Define Fracture of the Clavicle. Describe its clinical features, management and complications.

Site and Mechanism

The clavicle is one of the most commonly fractured bones, and the commonest site is the junction of the middle and outer thirds — the point where the bone changes its curvature and is weakest. The usual mechanism is a fall on the outstretched hand or on the point of the shoulder (rarely a direct blow). In children it is a frequent birth injury and a common greenstick fracture.

Clinical Features

The patient supports the arm and tilts the head towards the injured side to relax pull on the muscles. There is a visible and palpable prominence at the fracture, with the medial fragment pulled UP by sternocleidomastoid and the lateral fragment pulled down by the weight of the arm. Although rare, the underlying subclavian vessels and the brachial plexus must be checked, and the skin inspected for tenting.

Management

The great majority are treated conservatively — a broad arm sling (or a figure-of-eight bandage) for comfort, for about 3 weeks, followed by mobilisation. The clavicle unites reliably, and even a moderate bump usually remodels and causes no functional loss. Operative fixation (a plate) is reserved for: an open fracture, neurovascular injury, skin tenting/threatened skin, severe displacement or marked shortening, a 'floating shoulder' (with a scapular neck fracture), and established non-union.

Complications

• These are uncommon but examinable.
• malunion (with a visible bump and, if there is marked shortening, some functional loss) is the most frequent.
• non-union is rare and is seen mainly after severely displaced or comminuted fractures, open injuries and over-vigorous early movement.
• Neurovascular injury to the underlying subclavian/axillary vessels and the brachial plexus, and injury to the apex of the lung (pneumothorax), are rare but serious and must be excluded in a high-energy injury. Late compression of the neurovascular bundle by exuberant callus (thoracic-outlet-type symptoms) can occur.

Sternocleidomastoid elevates the medial fragment.

• Commonest site = junction of the middle and outer thirds; usual mechanism is a FOOSH or a fall on the point of the shoulder.
• Medial fragment is pulled UP by sternocleidomastoid, lateral fragment pulled down by the arm's weight; the patient tilts the head to the injured side.
• Most are treated conservatively with a sling/figure-of-eight for ~3 weeks; union is reliable and a bump remodels.
• Surgery for: open fracture, neurovascular injury, threatened/tented skin, severe displacement or shortening, floating shoulder, or non-union.