• Accounts for approximately 2.6% of all fractures¹ with peak incidence occurring in children and young adults. The clavicle is the most fractured bones in children⁴.
• The clavicle is the only osseous link between the upper extremity and chest wall. It is thin, superficial, and prone to fracture during a fall.
• 2 coracoclavicular (CC) ligaments at the distal end stabilize superior and inferior movement. Disruption of these ligaments in the context of a fracture is unstable and has a high incidence of non-union.
• Critical structures that are vulnerable to damage by clavicular fragments include the subclavian artery/vein, the brachial plexus, and the lung apex.

History and Physical

• Most commonly occurs from a fall/impact to the shoulder⁴. Less commonly from falling on an outstretched hand or direct blow to clavicle.
• The head may be tilted to the affected side and the affected arm may be held low and close to the body.
• Common findings include focal tenderness, ecchymosis, swelling, crepitus, and visible/palpable deformity.
• Ensure there is no open fracture or skin tenting, perform a neurovascular exam, and consider associated injuries such as pneumothorax or other fractures.

Imaging

• Obtain upright views to avoid underestimation of displacement.
• Standard clavicle views include an AP clavicle as well as 15^o cephalic tilt view.
• CXR can be considered for ruling out pneumothorax.
• Consider CT if there is significant proximal clavicular displacement as any potential intrathoracic damage should be further delineated.

Diagnostic considerations

• Always assess the neurovascular status of the affected limb, as the subclavian artery/vein and brachial plexus are located anatomically close.
• Consider CT to further evaluate when concerned for vascular injury.
• Consider pneumothorax/hemothorax, especially if the proximal clavicle is involved.
• Proximal clavicle fractures are typically associated (90%) with major trauma/injury and require a thorough examination². They are uncommonly isolated injuries.
• Concomitant ipsilateral scapular neck fractures leave the shoulder disconnected from the chest wall. These injuries are called “floating shoulders” and require orthopedic referral.

Indications for Orthopedic Referral

• Significant practice pattern variation may exist between institutions. Absolute indications for orthopedic referral include open fractures/skin tenting, neurovascular compromise, floating shoulder and severe displacement/comminution/shortening.
• Proximal 3^rd fractures with any clinically significant displacement warrant referral due to proximity to critical intrathoracic structures.
• Distal 3^rd fractures with CC ligament disruption warrant referral as these are unstable fractures.
• Consider referral for high level athletes, cosmetic concern, or significant seizure/neuromuscular disorder.

Non-operative management

• Immobilization is the mainstay of treatment, continue until clinical union is achieved (non-tender and full painless ROM).
• A sling for comfort is suggested.
• A figure of 8 bandage is no longer recommended due to similar outcomes, more pain and risk of complications³.
• Early elbow range of motion exercise is encouraged throughout immobilization.

Disposition

• Majority heal uneventfully.
• Fractures which do not require surgical referral can be seen by primary care physicians in 1-2 weeks.

Complications

Pediatric Considerations

• Non-operative treatment is usually effective, leading to faster clinical union than in adults (3-4 weeks).
• Any clavicular bowing (no cortex disruption) should be treated as a fracture.
• Unlike adults, distal fractures involving CC ligament disruption are not always unstable due to the periosteal sleeve often remaining intact, preventing displacement. Conservative management is appropriate in the absence of displacement.

1. Postacchini F, Gumina S, De Santis P, Albo F. Epidemiology of clavicle fractures. J Shoulder Elbow Surg 2002; 11:452-456

   
   

2. Throckmorton T, Kuhn JE. Fractures of the medial end of the clavicle. J Shoulder Elbow Surg 2007; 16:49.

   
   

3. Ersen A, Atalar AC, Birisik F, et al. Comparison of simple arm sling and figure of eight clavicular bandage for midshaft clavicular fractures: a randomised controlled study. Bone Joint J 2015; 97-B:1562.

   
   

4. Walls RM, Hockberger RS, Gausche-Hill M, Erickson TB, Wilcox SR. Shoulder Injuries. In: Rosen’s emergency medicine: Concepts and clinical practice. 10th ed. Philadelphia, PA: Elsevier; 2023.