A clavicle fracture is a bone fracture in the clavicle, or collarbone. It is often caused by a fall onto an outstretched upper extremity, a fall onto a shoulder, or a direct blow to the clavicle.
Clavicle fractures involve approximately 5% of all fractures seen in hospital emergency admissions. Clavicles are the most common broken bone in the human body. It is most often fractured in the middle third of its length. Children and infants are particularly prone to it. Newborns often present clavicle fractures following a difficult delivery.
After fracture of the clavicle, the sternocleidomastoid muscle elevates the proximal fragment of the bone. The trapezius muscle is unable to hold up the distal fragment owing to the weight of the upper limb, and thus the shoulder droops. The adductor muscles of the arm, such as the pectoralis major, may pull the distal fragment medially causing the bone fragments to override.
Hippocrates, 4th century BC:
The management of skeletal injuries in ancient Egypt – Collar bone:
Treatment usually involves resting the affected extremity and supporting the arm with the use of a sling. In older practice, a figure-8 brace was used, designed to immobilize and retract the shoulder, maintaining symmetric positioning to facilitate healing. More recent clinical studies have shown that the outcomes of this method were not measurably different from simple sling support, and due to the movement difficulties caused to the patient, this method has mostly lapsed. Current practice is generally to provide a sling, and pain relief, and to allow the bone to heal itself, monitoring progress with X-rays every week or few weeks. Surgery is employed in 5-10% of cases. However, a recent study supports primary plate fixation of completely displaced midshaft clavicular fractures in active adult patients.
More than 90% of clavicle fractures are successfully healed by non-operative treatment. The surgery is indicated when one or more of the following conditions presents.
A discontinuity in the bone shape often results from a clavicular fracture, visible through the skin, if not treated with surgery. Surgical procedure will often call for ORIF (Open Reduction Internal Fixation) where an anatomically shaped titanium or steel plate is affixed along the superior aspect of the bone via several screws. In some cases the plate may be removed after healing, but this is very rarely required (based on nerve interaction or tissue aggavation), and typically considered an elective procedure. Typical surgical complications are infection, neurological symptoms distal the incision (sometimes to the extremity), and non-union requiring re-plating.
Healing time varies based on age, health, complexity and location of the break as well as the bone displacement. For adults, a minimum of 3–4 weeks of sling immobilization is normally employed to allow initial bone and soft tissue healing, teenagers require slightly less, children can often achieve the same level in two weeks. During this period, patients may remove the sling to practice passive pendulum ROM exercises to reduce atrophy in the elbow and shoulder, but they are minimized to 15-20 degrees off vertical.
The immobilization is followed by a theraputic regimen of passive exercises, and later of active exercises. Full radiological union is typically achieved in 16 weeks for adult surgical patients, and shorter times are achieved by teenagers and young children. In patients who participated in prescribed physical therapy, 85-100% mobility returned in 6–9 months, with full strength returning in 9–12 months.More details can be found in the following studies:http://www.ejbjs.org/cgi/content/full/89/1/1http://www.ejbjs.org/cgi/content/full/91/2/447http://www.ejbjs.org/cgi/content/abstract/90/Supplement_2__Part_1/1http://www.jaaos.org/cgi/content/abstract/15/4/239
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