers
•turning head to affected side may relieve
pain

40. • Imaging – serenpidity view , ct scan
• It is important to remember that the subclavian vessels are in close
proximity to the bone medially
• Following identification, debridement, and reduction of the fracture,
it can be temporarily held reduced with K-wires
• Definitive plate fixation
Management

41. • If the medial fragment is large enough, then standard
plate and screw fixation can be performed; a plate
with an expanded end section
• this allows for placement of longer (22 to 24 mm)
cancellous screws
• If there is insufficient purchase, than the plate can be
extended across the joint onto the sternum.
• construct will eventually loosen due to motion
• Rarely, fixation with a hook plate intrasternally or
retrosternally may be required

42. • Radiology
zanca view
upright AP of bilateral shoulders
Ct scan – articular extension , vascular injury
Mid shaft fractures

43. Nonoperative
•sling immobilization
•indications
•< 2cm shortening and displacement
•< 1cm displacement of the superior shoulder suspensory complex
•No neuro vascular injury
•technique
•immobilize using sling or figure-of-eight brace
•prospective studies have not shown a difference in functional or
cosmetic outcomes between sling and figure-of-eight braces
•no attempt at reduction should be made
•after 2-4 weeks begin gentle range of motion exercises
•strengthening exercises begin at 6-10 weeks
Management

44. Operative
• External fixation
• Im nailing
• Plating with
 k-wires for preliminary
fixation
 Precontroured
 DCP

45. • This method takes advantage of the intrinsic healing ability of the
clavicle and allows restoration of length and translation without the
scarring or morbidity of a surgical approach
• Unfortunately, the practical difficulties associated with the position
and prominence of the fixation pins, coupled with a lack of patient
acceptance
External fixation

47. • approach
• beach chair or supine
• posterolateral incision 3-4cm
• “retrograde” technique
• instrumentation
• cannulated screw
• specialized screw systems (e.g, Dual Trak)
• titanium elastic nail
• smooth wires
• Locking im nail
• Contraindications
• substantial comminution
• segmental fractures
Closed Reduction and Intramedullary Fixation

50. • advantages
• smaller incision
• less soft-tissue disruption
• less prominent hardware
• avoids the supraclavicular cutaneous nerves commonly
injured with plating
• disadvantages
• higher complication rate including hardware migration,
hardware breakage, temporary brachial plexus palsy, and
skin breakdown over the entry portal
• Since no lock- failure to control axial length and rotation
• biomechanically inferior to plating
• (maximal load, cyclical stress)

51. delayed if required
•approach
•beach chair vs. supine
•direct superior vs. anterior incision
•instrumentation
•most common
•limited contact, pre-controured, dynamic compression plate
•k-wires for preliminary fixation
•Lag screw for vertically oriented anterosuperior fragment
•other options
•3.5mm reconstruction plate
•locking plates
Open Reduction Internal Fixation with plating

52. Anteroinferior
 easier screw trajectory
 ability to insert longer screws in
the wider AP dimension
 easier to contour a small-fragment
compression plate
 plate tends to
 obscure the fracture site
radiographically
Anterosuperior.
• general familiarity
• ability to extend it simply to both
the medial and lateral ends
• benefit of clear radiographic views
of the clavicle postoperatively.
• length of screws inserted range
from 14 to 16 mm in females to 16
to 18 mm in males

53. • If a lag screw has been placed, it is usually sufficient to secure the
fracture with three bicortical screws (six cortices) both proximally and
distally.
• If lag screw not possible, four screws should be inserted both
proximally and distally
• stable configuration, compression holes can be used to apply
compression
• comminuted or of an unstable pattern, then the plate should be
applied in a “neutral” mode
• Valsalva manouere

54. •advantages
•improved results with ORIF for clavicle fractures with > 2cm
shortening and > 100% displacement
•improved functional outcomes/less pain with overhead
activity
•faster time to union
•decreased symptomatic malunion rate
•improved cosmetic satisfaction
•improved overall shoulder satisfaction
•increased shoulder strength and endurance
•disadvantages
•increased risk of need for future procedures
•implant removal
•debridement for infection

56. • Nonoperative
• sling immobilization with gentle ROM exercises at 2-4 weeks and
strengthening at 6-10 weeks
• indications
• stable fractures (Neer Type I, III, IV)
• pediatric distal clavicle fractures (skeletally immature)
Lateral clavicular fractures

57. Operative
•open reduction internal fixation
•indications
•absolute
•open or impending open fractures
•subclavian artery or vein injury
•floating shoulder (distal clavicle and scapula neck fractures
with > 10mm of displacement)
•symptomatic nonunion
•relative
•unstable fracture patterns (Neer Type IIA, IIB, V)
•brachial plexus injury (questionable because 66% have
spontaneous return)
•closed head injury
•seizure disorder
•polytrauma patient

