The clavicle accounts for 3% to 5% of all fractures with a 2:1 male to female ratio. It is also the most commonly fractured bone in children. Clavicular fractures are classified anatomically and mechanistically into three groups. Fractures of the medial third are uncommon (5%) and occur as a result of a direct blow to the anterior chest. Fractures of the middle third are the most frequent ( Figs. 45.6 and 45.9 ), accounting for 80% of all injuries. The usual mechanism of injury involves a direct force applied to the lateral aspect of the shoulder as a result of a fall, sporting injury, or motor vehicle collision (MVC). Fractures of the lateral third (15%) result from a direct blow to the top of the shoulder and are classified further into subtypes. Type I fractures are stable and minimally displaced because the coracoclavicular ligament remains intact. Type II fractures are associated with a torn coracoclavicular ligament and have a tendency to displace because the proximal fragment lacks any stabilizing forces ( Fig. 45.7 ). Type III injuries involve the articular surface.

Displaced Midclavicular Fracture.

Type II lateral clavicular fracture and torn coracoclavicular ligament.

Courtesy Erik Foss, MD.

The affected extremity is held close to the body as a result of the effect of gravity and the pull of the muscles (pectoralis major, latissimus dorsi, sternocleidomastoid) on either side of the fracture site. The head is often tilted toward the injured side in an attempt to relax the effects of these displacing muscular forces. Tenderness, ecchymosis, crepitus, and a palpable or visible deformity may be present. Examine for any tenting of the skin, because this can cause progression to an open fracture. Furthermore, tenting of the skin is one of the indications for operative fixation and reduction. Although rare, it is prudent to evaluate for associated neurovascular and pulmonary injury due to close proximity of the subclavian vessels, brachial plexus, and lung apex. The most common complications are delayed union, nonunion, and symptomatic malunion. Displaced middle third fractures have a 15% to 20% rate of nonunion and up to 25% rate of symptomatic malunion. Type III lateral clavicle fractures can lead to subsequent AC joint osteoarthritis.

In patients with direct fall onto lateral shoulder the differential diagnosis includes soft tissue injury (hematoma, contusion, strain, sprain), AC, GH, and SC joint injuries as well as rib, scapula, and humerus fractures.

Clavicle-specific plain radiographs may be required to confirm the presence of a fracture, although most clinically significant fractures are diagnosed on chest or shoulder radiographs. Fractures in children can be reliably diagnosed or ruled out by POCUS, decreasing the exposure to radiation ( Fig. 45.8 ).

Ultrasound images of the clavicle. (A) Normal. (B) Midclavicular fracture.

Courtesy Keith Cross, MD.

Principles of initial management for simple fractures include pain control, immobilization primarily for comfort, and proper follow-up care. In addition to oral analgesics, pain associated with clavicle fractures can also be managed with an ultrasound-guided superficial cervical plexus block in the ED. Fractures of the clavicle are adequately immobilized with a simple sling since this results in similar functional outcomes and rates of union while providing greater pain relief than a figure-of-eight clavicular bandage. Emergent orthopedic consultation should be sought for open fractures or fractures associated with neurovascular injuries, skin tenting, or interposition of soft tissues. More urgent orthopedic consultation (within 72 hours) is recommended for type II lateral clavicle fractures, because these fractures have up to a 30% incidence of nonunion and may require surgical repair. Severely comminuted or displaced fractures of the middle third (defined as over 18 mm of initial shortening) are also associated with a higher incidence of nonunion and long-term functional deficits and deserve urgent orthopedic evaluation for consideration of operative reduction. ^,

Most fractures of the clavicle heal uneventfully, and follow-up can be provided by a primary care physician. A sling should be worn until the patient is comfortable, which may precede radiographic evidence of callous formation. Early passive shoulder range-of-motion exercises ( Fig. 45.10 ) are encouraged to reduce the risk of adhesive capsulitis (commonly referred to a “frozen shoulder”). Adolescents and adults generally require 4 to 8 weeks of immobilization. Contact sports should be avoided until the bone healing is solidified (6 to 8 weeks). Full range of motion of the shoulder and an absence of pain are two reliable clinical signs that the fracture has healed.

Greenstick fracture of the clavicle (arrow).

Types of Active and Passive Shoulder Exercises.

(A) Passive flexion. (B) Passive external rotation. (C) Pendular. (D) Passive internal rotation.

