Clavicle Fracture

History: fall onto the shoulder (most common), fall onto outstretched hand, or direct blow, with sudden severe pain and inability to lift the arm. High-energy mechanisms warrant full trauma assessment including cervical spine and chest.

Examination:

• •Tenderness, swelling, and often a visible step or Z-deformity over the clavicle
• •Skin assessment: tenting, blanching, dusky discoloration, threatened skin, or open wound
• •Neurovascular examination: radial pulse, axillary nerve (regimental badge sensation plus deltoid contraction), and a full upper limb screen
• •Palpate the scapula posteriorly to exclude floating shoulder
• •Assess the acromioclavicular joint for concomitant disruption (scarf test)

Red flags: open fracture, threatened skin (tenting, blanching, or dusky discoloration), neurovascular compromise, displaced floating shoulder, and in under-25s a medial clavicular injury with dysphagia or dyspnoea (suspect posterior SCJ dislocation).

Plain radiographs are first-line: AP view of the clavicle plus a 30-degree cephalic tilt view. The Zanca view (10-15 degrees cephalic tilt) is the canonical view for lateral third fractures and suspected ACJ pathology.

CT is indicated for medial third fractures, suspected posterior SCJ dislocation or physeal injury in under-25s (the medial clavicular physis remains open until around age 25), complex comminution, or pre-operative planning. CT with 3D reconstruction is the gold standard for medial third and SCJ injuries.

Chest radiograph if pneumothorax is clinically suspected in a high-energy mechanism. CT angiography for any suspected vascular injury (expanding haematoma, absent pulses, pale cold hand). Routine bloods are not required; pre-operative bloods as appropriate if surgery is planned.

Most uncomplicated closed clavicle fractures are managed via fracture clinic or virtual fracture clinic pathways.

Mid-shaft fractures:

• •Undisplaced or minimally displaced: broad arm sling for comfort (2-4 weeks), simple analgesia, early pendular exercises. Figure-of-eight bandages offer no added benefit and are uncomfortable
• •Displaced (completely displaced, shortening over 2 cm, or significant comminution): shared decision making. Ban et al 2021 (BJJ) showed neither universal surgery nor universal conservative management is superior; surgery offers faster short-term recovery and lower non-union with comparable 1-year function. Surgery is commonly favoured in high-demand athletes and manual workers prioritising rapid return

Lateral third fractures (the Neer classification governs management):

• •Type I: fracture lateral to intact CC ligaments. Stable
• •Type IIA: fracture between the CC ligaments with both conoid and trapezoid attached to the distal fragment. Unstable
• •Type IIB: fracture medial to the CC ligaments with conoid torn but trapezoid still attached to the distal fragment. Unstable
• •Type III: intra-articular fracture extending into the ACJ. Bone is usually stable but carries a risk of secondary ACJ osteoarthritis
• •Type IV: paediatric pattern where the bony fragment is displaced superiorly but the periosteal sleeve remains attached to the CC ligaments
• •Type V: comminuted fracture in which the CC ligament remains attached to an inferior fragment, separating it from both medial and lateral pieces

Treatment by Neer type:

• •Types I, III, and IV: non-operative; sling, analgesia, early movement. Type III may need secondary ACJ resection if symptomatic OA develops
• •Type II (A and B): commonly operative in adults. Hall et al 2021 (COTS) showed comparable 1-year functional outcomes between operative and non-operative management but higher non-union and re-operation rates without fixation. Hook plate or locking plate with CC augmentation is commonly offered to higher-demand patients; hook plates are temporary and typically removed at 3-6 months
• •Type V: specialist input, often operative given the unstable inferior CC-bearing fragment

Medial third fractures are most often managed non-operatively. In under-25s, exclude posterior SCJ dislocation on CT before assuming a simple fracture.

Analgesia per NICE NG38: paracetamol first-line; codeine as step-up; oral NSAIDs only in non-frail adults. NSAIDs are not offered to frail or older adults with fractures.

Urgent orthopaedic assessment is required for open fracture, threatened skin, neurovascular compromise, or displaced floating shoulder. Supraclavicular nerve injury (chest wall numbness inferior to the scar) is a specific consent point for clavicle ORIF.

Progression is individual and guided by pain, fracture pattern, and clinical plus radiographic union.

• •Early phase: broad arm sling for comfort; early pendular exercises to prevent stiffness; regular analgesia and ice
• •Intermediate phase: wean the sling as comfort allows; progressive active-assisted range of motion (pulleys, wall walks, table slides)
• •Late phase: progressive resistance strengthening and scapular stabilisation

Return-to-activity benchmarks:

• •Desk-based work: often 2-3 weeks
• •Manual work: 6-12 weeks depending on demands
• •Contact or overhead sport: typically 3 months for non-operative management; fixation may permit earlier return guided by the operating team

Post-ORIF rehabilitation is surgeon-led with early active motion and weight progression as the construct allows.

Modifiable factors: smoking slows fracture healing (signpost NHS Stop Smoking services); optimise vitamin D, nutrition, and glycaemic control; address fear-avoidance and graded return-to-work planning.

• •Ban et al (2021) BJJ - Multicentre RCT showed no universal superiority of surgery for displaced mid-shaft clavicle fractures; surgery confers faster short-term recovery and lower non-union but comparable 1-year function.
• •Hall et al (2021) COTS J Orthop Trauma - Comparable 1-year functional outcomes for operative vs non-operative management of displaced Neer type II lateral fractures; non-operative management carries higher non-union and re-operation rates.
• •NICE NG38 - Non-complex fracture management: directs the analgesia ladder and warns against NSAIDs in frail or older adults with fractures.
• •BOAST open fracture standards - Govern open clavicle fracture care including time-to-antibiotics and tetanus cover.
• •BESS shoulder care pathways - UK shoulder framework directing referral and follow-up after clavicle injury.

• •Allman by thirds is the high-yield framework: Group I middle 80%, Group II lateral 15%, Group III medial 5%
• •Neer type II lateral third fractures (A and B) lose their CC ligament tether and carry the highest non-union and re-operation rates
• •Ban 2021 RCT: surgery for displaced mid-shaft fractures gives faster recovery and lower non-union; 1-year function is similar
• •Hook plates are temporary implants, commonly removed at 3-6 months once union is confirmed
• •Floating shoulder is ipsilateral clavicle plus scapular neck fracture (SSSC double disruption); displaced cases warrant operative consideration
• •Medial clavicle injury in an under-25 with dyspnoea or dysphagia should prompt CT to exclude posterior SCJ dislocation