Clavicle Fracture Management: Anatomy, Treatment, PT & 25 MCQs

Fracture of the Clavicle (Collarbone)

Clavicle fractures are among the most common bony injuries in the body (approx. 5-10% of all fractures). The clavicle acts as the only bony strut connecting the upper limb to the trunk. It is also the most common fracture during birth.

1. Anatomy & Displacement Pattern

When the clavicle fractures, the fragments displace in a specific pattern due to muscle pull:

• Medial Fragment: Pulled upward and backward by the Sternocleidomastoid (SCM) muscle.
• Lateral Fragment: Pulled downward, forward, and medially by the weight of the arm and the Pectoralis Major.

2. Allman Classification

This is the most widely used system based on anatomical location:

• Group I (Middle 1/3): The most common (80%). The bone is weakest here (junction of medial convex and lateral concave curves).
• Group II (Lateral 1/3): (15%). Further sub-classified by Neer based on Coracoclavicular (CC) ligament integrity.
• Group III (Medial 1/3): (5%). Rare; requires high-energy trauma.

3. Clinical Features

• Pain and inability to lift the arm.
• The patient supports the elbow of the injured side with the normal hand.
• Deformity: Visible step-off or bump.
• Tenting of Skin: The sharp bone fragment presses against the skin (Warning sign!).

⚠ Critical Complications (The "Must Know"):
1. Malunion: The most common complication (cosmetic bump, shortening).
2. Neurovascular Injury: Rare, but check Brachial Plexus and Subclavian vessels.
3. Non-union: Risk increases with smoking and massive displacement.
4. Pneumothorax: If the apical lung is punctured (rare).

4. Medical Management

Conservative (Non-Operative)

Indicated for most Group I fractures with minimal displacement.

• Arm Sling or Triangular Sling: For comfort and support.
• Figure-of-8 Bandage: Attempts to retract shoulders (though evidence suggests it offers no better union rate than a simple sling and may cause nerve compression).
• Duration: 3-4 weeks for children, 6-8 weeks for adults.

Surgical (ORIF)

Absolute Indications:

• Open fractures.
• Neurovascular injury.
• Skin tenting (impending open fracture).
• "Floating Shoulder" (Clavicle fracture + Scapular neck fracture).
• Symptomatic non-union.

Method: Plate and Screw fixation is the gold standard.

5. Physiotherapy Management

Phase 1: Protection (0-3 Weeks)

• Immobilization in sling.
• Active ROM of elbow, wrist, and hand (to prevent stiffness).
• Postural correction.

Phase 2: Mobilization (3-6 Weeks)

• Pendulum exercises (Codman's).
• Assisted active flexion and abduction (limit to 90 degrees initially).
• Scapular setting exercises (retraction).

Phase 3: Strengthening (6+ Weeks)

• Full ROM exercises.
• Theraband strengthening for Rotator Cuff.
• Return to contact sports usually after 3 months (once radiological union is solid).

Exam Corner: 25 Practice MCQs

Q1. Which part of the clavicle is most commonly fractured?

Answer: B) Middle 1/3. Approximately 80% of fractures occur here because it is the junction of two curves and lacks muscle reinforcement.

Q2. In a displaced clavicle fracture, the medial fragment is elevated by which muscle?

Answer: B) SCM. The Sternocleidomastoid pulls the medial fragment superiorly.

Q3. Which muscle pulls the lateral fragment downwards and medially?

Answer: A) Pectoralis Major. Gravity and the Pectoralis Major pull the arm and lateral fragment down and in.

Q4. The classification system used for clavicle fractures is:

Answer: B) Allman. It divides the clavicle into thirds.

Q5. What is the most common complication of a clavicle fracture?

Answer: B) Malunion. The bone often heals with a bump or shortening, but function usually remains good.

Q6. "Floating Shoulder" implies a fracture of the clavicle combined with:

Answer: B) Scapular neck fracture. This creates an unstable shoulder girdle and usually requires surgery.

Q7. Which neurovascular structure is immediately posterior to the middle third of the clavicle?

Answer: B) Subclavian vessels and Brachial Plexus. These are at risk in severe posterior displacement.

Q8. Which specific X-ray view helps assess clavicle displacement/shortening best?

Answer: C) 45° Cephalic Tilt. It projects the clavicle away from the thoracic cage ribs.

Q9. The figure-of-8 bandage is used to:

Answer: A) Retract the shoulders. It pulls shoulders back to align fragments, though patient compliance is often poor compared to a sling.

Q10. Which of the following is an ABSOLUTE indication for surgery?

Answer: B) Skin tenting. If the skin is compromised, surgery is needed to prevent conversion to an open fracture.

Q11. A "Greenstick" fracture of the clavicle is most common in:

Answer: B) Children. Their periosteum is thick, leading to incomplete fractures.

Q12. When does the clavicle usually ossify?

Answer: A) First bone to ossify. It begins ossification at the 5th week of gestation.

Q13. Neer classification is specifically used for fractures of the:

Answer: C) Lateral 1/3. It assesses the relationship with the Coracoclavicular ligaments.

Q14. During early physiotherapy (Week 1-3), which movement is generally encouraged?

Answer: B) Elbow, wrist, and hand ROM. Distal joints must be kept mobile while the fracture site is protected.

Q15. What is the primary mechanism of injury for clavicle fractures?

Answer: B) Fall onto the shoulder. Direct blows are less common causes than falls (FOOSH).

Q16. Which type of Clavicle fracture is rare?

Answer: A) Medial 1/3. It accounts for only ~5% of cases.

Q17. In Neer Type II distal clavicle fractures, the fracture line is:

Answer: B) Medial to the CC ligaments. This detaches the proximal fragment from the ligaments, making it highly unstable.

Q18. A patient with a clavicle fracture presents with shortness of breath and decreased breath sounds on the injured side. You suspect:

Answer: B) Pneumothorax. A displaced fragment can puncture the pleura/lung apex.

Q19. The Clavicle is classified as which type of bone?

Answer: A) Long bone. It is a modified long bone placed horizontally.

Q20. Which lifestyle factor significantly increases the risk of Non-union?

Answer: B) Smoking. Nicotine vasoconstriction impedes bone healing.

Q21. The primary type of ossification for the clavicle is:

Answer: A) Intramembranous. Unlike other long bones, it ossifies primarily via intramembranous ossification (except the ends).

Q22. Pendulum exercises (Codman's) rely on:

Answer: B) Gravity and momentum. This allows movement without stressing the fracture site with muscle pull.

Q23. The typical healing time for an adult clavicle fracture is:

Answer: C) 6 to 8 weeks. Clinical union often precedes radiological union.

Q24. A late complication involving pain, numbness, and tingling in the arm caused by hypertrophic callus is:

Answer: A) Thoracic Outlet Syndrome. Excess bone formation can compress the plexus/vessels in the costoclavicular space.

Q25. If conservative treatment fails and the bone does not join after 6 months, it is called:

Answer: B) Non-union. This usually requires bone grafting and fixation.