Fractures of the scapula are rare, accounting for approximately 1% of all shoulder fractures and caused by high-energy trauma, such as high-speed MVCs and falls from heights. Scapular fractures rarely require management but are associated with major injury (75% to 98%), specifically injuries to the ipsilateral lung, chest wall, and shoulder girdle complex. The most common associated orthopedic injuries are fractures of the ribs, proximal humerus, and clavicle. Associated lung injuries, including pneumothorax, hemothorax, and pulmonary contusion, usually occur acutely, but may manifest up to 2 to 3 days after the initial injury. Associated injuries of the head, spinal cord, brachial plexus, and subclavian or axillary vessels are less common.

Scapular fractures are divided into two main types: extra-articular (neck [ Fig. 45.11 ], body, acromion process, coracoid process, spine) and intra-articular (with partial or total glenoid involvement).

Extra-Articular Fracture Involving the Neck of the Scapula.

Note the associated midclavicular fracture.

In a conscious patient, the shoulder is held in a position of most comfort, usually with the arm adducted and held close to the body. Any attempts at movement will result in significant pain. Tenderness, crepitus, or hematoma may be noted over the fracture site. The clinical findings occasionally mimic those seen with a rotator cuff tear. Associated injuries of the ipsilateral lung, chest wall, and shoulder girdle account for most complications. Neurovascular (e.g., brachial plexus, axillary artery, suprascapular nerve) injuries also have been reported with fractures of the acromial process, coracoid process, scapular neck, body, or spine fractures that extend into the suprascapular notch. Delayed complications include adhesive capsulitis and rotator cuff dysfunction.

High energy trauma that can lead to a scapula fracture should also include the following on the differential diagnosis: rib fracture, pneumothorax, hemothorax, glenohumeral dislocation, humerus fracture, and clavicle fracture. The shoulder girdle is complex, so high-energy injury mechanisms to one part can affect any other associated part.

Presence of a scapular fracture should prompt a thorough search for associated thoracic, intracranial, orthopedic, and neurovascular injuries . Most fractures, including fractures with severe comminution heal rapidly with nonoperative therapy. Initial therapy consists of analgesia, immobilization in a sling for comfort to support the ipsilateral upper extremity, and passive range-of-motion exercises (see Fig. 45.10 ). Most patients require a sling for 2 to 4 weeks, physical therapy, and follow-up assessment for delayed displacement.

Nondisplaced fractures of the body, spine, and acromion process usually require no further therapy. Displaced acromial fractures that impinge on the GHJ require surgical management. Rarely, the acromion is fractured as part of a superior dislocation of the humeral head. In these instances, an accompanying tear of the rotator cuff which may require surgical repair is invariably present. If the coracoclavicular ligaments remain intact, fractures of the coracoid process respond well to conservative therapy. Severely displaced coracoid fractures with ruptured coracoclavicular ligaments usually require open reduction and internal fixation. Scapular neck and glenoid fossa fractures present the most difficult management issues. Although most of these injuries also do well with conservative therapy, open reduction and internal fixation may be necessary to improve long-term function.

Fractures of the proximal humerus occur primarily in the older population, in whom structural changes (osteoporosis) weaken the proximal humerus, predisposing it to injury from low-energy falls. Although most of these injuries involve minimal displacement and are adequately managed with conservative therapy, significantly displaced fractures may require operative intervention. Displacements encountered with fractures of the humerus usually reflect the pull of the attached muscle groups.

Fractures of the proximal humerus separate along old epiphyseal lines, producing four distinct segments consisting of the articular surface (anatomic neck), greater tuberosity, lesser tuberosity, and humeral shaft (surgical neck). The Neer classification system is based on the relationship of these fracture fragments. In this system, a segment is considered displaced if it is angled more than 45 degrees or separated more than 1 cm from the neighboring segment. Because this classification system considers only displacement, the number of fracture lines is irrelevant. There are four major categories of fracture: (1) minimal displacement ( Fig. 45.12 ), (2) two-part displacement ( Fig. 45.13 ), (3) three-part displacement, and (4) four-part displacement. When present, anterior and posterior dislocations are included as part of the classification. Impaction and head-splitting fractures are classified separately.

Three-part minimally displaced fracture of the proximal humerus involving the greater and lesser tuberosities.

Anteroposterior (A) and axillary (B) radiographic views of a two-part displaced fracture of the proximal humerus. The degree of displacement often is better visualized on the axillary view.

Courtesy David Nelson, MD.

