Most low-energy clavicular fractures that are simple and in good position can be treated conservatively.
In scapular fractures, high trauma energy has usually been directed at the thoracic region. The possibility of a major trauma elsewhere in the thorax should be taken into account.
Fracture of the clavicle
Mechanism
Usually a fall either with the arm outstretched or onto the shoulder
Signs and symptoms
Local pain and, due to the thin layer of subcutaneous tissue, visible displacement is often present.
Investigations
An x-ray in order to verify the diagnosis and identify the extent of displacement (picture F1)
Chest x-ray as needed, if there are grounds to suspect a thoracic injury as well
Circulation to the limb and nerve integrity (pulses, skin sensation, functioning of the upper limb)
The fracture is immobilised with the aid of a sling that is worn for about 2-3 weeks. The elbow and wrist joints are mobilised immediately with daily exercises. The arm sling can be removed when washing oneself etc.
Surgery is always indicated in
compound fractures or fractures where the edge of the broken bone significantly threatens the integrity of the skin
fractures associated with nerve or vascular injury
so-called floating shoulder.
Surgery should also be considered in
midshaft fractures if fracture displacement exceeds the diameter of the bone itself, i.e. there is no bone contact between the fragments, or if there is shortening of more than 15-20 mm
lateral third fractures when combined with a rupture of the coracoclavicular ligament (the space between the coracoid process and the clavicle is widened as compared with the unaffected side, and the midshaft of the clavicle is elevated)
dislocated lateral fractures extending to the articular surface
fractures that have failed to unite and remain symptomatic after 6 months.
Follow-up and rehabilitation
In clavicular fractures, the dislocation may increase during the weeks following the injury.
Repetitive x-ray follow-up of a fully well-positioned fracture is usually unnecessary.
A significantly dislocated fracture that at the initial phase, however, does not meet the criteria for surgical treatment should be clinically and radiologically controlled after 1 to 2 weeks, at which time it is still possible to change the line of treatment if the dislocation of the fracture has increased.
Later follow-up visits are unnecessary, if the position has remained unchanged. A non-union fracture is operated on later if it causes significant subjective inconvenience.
The prognosis of a bone-grafting operation is worse than that of a fresh fracture because the original cause that led to the non-union (e.g poor circulation) usually remains.
Instructions for rehabilitation
Pendulum and rotation exercises as well as assisted raising exercises of the arm may be started at 1 week from the injury, and they should be started no later than about 3 weeks after the injury.
If a conservatively treated fracture is stabilized and painless, active exercises without restrictions in the range of motion can already be allowed after 3 weeks, however without any additional load.
After 6 weeks, active exercises without restrictions in the range of motion are started in both conservatively and operatively treated cases.
According to the progress of the bone union, loading can be increased and all restrictions removed 6 to 9 weeks after the injury.
Fracture of the scapula
Scapular fractures usually suggest a high-energy trauma directed at the thoracic region, and thus the possibility of a significant injury to the thorax should be taken into account.
The diagnosis is based on x-ray imaging, and a suspicion calls for further imaging studies.
Fractures of the body of the scapula are treated conservatively. An arm sling is worn for 2-3 weeks, after which shoulder joint exercises are introduced.
Fractures of the scapular neck and fractures extending to the articular surface require a CT scan and usually surgical treatment, if there is significant displacement of the fracture.
”Floating shoulder”, i.e. an ipsilateral clavicle and scapular neck fracture, needs surgical management.
References
Virtanen KJ, Remes V, Pajarinen J et al. Sling compared with plate osteosynthesis for treatment of displaced midshaft clavicular fractures: a randomized clinical trial. J Bone Joint Surg Am 2012;94(17):1546-53. [PubMed]