UPPER EXTREMITY FRACTURES
Clavicle fractures (Figure 39–1) are relatively common as a result of sports injury or direct trauma, accounting for 2–5% of all fractures in adults. The typical mechanism of injury is a fall directly on the shoulder with the arm at the side. Rarely, fractures may also occur from a direct blow or fall onto an outstretched hand. The patient will complain of pain involving the affected shoulder and will typically hold the arm in adduction and internal rotation, avoiding any motion. There may be swelling, discoloration, deformity, and crepitus on palpation at the fracture site. Displaced fractures may cause visible tenting of the skin.
Clavicle midshaft fracture. (Used with permission from Justin Montgomery, MD; University of Kentucky Radiology.)
Clavicle fractures are best seen on an anteroposterior (AP) view. An AP view with the beam directed 30°–45° cephalad is sometimes necessary to lessen rib interference. A serendipity view may also be obtained to assess for sternoclavicular dislocations. A computed tomography (CT) scan can better visualize poorly seen medial or lateral one-third fractures. Additional x-rays of the ipsilateral shoulder may be necessary to evaluate for associated injuries. All x-rays need to be carefully examined for the presence of a concomitant scapular fracture resulting in a floating shoulder.
Complications may include injuries to the subclavian blood vessels or brachial plexus. Associated pneumothorax is also a rare complication. Fractures displaced ≥100% appear to be at increased risk for nonunion. Excessive callus formation can lead to cosmetic deformity or, more rarely, compromise of neurovascular structures. It may require years for a large callus to remodel. Intraarticular fractures on either the medial or lateral end can lead to degenerative arthritis. Other long-term sequelae include pain both at rest and with activity, weakness, and paresthesias.
Nonsurgical management is the treatment of choice for most clavicle fractures and usually involves a sling for 2–6 weeks, analgesics, and avoidance of overhead activity. A sling is primarily used instead of a figure-of-eight bandage due to comfort. Clavicle fractures can be categorized using the Allman classification.
Middle one-third clavicle fractures (group I) account for approximately 80% of fractures. Treatment for displacement or overlapping of >2 cm is controversial, but minimally displaced midshaft fractures can be treated conservatively. Distal one-third clavicle fractures (group II) include multiple different subtypes that depend on fracture location in relation to the coracoclavicular ligaments. The vast majority may be treated conservatively, but certain subtypes may need orthopedic referral. Medial one-third fractures (group III) are the least common clavicular fractures and are almost always treated ...