The classic mechanism of injury involves a fall on an outstretched abducted arm. Concurrent pronation limits further abduction and levers the humerus against the acromial process; this produces a fracture or dislocation, depending on the tensile strengths of the bone and surrounding ligaments. Older patients are prone to fracture, whereas younger persons are apt to have dislocations. The combined injury (fracture and dislocation) may be seen in middle-aged patients. Proximal humerus fractures also may result from a direct blow to the lateral side of the arm or from an axial load transmitted through the elbow. High-energy mechanisms and polytrauma are more common in younger persons.

The affected arm is held close to the body, and movement is restricted by pain. Tenderness, hematoma, ecchymosis, deformity, or crepitus may be noted over the fracture site. A thorough neurovascular examination is essential to identify associated injuries of the axillary nerve, brachial plexus, or axillary artery (see Table 45.1 ). The most common complication of proximal humeral fractures is adhesive capsulitis. This complication can be prevented by the early initiation of pendular shoulder exercises, along with a thorough rehabilitation program. One of the most devastating complications is avascular necrosis (AVN), which is more common in multi-part fractures, and fracture-dislocations due to the disruption of the blood supply to the humeral head. Repeated forceful attempts at reduction of fracture-dislocations may be associated with subsequent heterotopic bone formation (myositis ossificans). Neurovascular injuries (axillary nerve, brachial plexus, and axillary artery) may be encountered with displaced surgical neck fractures and fracture dislocations.

The differential diagnosis of a proximal humerus fracture includes: glenohumeral dislocation, AC joint separation, rotator cuff tendon tear, or soft tissue injury including hematoma, contusion, and muscle strains.

The three-view trauma series allows for assessment of the number of fracture fragments and degree of displacement or angulation. Cross-sectional imaging is usually not necessary in the ED; however, there may be certain situations where it is helpful, including making the diagnosis of an occult fracture, orthopedic surgery request for surgical planning, and further evaluation of neurovascular structures. If there is high concern for a vascular injury, a CT scan with contrast is the most appropriate study. If there is concern for a peripheral nerve injury, an MRI may be helpful, although a normal MRI does not rule out an associated nerve injury. In such instances, patients may require an outpatient electromyography (EMG) and orthopedic consultation.

Minimally displaced fractures (see Fig. 45.12 ) constitute up to 80% to 85% of all cases. In these instances, limited displacement or angulation is present, and the fracture segments are held together by the capsule, periosteum, and surrounding muscles. Initial treatment consists of adequate analgesia and immobilization with a sling. A Cochrane review noted that rapid commencement of physiotherapy (within 1 week) resulted in less pain without compromising long-term outcomes. Initial passive exercises (see Fig. 45.10 ) are gradually replaced by more active and resistive exercises. Most nondisplaced fractures heal over 4 to 6 weeks.

The management of displaced two-part, three-part, and four-part fractures remains controversial and an orthopedist should be consulted. A prospective randomized clinical trial failed to show a significant functional difference between operative and nonoperative treatment of displaced two-part, three-part and four-part fractures in elderly patients. ^, If operative treatment is selected, the procedures of choice for three-part and four-part fractures are reverse hemiarthroplasty or hemiathroplasty. ^,

Fracture-dislocation injuries are best managed in consultation with an orthopedic surgeon before attempts at reduction (except in cases of neurovascular compromise or unavailability of an orthopedic surgeon). Reductions of these injuries in the ED may be unsuccessful, and manipulation can cause separation of previously non-displaced segments. Closed reduction under fluoroscopic visualization and general anesthesia is preferable.

Fractures of the proximal humeral physis and metaphysis are uncommon and account for a small proportion of pediatric fractures. The injury can occur at any age while the physis remains open but is most common in adolescent boys. The most common mechanism of injury involves a fall onto the outstretched hand, and the fracture typically occurs through the zone of hypertrophy in the epiphyseal plate. Injuries can be classified according to their location (Salter system), stability, and degree of displacement.

The patient typically holds the injured arm tightly against the body, using the opposite hand. The area over the proximal humerus is swollen and tender to palpation. Complications are rare and include malunion, growth plate disturbances, and injuries to the neurovascular bundle. Markedly displaced or angulated fractures can result in a residual loss of mobility.

The differential diagnosis for pediatric proximal humeral fractures varies based on age and acuity of the injury. Differential diagnoses for acute traumatic injuries include osteochondral lesion in the GHJ (rare in the upper extremity), AC joint injury (more common in late teenage years as physis reaches maturity), and glenohumeral dislocation.

Orthogonal radiographs help confirm the diagnosis. Comparison views may be helpful with minimally displaced fractures ( Fig. 45.14 ). POCUS can also be used to identify these injuries.

(A) Salter I injury of the right proximal humeral epiphysis. (B), Normal left side is included for comparison.

