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Editors

JarkkoPajarinen

Fractures of the Clavicle and Scapula

Essentials

  • 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 )
  • Chest x-ray as needed, if there are grounds to suspect a thoracic injury as well (picture )
  • Circulation to the limb and nerve integrity (pulses, skin sensation, functioning of the upper limb)

Treatment Surgical Interventions for Acute Fractures or Non-Union of Middle Third Clavicle, Surgical Versus Conservative Interventions for Treating Fractures of the Middle Third of the Clavicle

  • Most low-energy non-displaced clavicular fractures can be treated conservatively Conservative Treatment of Middle Third Clavicle Fractures. Bone union usually occurs within approximately 6-9 weeks in adults. The functional result is good even if a mild cosmetic disadvantage often remains.
  • 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]

Evidence Summaries ⬆