Fraktur Klavikula

01Pathophysiology

The clavicle is an S-shaped bone that serves as the only bony connection between the upper extremity and the axial skeleton, articulating medially with the sternum (sternoclavicular joint) and laterally with the acromion of the scapula (acromioclavicular joint). It functions as a strut that holds the shoulder girdle away from the thorax and provides attachment for muscles including the sternocleidomastoid, deltoid, and trapezius.

The middle third of the clavicle is its weakest point because it is the thinnest segment and sits at the junction of the two curves of the bone, lacking both the ligamentous support of the medial coracoclavicular and sternoclavicular ligaments and the muscular bulk that protects the lateral and medial ends. This is precisely why approximately 80% of all clavicle fractures occur in the middle third. When a patient falls onto the lateral shoulder, force is transmitted medially through the clavicle, concentrating stress at this vulnerable midpoint.

In displaced middle-third fractures, the sternocleidomastoid muscle pulls the proximal fragment superiorly and posteriorly, while the weight of the arm and the pull of the pectoralis major and deltoid drag the distal fragment inferiorly and medially. This explains the classic presentation of a visible or palpable "step-off" deformity and the patient's drooped, shortened shoulder.

In neonates, the clavicle is the most commonly fractured bone during delivery. The mechanism involves compression of the shoulders in the birth canal, particularly when there is shoulder dystocia or when the infant is large for gestational age (macrosomia). The periosteum in neonates is thick and often incompletely disrupted, producing greenstick fractures that heal rapidly. The infant demonstrates pseudoparalysis, meaning the arm is not truly paralyzed but rather voluntarily held still because movement produces pain. This directly explains why the Moro reflex is asymmetric: the infant does not abduct and extend the affected arm during the startle response because doing so stretches the fracture site.

The proximity of the clavicle to the subclavian vessels and the brachial plexus, which run directly posterior and inferior to the middle third of the bone, means that significantly displaced fractures carry a risk of neurovascular injury. This anatomic relationship is why a thorough neurovascular examination of the upper extremity is mandatory in every clavicle fracture assessment.

02Classification and Clinical Manifestation

Allman Classification (By Location)

Neer Classification (Distal Third Fractures)

Clinical Manifestation by Population

03Diagnostic Workup

The evaluation of a suspected clavicle fracture begins with a standard AP radiograph of the clavicle, which is the best initial test and is sufficient to confirm the diagnosis in the great majority of cases. The radiograph reveals the fracture line, the degree of displacement or comminution, and the involved third of the clavicle. For middle-third fractures, a 15 to 20 degree cephalic tilt view may be added to better assess the degree of vertical displacement by moving overlying bony structures out of the field.

When a medial-third fracture is suspected, the standard AP view is often inadequate because the sternoclavicular region is obscured by overlapping structures. In this setting, a serendipity view (AP radiograph with 40-degree cephalic tilt) helps determine whether the medial fragment is displaced anteriorly or posteriorly. However, CT scanning is the most accurate test for medial-third fractures and should be obtained whenever posterior displacement is suspected, because a posteriorly displaced fragment can compress or lacerate the subclavian vessels, brachiocephalic vein, trachea, or esophagus.

A chest radiograph should be obtained for all displaced fractures, particularly those involving the medial third or high-energy mechanisms, to evaluate for pneumothorax, hemothorax, or signs of vascular injury. In neonates, ultrasound is a practical and radiation-free alternative for confirming a clavicle fracture and monitoring callus formation.

The clinical neurovascular examination is just as important as the imaging. Every patient with a clavicle fracture must have documented evaluation of the brachial plexus (motor and sensory testing of the upper extremity) and the subclavian/axillary vasculature (radial pulse, capillary refill, upper extremity color and temperature). An absent pulse or expanding hematoma at the base of the neck warrants emergent CT angiography and surgical consultation.

04Management and Treatment

Nonoperative management is the standard of care for the majority of clavicle fractures. A simple arm sling is preferred over the figure-of-eight bandage, as studies have demonstrated equivalent outcomes with better patient comfort and compliance using the sling. The patient is instructed to wear the sling for comfort for the first 2 to 3 weeks, then begin gentle pendulum exercises and progressive range of motion as pain subsides. Full activity and contact sports are restricted until there is radiographic evidence of union and the patient has regained symmetric strength, typically at 8 to 12 weeks.

Pain control consists of acetaminophen (1 g every 6 to 8 hours as needed) and NSAIDs such as ibuprofen (400 to 600 mg every 6 to 8 hours with food). There has been debate about whether NSAIDs impair fracture healing, but current evidence does not support withholding short-course NSAIDs for pain management in clavicle fractures. Opioids should be reserved for breakthrough pain in the acute period only.

Surgical fixation is indicated when nonoperative management is unlikely to achieve satisfactory union or functional outcomes. The clearest indications include: open fractures, neurovascular injury, displacement with shortening exceeding 2 cm, complete displacement with no cortical contact between fragments, skin tenting with threatened breakdown, Neer Type II distal fractures, floating shoulder, and polytrauma patients who need early mobilization. The standard surgical approach for middle-third fractures is ORIF with a precontoured superior locking plate, which provides excellent stability and predictable union rates above 95%.

For neonatal clavicle fractures, the management is exclusively supportive. No immobilization device is necessary beyond gentle handling and pinning the sleeve of the infant's clothing to limit arm movement. Parents should be counseled that a palpable callus (a firm lump at the fracture site) will develop at 1 to 2 weeks and is a sign of normal healing, not a complication. Complete healing occurs within 2 to 3 weeks, and long-term outcomes are uniformly excellent with full remodeling.

05Differential Diagnosis and Distractors

06Traps and High-Yield Pearls

The single most tested concept around clavicle fractures is the neonatal presentation. A vignette describing a large-for-gestational-age newborn delivered after a prolonged second stage or shoulder dystocia, who now has decreased movement of one arm and an asymmetric Moro reflex, is pointing you toward a clavicle fracture. The trap is selecting Erb palsy instead, which is the most common wrong answer. The discriminator is straightforward: Erb palsy produces a characteristic "waiter's tip" posture with true neurologic findings (absent biceps reflex, weakness in shoulder abduction and elbow flexion), while a clavicle fracture produces focal bony tenderness and crepitus with an intact neurologic examination. If the vignette describes swelling, a palpable lump, or crepitus over the clavicle and does not mention a specific posture or reflex loss beyond the Moro, clavicle fracture is the answer.

A second common pitfall involves the management of Neer Type II distal clavicle fractures. Students often apply the general rule that "clavicle fractures are treated conservatively" and select nonoperative management for all subtypes. However, Type II distal fractures have a nonunion rate approaching 30% with conservative treatment because the coracoclavicular ligaments remain attached to the distal fragment while the proximal fragment is free to displace superiorly. When a vignette describes a fracture of the lateral clavicle with superior displacement of the medial fragment, the correct answer is surgical fixation.

Third, be alert to the vignette that embeds a pneumothorax or vascular injury alongside a clavicle fracture. A patient with a displaced medial-third clavicle fracture who develops dyspnea, decreased breath sounds, or subcutaneous emphysema requires a chest radiograph and potentially CT angiography before any orthopedic intervention. The "next best step" in that scenario is addressing the life-threatening complication, not applying a sling.

Finally, remember that for typical nondisplaced or minimally displaced middle-third fractures in adults, the answer is always a simple sling and not a figure-of-eight bandage. The figure-of-eight bandage appears frequently as a distractor, but contemporary evidence and guidelines favor the sling for better comfort and equivalent outcomes.