Fractures of the proximal humeral epiphysis can result in significant permanent injury and disability as the physis accounts for 80% of the longitudinal growth of the bone. Urgent orthopedic consultation should be obtained for all such injuries in the ED.

SCJ dislocations are infrequent and account for less than 1% of all dislocations. Significant forces are required to disrupt the strong ligamentous stabilizers of this joint. The most common causes are MVCs and injuries sustained in high impact contact sports. The vast majority of dislocations are anterior. Posterior dislocations, although less common, can be associated with life-threatening injuries within the superior mediastinum. The usual mechanism of injury for anterior and posterior dislocations is pictured in Fig. 45.15 . Posterior dislocations can also result from a direct blow to the medial clavicle.

Mechanisms That Produce Posterior and Anterior Displacements of the Sternoclavicular Joint.

(A ) When a compression force (upper arrow) is applied to the posterolateral aspect of the shoulder, the medial end of the clavicle is displaced posteriorly (lower arrow). (B) When the lateral compression force (upper arrow) is directed from the anterior position, the medial end of the clavicle is dislocated anteriorly (lower arrow). The same mechanism could apply with any type of lateral compression injury of the shoulder.

From Neer CS, Rockwood CA. Fractures and dislocations of the shoulder. In Rockwood CA, Green DP, eds. Fractures in adults . 4th ed. Philadelphia: JB Lippincott; 1984.

Injuries to the SCJ can be graded into three types. A grade I injury is a mild sprain of the sternoclavicular and costoclavicular ligaments. A grade II injury is associated with subluxation of the joint (anterior or posterior) secondary to disruption of the sternoclavicular ligament and capsule. Complete rupture of the sternoclavicular and costoclavicular ligaments results in a grade III injury (true dislocation). In patients younger than 25 years old, these may represent Salter type I injuries if the medial clavicle epiphysis is unfused.

Clinical suspicion based on mechanism and exam is the single most important factor in diagnosing these injuries. The injured extremity is flexed at the elbow and supported across the trunk by the opposite arm. Pain results from any movement of the upper extremity or lateral compression of the shoulders. The SCJ may be mildly swollen and tender to palpation. With an anterior dislocation, the displaced medial end of the clavicle may be palpable. Posterior dislocations are more painful and may be associated with complaints of hoarseness, dysphagia, dyspnea, and weakness or paresthesia in the ipsilateral upper extremity. The patient’s neck is often flexed toward the injured side and the clavicular notch of the sternum may not be palpable. Hoarseness may be related to tracheal injury. Damage to the innominate vein may present as cyanosis and venous congestion of the neck, which should prompt vascular imaging and consultation. Complications of anterior injuries are primarily cosmetic. By contrast, 25% of posterior dislocations may be complicated by life-threatening injuries to intrathoracic and superior mediastinal structures. These include compression or laceration of the great vessels, tracheoesophageal fistula, tracheal compression, pneumothorax, thoracic outlet syndrome, and brachial plexus injuries.

The differential diagnosis for patients with traumatic SC joint pain include medial clavicle fracture, rib fracture, costochondral injury, sternum fracture, sternoclavicular dislocation, contusion, mediastinal injury, and pneumothorax.

Although diagnosed clinically, sternoclavicular dislocation requires radiological confirmation. Findings on standard anteroposterior, oblique, and specialized (40-degree cephalic tilt) SCJ views are challenging to interpret. These dislocations and associated injuries are best visualized by a chest CT angiogram ( Fig. 45.16 ). POCUS can be a useful bedside adjunctive test.

This computed tomography (CT) scan shows posterior dislocation of the right sternoclavicular joint (SCJ; arrow ) with compression of the superior mediastinum.

Courtesy Donald Sauser, MD.

Treatment of grade I injuries includes sling immobilization for comfort and primary care follow-up. Immobilization generally is maintained until symptoms improve and full painless motion is restored. Grade II injuries should be immobilized with a sling and the patient referred for orthopedic follow-up care. Grade II injuries require a longer course of immobilization (4 to 6 weeks) and are more likely to be associated with persistent pain. Grade III injuries are generally managed by closed reduction and rarely with open reduction.

Anterior dislocations may be reduced in the ED with proper analgesia and on occasion may require general anesthesia. Patient positioning is optimized by a bolster between the scapulae ( Fig. 45.17 ). Stable reductions should be maintained in a sling and referred for orthopedic follow-up care. Most reductions are unstable; and because the deformity is primarily cosmetic and not functional, the treatment of choice for recurrent anterior dislocations is benign neglect and pain control.

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