Clavicle Fractures -

Incidence

S-shaped
Medial portion is cylindrical
Lateral portion is relatively flat
Medullary canal is small due to thick cortical bone
Ligaments:
- Medial (very strong)
  - sternoclavicular, costoclavicular, and interclavicular ligaments
- Lateral
  - acromioclavicular and the two coracoclavicular ligaments, the conoid and the trapezoid
Muscles attached to osseous surface
- platysma, sternocleidomastoid, pectoralis major, subclavius, deltoid, and trapezius.
The clavicle shields important underlying neurovascular structures
- brachial plexus, subclavian vessels
- only bone that connects the upper limb to the axial skeleton

Allman Classification of Clavicle Fractures

Middle third fractures: weakest point of the clavicle lies at the transition region between the curves where the bone is found to be thinnest and lacks any muscular or ligamentous support

Type	Description
I	coracoclavicular ligaments intact, attached to medial segment
II	coracoclavicular ligaments detached from the medial segment but trapezoid intact to distal segment
IIA	both the conoid & trapezoid remain attached to the distal segment
IIB	the conoid is torn
III	intraarticular extension into the acromioclavicular joint

Neer’s Classification of Lateral Third Clavicular Fractures

Group		Description
1	Fracture of the Middle Third
2	Fracture of the Distal Third
	Type I	minimal displacement (interligamentous)
	Type II	displaced secondary to fracture line medial to the coracoclavicular ligaments A – conoid & trapezoid attached B – conoid torn, trapezoid attached
	Type III	fractures of the articular surface
	Type IV	periosteal sleeve fracture (children)
	Type V	comminuted with ligaments attached neither proximally nor distally, but to an inferior comminuted fragment
3	Fracture of the Proximal Third
	Type I	minimal displacement
	Type II	displaced (ligaments ruptured)
	Type III	intraarticular
	Type IV	epiphyseal separation (children & young adults)
	Type V	communited

Craig Classification of Clavicle Fractures

Tradition view

most fractures can be treated nonoperative because of high rates of union and low chance of complations
True for children and adolescent, ? Not true for adults and elderly
- Nonunion / malunion
- pain, deformity, weakness, neurovascular symptoms, decreased function

Options
- Broad arm sling
- Figure of eight brace
Indications
- majority of fractures
  - medial third fractures
  - middle third fractures
  - distal third types I, IV, V

ORIF
- Indications
  - DIsplacemnt / shortening >15 – 20 mm
  - Distal type II (a and b)
  - open fractures;
  - associated vascular injury;
  - progressive neurological deficits;
  - gross displacement with skin tenting that will likely lead to skin breakdown;
  - significant medialization of the shoulder girdle;
  - torn coracoclavicular ligaments with distal fracture;
  - ipsilateral fractures of the clavicle and scapula (floating shoulder);
  - multiply injured patients;
  - bilateral clavicular fractures;
  - complex, ipsilateral, upper-extremity fracture.
- Contraindications
  - compromised soft tissue,
  - active infection at or near the operative site,
  - an unreliable or noncompliant patient
Closed treatment with late excision arthroplasty
- Indications
  - Distal third Type III