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Clavicle fracture
Last reviewed: 04.07.2025
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ICD-10 code
S42.0 Fracture of clavicle.
What causes a collarbone fracture?
The mechanism of injury is mostly indirect: a fall on an outstretched arm, elbow or shoulder joint, compression of the shoulder girdle. But a direct mechanism of injury is also possible - a blow to the collarbone area with some object or during a fall.
Anatomy of the clavicle
The clavicle is the only bone that connects the upper limb to the trunk. It is a tubular bone with an S-shape, which is why in some northern regions of the country its old Russian name "ognivo" is still encountered. The absolute length of the clavicle of an adult is 12.2-16.0 cm. The average length relative to height in men is 8.8%, in women - 8.3%. The clavicle consists of a body (middle part) and two ends: acromial and sternal. The ends are somewhat thickened and form articulations with the scapula and sternum.
The nature of the movements is determined by the shape of the joints and the direction of muscle pull. The acromioclavicular joint is an amphiarthrosis and is characterized by low mobility. The joint has a dense fibrous capsule, into which the acromioclavicular ligament is woven. Another, stronger ligament that holds the articulation of the clavicle with the acromion is the coracoclavicular ligament, which consists of two ligaments (trapezoid and conical).
The sternoclavicular joint is spherical in shape. Its fibrous capsule is reinforced by the anterior and posterior sternoclavicular ligaments. In addition, there are costoclavicular and interclavicular ligaments that protect the articulating bones from separation. Five muscles are attached to the clavicle.
- In the area of the sternal end: from the upper outer edge comes the sternocleidomastoid muscle of the neck, from the lower anterior - the clavicular part of the pectoralis major muscle.
- In the area of the acromial end: the trapezius muscle is attached to the anterior superior surface, and the deltoid muscle is attached to the anterior inferior edge.
- The fifth muscle - the subclavian - runs along the back of the clavicle in its middle part. It should be remembered that the subclavian artery, vein and nerves of the brachial plexus are located under this muscle. A little more medially, at the level of the sternoclavicular joint on the right are the brachiocephalic trunk and the common carotid artery, on the left - the subclavian artery, on both sides - the vagus nerve.
From a physiological point of view, the clavicle is a kind of springy spacer between the sternum and the shoulder joint, preventing it from taking a more medial position. The support for the shoulder and the mobility in the clavicle joints contribute to a significant range of motion of the shoulder and shoulder girdle. An important role in the biomechanics of these movements is played by the muscles attached to the clavicle. In addition, the clavicle serves as protection for the vascular-nerve bundle.
Symptoms of a Collarbone Fracture
Symptoms of a clavicle fracture include sharp pain at the site of the fracture, the patient assumes a characteristic forced position, supporting the arm on the side of the injury.
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Diagnosis of clavicle fracture
Anamnesis
The anamnesis shows a corresponding injury.
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Inspection and physical examination
Diagnosing a clavicle fracture is not difficult, since the bone is located under the skin and is accessible for examination (however, even here the doctor is not immune to mistakes).
The patient's appearance is characteristic: the head is turned and tilted toward the side of the injury, the shoulder girdle is lowered and displaced forward, and the medial edge of the scapula and its lower angle move away from the chest as a result of the absence of a "strut" that the clavicle served as. The shoulder is lowered, pressed to the body and rotated inward. The subclavian fossa is smoothed out. Usually, swelling is visible in the clavicle area due to the protruding central fragment.
Palpation reveals a disruption in bone continuity; it is possible (but not desirable!) to determine pathological mobility and crepitus.
A fracture of the clavicle is very often accompanied by displacement of the fragments, especially if the fracture line is oblique and passes through the middle of the bone. Due to the disruption of the physiological balance of the muscles, the fragments are displaced and assume a typical position. The central fragment, under the action of the sternocleidomastoid muscle, is displaced upward and backward, and the peripheral fragment is displaced downward, forward and inward. The reason for the dislocation of the distal fragment is the disappearance of support between the shoulder joint and the sternum. The traction of the deltoid muscle and the limb's own weight displace the peripheral fragment downward. Traction of the pectoralis major and minor muscles rotates the shoulder inward, brings the limb closer to the body and not only increases the downward displacement, but also shifts the fragment inward. The fragments move one after another, the clavicle shortens. Contraction of the subclavian muscle aggravates the medial displacement of the peripheral fragment.
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Laboratory and instrumental diagnostics of clavicle fracture
X-ray of the clavicle is usually performed only in the direct anteroposterior projection, very rarely (in case of comminuted fractures, to clarify the location of the intermediate fragment) - in the axial projection.
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Treatment of clavicle fracture
Non-drug and drug treatment of clavicle fracture
The most common conservative treatment for a clavicle fracture involves immediate repositioning of the fragments followed by fixation in the correct position for the period necessary for fusion.
Local anesthesia. 10-20 ml of 1% procaine solution is injected into the fracture area, and manipulation begins after 5-7 minutes. The purpose of repositioning is to bring the peripheral fragment to the central one by raising the shoulder girdle and moving it outward and backward. There are several ways to match the clavicle fragments.