58. Open Reduction Internal Fixation with plate or hook plate
•position
•beach chair vs. supine
•approach
•superior approach to AC joint
•temporary fixation with k wires
•instrumentation
•locking plates
•precontoured anatomic plates
• hook plates vary in hook depth and number of holesproper hook depth
ensures the AC joint is not over- or under-reduction
•Since the primary deforming force at the fracture site is superior
displacement of the proximal fragment

59. • The fracture is reduced and it may be held with either
a K-wire or a lag screw
• larger distal fragment needed for multiple locking screws
• > 3-4 bicortical screws into medial fragment should be the goal
to reduce the risk of screw pull-out
• If fixation is judged to be inadequate- long screw typically 30 to
40 mm long, helps secure the proximal fragment to the
coroacoid and prevents this superior displacement
• it may be necessary to augment fixation by using a hook plate
with fixation under the acromion to prevent superior migration
of the proximal fragment

60. hook plate
•technique
•hook plates are generally used when there is insufficent bone in the distal
fragment for conventional clavicle plate fixation
•An entrance into the subacromial space is then made with a pair of heavy
curved scissors
•this space is made posteriorly, so that there will be no impingement of the
rotator cuff
•the hook should be placed posterior to AC joint and positioned as far lateral as
possible to avoid hook escape
•> 3-4 bicortical screws should be placed into the proximal (medial) fragment to
reduce the risk of screw pull-out
•Alternatively, the plate can be “walked down”
•onto the clavicular shaft by sequential placement of the screws from distal to
proximal
•Hook plate allows some motion at ac joint unlike static fixation

61. • ipsilateral fractures of the clavicle and scapular neck
• ‘1. A clavicle fracture that warrants, in isolation, fixation
• 2. Glenoid displacement of greater than 2.5 to 3 cm
• 3. Displaced intra-articular glenoid fracture extension
• 4. Patient-associated indications (i.e., polytrauma with a requirement for
early upper extremity weight bearing)
• 5. Severe glenoid angulation, retroversion, or anteversion >40 degrees
(Goss Type II)
• 6. Documented ipsilateral coracoacromial and/or AC ligament disruption or
its equivalent (coracoid fracture, i.e., AC joint disruption)
Floating shoulder

62. Complications

63. • Associated injuries
• Signs and symptoms
• Physical examination
• Imaging modalities
• Treatment options
• Management of complications
• Role of arthroscopy
Ac joint injury

64. • Glenohumeral Intra-Articular Pathology
• grade III to V injuries, arthroscopic evaluation determined superior
labral anterior to posterior (SLAP) lesion
• As there is overlapping innervation to this region of the shoulder
through the lateral pectoral and suprascapular nerves it may be
difficult for the patient to completely localize their pain
Associated injuries

65. • Fractures
• Distal clavicle fracture
• base or neck of the coracoid process
• clavicle shaft in conjunction with an AC joint
separation
• Bipolar Injuries: AC and SC Joint Dislocations
• Floating clavicle
• SC is anteriorly displaced and AC posteriorly displaced
• Bilateral (Balser) hook plates
• Branchial plexus injuries – Rare
• Scapulothoracic Dissociation

66. • CC Ossification
• Secondary to healing
• No pain , only radiological finding
• must be removed to facilitate full reduction of the AC joint
and CC distance at the time of operative intervention
• OSTEOLYSIS OF DISTAL CLAVICLE
• pain at the AC joint with cross-arm adduction and
overhead lifting.
• repeated microtrauma with a recurrent inflammatory
process was part of the etiology
• rheumatoid arthritis, hyperparathyroidism, and
scleroderma – if bilateral
• Gorham’s massive osteolysis, gout , multiple myeloma

67. • Symptoms
• pain
• usually over AC joint
• can also be referred to the trapezius
• After pain subsided -deformity
• lateral clavicle or AC joint tenderness
• abnormal contour of the shoulder compared to
contralateral side
• stability assessment
Signs and symptoms

68. • Diffuse Shoulder Pain—anterolateral neck, Ac joint,
anterolateral deltoid Point tender at Ac joint ±
deformity (prominence) Positive
• cross-arm adduction test (arm flexed 90 degrees,
adducted across chest) produces compression pain
localized to Ac joint
• O’Brien’s active compression test with
localized pain over AC joint
• Paxinos test (thumb pressure directed anterior at the
posterior Ac joint

69. • clinical triad
• point tenderness at the AC joint
• pain exacerbation with cross-arm adduction,
• relief of symptoms by injection of a local anesthetic agent

70. Radiographs
bilateral anteroposterior (AP) view of AC joints
•In standing position to detect deformity
•compare displacement to contralateral side
•measured as distance from top of
coracoid to bottom of clavicle
•use 1/3 penetration on AP to visualize AC
joint
•axillary lateral view
•required to diagnose Type IV (posterior)
•zanca view
•Stress view gives integrity of deltopectoral fascia

71. • Stryker Notch View A variant of an AC joint injury
involves a fracture of the coracoid process
• cross-arm stress view—Basmania view (AP with arm
adducted)

