Anatomy

• S shaped tubular bone
• connecting shoulder girdle with chest

Incidence

• common
• underlying structures
• vessels
• brachial plexus
• lung, mediastinum

Shaft Fractures

Newborns & Infants

• common as birth injuries
• unites by D7 to D10
• ensure comfort
• avoid P° on clavicle
• handle gently - avoid movement of affected limb with feeding, changing clothes
• with pseudoparalysis - cotton wool under in axilla, flex elbow to 90° & strap arm to chest

Ages 2 to 12 years

• treated symptomatically
• no reduction if < 6 years old - will remodel - figure of 8 bandage
• see the child weekly to assess skin, NV status & look for any other problems
• unites in 3 - 4 weeks
• undisplaced, incomplete & plastic deformation
• simple sling for comfort
• avoid vigorous activities for 3 months

Ages 12 to 16 years

• limited remodelling & closed reduction if necessary
• # heals in about 6 weeks
• multiple trauma - clavicular # treated by recumbancy with a pillow between scapulae

Medial & Distal Fractures

• mostly physeal injuries
• sling is treatment of choice
• medial #’s - rarely a problem, rarely significant displacement
• lateral #’s - stable because the C-C & A-C ligs attached to the periosteal tube
• remodelling will occur

Adults

• more difficult to treat - bone & periosteum is different from children
• associated ST & bone injury may be greater
• potential for healing is less

Shaft Fractures

• reduce if necessary
• figure of 8 &⁄or sling
• immobilize for 6 - 8 weeks

Indications for primary ORIF

• NV injury
• threatened skin
• open fracture
• multiple trauma
• floating shoulder - displaced clavicle # + unstable scapula #
• some type 2 distal clavicle #’s
• medical reasons - seizures, Parkinson’s
• ???? cosmesis

• very few clavicle #’s need 10 ORIF

Options

• plate
• intramedullary pins (Steinman’s or Knowles pins)
• with or without primary bone grafting

Distal Clavicle Fractures

• Type 1
• ligs are intact - displacement is minimal
• sling + early mobilization (isometric exercises)

• Type 2
• difficult to treat non operatively - immobilization is difficult
• fragments are distracted by muscle forces & the weight of the arm
• proximal fragment is unstable - non-union occurs often
• sling does not reduce the deformity & a figure of 8 can increase the deformity
• if there is bony contact - conservative treatment is an option
• probably best treated by ORIF if displaced & unstable

Options

• cerclage wires, intramedullary pins, sutures binding the proximal fragment to the coracoid process, ligament repair if necessary
• may or may not choose to primarily bone graft
• Type 3
• if unstable & seen acutely - treat as for type 2

Medial clavicle injuries

• symptomatic support only unless there is NV injury
• then ORIF - avoid intramedullary fixation because of complications
• technique of Roussow & de Beer
• mediolateral intramedullary fixation
• figure of 8 & /or sling