- First method. The patient is placed on his back on the edge of the table with a high bolster placed between the shoulder blades. The arm on the side of the fracture is hung off the table. After 10-15 minutes, the surgeon's assistant stands at the patient's head and, grasping the patient's armpits with his hands, moves his shoulders upward and backward. The surgeon, standing facing the patient, fixes the shoulder joint with one hand, and adjusts and holds the fragments with the other.
- The second method is similar to the first, but it is performed with the patient in an upright position, seated on a low stool. The surgeon's assistant stands behind the victim, grasps his armpits from the front and, resting his knee on the patient's back, lifts and spreads his shoulders as much as possible. The surgeon performs repositioning directly at the fracture site.
- The third method is used when there is no assistant. Two stools are placed nearby. The patient and the surgeon sit sideways on them. The doctor places his forearm in the patient's armpit, while holding the victim's shoulder and elbow in the adduction position with his chest. Then he lifts the patient's shoulder with his forearm and, acting as a lever, moves it back. With his free hand, he aligns the fragments.
When performing any of the described methods of repositioning, one should not, as advised in some textbooks, abduct the victim's shoulder, since this stretches the pectoralis major muscle, adducts the shoulder joint, which makes it difficult to align the fragments.
At the end of the manipulation, without weakening the traction, it is necessary to fix the shoulder girdle and the shoulder on the affected side in the position achieved by repositioning. It is best to do this with a plaster cast. Of the many proposed bandages, the bandage proposed in 1927 by M.P. Smirnov and V.T. Vanshtein has stood the test of time and earned recognition. When performing immobilization, it is necessary to place a cotton-gauze roll in the armpit.
Another device that creates reliable fixation of fragments is the SI Kuzminsky splint. In case of failure with one-stage repositioning, this splint can be used for gradual (over 2-3 days) alignment of fragments. Correct positioning of body segments and correction of traction by moving the belts allow the splint to be used as a repositioning device.
Special tires previously proposed by Bohler (1928), Kh.D. Rakhmanov (1949), M.K. Tikhomirov (1949), M.I. Chizhin (1940) are currently practically not used and have only historical significance.
Good results, if used correctly, are given by the method of A.V. Titova (1950), based on the use of a certain size and shape of "oval" placed in the armpit of the patient. The arm is suspended on a sling. Early functional treatment is prescribed.
Soft tissue bandages are not suitable for fixing clavicle fragments: the figure-8 bandage and Delbet rings do not create an elevation of the shoulder girdle, but only move it backwards; the sling, Desault and Velpeau bandages do not fix the fragments in the desired position. In addition, after 1-2 days, the bandage turns, as a rule, weaken, as a result of which the bandage ceases to perform a fixing role. However, as an exception, the listed bandages can be used in children (with subperiosteal fractures) and in elderly and senile individuals.
A clavicle fracture is often a component of multiple trauma, in which case the above treatment methods become unacceptable due to the patient's forced lying position. We believe that in such situations, the Kuto method should be included in the arsenal of disaster medicine, which consists of the following. The patient lies on his back, closer to the edge of the bed with his arm hanging down for 24 hours. Then the arm, bent at the elbow, is placed on a low stool for 14-21 days. UHF, massage, exercise therapy for the elbow joint and fingers are prescribed.
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Surgical treatment of clavicle fracture
Surgical treatment of a clavicle fracture is performed according to strict indications: damage to the vascular-nerve bundle, open fracture, multi-fragmentary fracture with the risk of damage to blood vessels and nerves, interposition of soft tissues, risk of skin perforation by a sharp fragment. If a fragment with a sharp edge significantly stands out, and the skin at the site of protrusion is anemic (white), one should not wait for an open fracture to occur - it is necessary to operate on the patient. The operation makes it possible to make an incision in the required projection and under aseptic conditions.
Surgical treatment of a clavicle fracture involves exposing the fragments, open repositioning, and fixing the bone fragments using one of the methods. The most commonly used method is intraosseous osteosynthesis with a metal pin. The fixator can be inserted from the side of the central fragment or retrogradely, when the pin is inserted into the peripheral fragment until it exits behind the acromion, and then, having aligned the bone fragments, the pin is inserted into the central fragment, moving it in the opposite direction.
There are also possible bone fixation methods using plates, cerclages, bone homotransplants, which cover the fracture line. To avoid displacement, the transplant is attached to the collarbone with screws or wire. Immobilization is performed using a plaster thoracobrachial bandage.
Currently, researchers use external fixation devices, usually of their own design, to treat clavicle fractures.
Regardless of the method of treatment and the type of fixing device, immobilization should last at least 4-6 weeks. From the 3rd-4th day, UHF is required on the fracture area and exercise therapy for non-immobilized joints. On the 7th-10th day, static contractions of the muscles of the forearm and shoulder begin. From the 18th-21st day, electrophoresis of calcium and phosphorus preparations is prescribed on the fracture area.
After the immobilization period, the plaster cast is removed and an X-ray is taken. If consolidation has occurred, rehabilitation treatment begins: exercise therapy for the joints of the upper limb, massage of the shoulder and shoulder, ozokerite and electrophoresis of procaine, calcium chloride on the shoulder joint, laser therapy, hydrotherapy in the pool, etc.