72. •brief sling immobilization, rest, ice, physical therapy
•indications
•type I and II
•type III in most individuals
•good results when clavicle displaced < 2cm
•rehab
•early shoulder range of motion
•regain functional motion by 6 weeks
•return to normal activity at 12 weeks
•consider corticosteroid injections
•outcomes
•type III treated non-op had higher DASH scores at 6 weeks and
3 months, and equal function at 1 year with lower rate of
secondary surgery (removal of hardware) compared to those
treated operatively
•complications
•AC joint arthritis
•chronic subluxation and instability
Nonoperative

73. Cc interval restoration (ORIF vs. Ligament Reconstruction)
•indications
•acute type IV, V or VI injuries
•acute type III injuries in laborers, elite athletes, patients with cosmetic
concerns
•chronic type III injuries that failed non-op treatment
•historically it was thought acute injuries were treated with ORIF and
chronic injuries were treated with CC ligment reconstruction
•contraindications
•patient unlikely to comply with postoperative rehabilitation
•skin problems over fixation approach site
•First method is pins and screw fixation
operative

74. •has fallen out of favor
•technique
•screw placement from distal clavicle to coracoid, superior to
inferior
•pros
•rigid internal fixation
•cons
•danger of screw being too long and damage to critical structure
below coracoid
•routine screw removal at 8-12 weeks is advised to prevent screw
breakage
•due to normal motion between clavicle and scapula
•complications
•hardware irritation & failure at level of screw purchase in coracoid
ORIF with CC screw fixation
(Bosworth screw)

75. •technique
•suture placed either around or through clavicle and around the base of the
coracoid
•can also use suture anchors for coracoid fixation
•pros
•no risk of hardware failure or migration
•
•cons
•suture not as strong as screw fixation
•requires careful suture passage inferior to coracoid due to proximity of crucial
neurovascular structures
•complications
•suture erosion causing distal third clavicle fracture
•hardware irritation
ORIF with CC suture fixation

76. • ORIF with AC pin fixation (Phemister Technique)
• approach
• can be done percutaneously
• technique
• smooth wire or pin fixation directly across AC joint
• cons
• hardware irritation
• complications
• high incidence of pin migration
• generally not performed due to high complication rates

77. ORIF with AC hook plate fixation
•approach
•exposure of distal and middle clavicle
•technique
•use of standard hook plate over superior distal clavicle
•pros
•rigid fixation
•cons
•requires second surgery for plate removal
•complications
•acromial erosion , fracture
•hook pullout

78. CC ligament reconstruction with coracoacromial (CA) ligament
(Modified Weaver-Dunn)
•approach
•proximal aspect of anterolateral approach to the shoulder
•arthroscopic technique also described
•technique
•distal clavicle excision
•transfer of coracoacromial ligament to the distal clavicle to
recreate CC ligament
•reinforce with internal fixation
•cons
•coracoacromial ligament only 20% as strong as normal CC
ligament
•lack of internal fixation risks failure of soft tissue repair

80. •Technique
• Saber incision
• The deltotrapezial fascia is then elevated from the distal clavicle as
full-thickness flaps
•. Tagging stitches are placed in the flaps to aid in retraction and then
facilitate accurate reapproximation at closure
•figure-of-eight passage of graft, looping around coracoid and
fixation through clavicular tunnels
•reinforce with internal fixation
CC ligament reconstruction with free
tendon graft

81. • Bone tunnel placement
• Guide pin placement for the conoid ligament tunnel is placed 45 mm
medial to the distal clavicle and posterior to the midline of the
clavicle in the coronal plane
• A second pin is placed lateral to the conoid pin by 20 mm and just
anterior to the clavicle midline again in the coronal plane-trapezoid
• should not be less than 15 mm from the end of the clavicle
• minimum of 20-mm bone bridge between the tunnels to prevent
fracture
• placed at least 3 mm from the edge of the clavicle toward the
midline
• “ream-in, pull-out” technique , made eccentrically
• made eccentrically

82. • type IV AC joint dislocation the bone tunnel positions can be adjusted
more posterior to the midclavicle line – anterior vector
• graft autograft
• palmaris longus
• semitendinosus
• allograft
• tibialis anterior
•pros
• graft reconstruction more closely recreates strength of native CC
ligament
•cons
•standard risks of allograft use or autograft harvest
•lack of internal fixation risks failure of soft tissue repair

83. • Migration of Pins in Acromioclavicular Joint Injuries
• AC arthritis
• more common with surgical management than with nonoperative treatment
• Hardware failure
• CC screw breakage/pullout
• Coracoid fracture
• can occur with coracoid tunnel drilling
• Clavicle fracture
• Failure of Soft Tissue Repairs in Acromioclavicular Joint Injuries
Complications

84. • The coracoid was visualized through the subcoracoid recess
• release the coracoacromial ligament from the undersurface of the
acromion and transfers it to the inferior clavicle
• Latest progression-anatomic placement of two suture–button devices
corresponding to the position of the ruptured trapezoid and conoid
ligaments using two independent 3.5-mm clavicle and coracoid bone
tunnels
Arthrosccopic repair

85. THANK YOU SIR