Fractures of Clavicle: Classification, Symptoms, Treatment Options, and Rehabilitation

The clavicle is an S‑shaped bone that articulates with the sternum at the sternoclavicular joint and with the scapula at the acromioclavicular joint. Laterally, at its acromial end, it is flattened; the body is cylindrical, and the sternal end may be described as prismatic. It plays a key role in maintaining shoulder stability.

Etiology and Mechanism of Injury

Clavicle fractures occur primarily as a result of direct or indirect trauma.

Most common causes include:

1. Falling onto the shoulder or an outstretched hand.
2. Sports injuries (most often cycling or football).
3. Road traffic accidents.

The primary mechanism of injury is a fall directly onto the lateral aspect of the shoulder, producing a compressive force that leads to fracture (seen in approximately 85 % of cases). Less commonly, the fracture may result from a direct blow to the clavicle or from indirect force transmitted through the arm.

Displacement of clavicular fragments is determined by the pull of muscles attached to the bone:

• Medial (central) fragments: displaced superiorly and posteriorly due to the pull of the sternocleidomastoid muscle.
• Lateral fragments: displaced inferiorly and medially due to the action of the pectoralis major muscle and the weight of the upper limb.

Epidemiology

Clavicle fractures account for approximately 2.6–5 % of all fractures and up to 44 % of injuries to the pectoral girdle. They are most common in young, active individuals and children, with peak incidence in males aged 13–20 years.

Classification of Clavicle Fractures

The basic classification relies on the location of the fracture relative to the anatomical regions of the clavicle:

• Midshaft (middle 1/3) fractures: 75–80 % of all clavicle fractures.
• Acromial end (lateral 1/3) fractures: 15–25 %.
• Sternal end (medial 1/3) fractures: 2–5 %.

The high frequency of midshaft (middle 1/3) fractures is due to this region being the thinnest and narrowest portion of the clavicle and lacking ligamentous and muscular support.

Neer Classification (for Acromial End Fractures)

The Neer classification is widely used in clinical practice to guide treatment decisions for fractures of the acromial (distal) end of the clavicle. It identifies five major fracture types and two subtypes.

3D-Models of Clavicle Fractures:

Extra‑Articular Fracture of Sternal End of Clavicle

Comminuted Midshaft Fracture

Extra‑Articular Comminuted Fracture of Acromial End of Clavicle (Neer Type V)

Clinical Manifestations and Symptoms

Typical clinical manifestations of clavicle fractures include:

1. Immediate shoulder pain and loss of function.
2. The arm is held close to the body and supported by the opposite hand.
3. Swelling, hematoma, and a palpable bony prominence beneath the skin.
4. Possible “skin tenting”, or, less commonly, an open fracture.
5. Possible injury to adjacent vessels and nerves.

Diagnosis

Diagnosis is based on clinical evaluation and radiologic imaging.

Clinical Evaluation

• History of injury: The patient reports a traumatic event accompanied by a distinct cracking sound followed by pain.
• Examination: Visible deformity in the clavicular region, soft‑tissue swelling, and a hematoma over the fracture site.
• Palpation: Localized tenderness and crepitus.
• Range of motion: Limited movement of the ipsilateral upper extremity due to pain.

Radiologic Methods

• Radiography: Standard anteroposterior view and a 15° cephalic tilt (Zanca view) demonstrate the fracture location, displacement, and presence of fragments.
• CT (computed tomography): Indicated for complex comminuted fractures and fractures of the sternal or acromial ends.

Treatment of Clavicle Fractures

Medical Therapy

Medical therapy is associated with a high rate of bone union in children and in minimally displaced fractures in adults.

Indications:

1. Midshaft fractures without displacement or with minimal displacement.
2. No associated vascular or nerve injury.
3. No skin compromise or significant shortening of the shoulder girdle (less than 2 cm).

Procedure:

1. Sling or figure‑of‑eight brace (Delbet rings) for immobilization.
2. Pain control and gradual return to activity over 6–12 weeks.
3. Physical therapy: Passive, pain‑free range of motion beginning at Week 2; resistance exercises starting at Week 6; return to full athletic activity by Month 4–6.

Surgical therapy

Surgery may provide earlier functional recovery and reduce the risk of nonunion or malunion in significantly displaced fractures.

Indications:

1. Diaphyseal fractures with significant shortening (> 2 cm) and displacement.
2. Open fractures.
3. Associated vascular or nerve injury.
4. Skin tenting around fragments with risk of skin breakdown.
5. Multifragmentary fractures; injury to the capsuloligamentous structures of the acromioclavicular or sternoclavicular joints.

Procedure:

1. Open reduction and internal fixation (ORIF) using plates and screws. Immobilization in a soft sling for 7–10 days, followed by active motion in a pain‑free range. Resistance and strengthening exercises beginning at Week 6. Return to athletic activity at approximately 3 months.
2. Intramedullary osteosynthesis (less frequently).

Rehabilitation: Principles and Phases

Rehabilitation follows a staged progression of orthopedic protection and gradually increasing load: immobilization (sling) → early passive motion → active motion → muscle strengthening → return to activity. The rate of progression depends on fracture type and treatment method.

Rehabilitation for Fractures of Sternal End of Clavicle

Rehabilitation for Midshaft Clavicle Fractures

Medical Therapy

Surgical Therapy

Rehabilitation for Fractures of Acromial End of Clavicle

Medical Therapy

Surgical Therapy

Return‑to‑Sport Protocol

General Requirements:

• No local tenderness at the fracture site.
• Radiographic evidence of fracture union
• Full, pain‑free active range of motion in the shoulder.
• Ability to perform sport‑specific movements without limitation.

The process of returning to sport should be structured according to the timeline of the injury.

Load Progression by Phases:

• Phase 1 (up to 2–3 weeks): Only isometric activation of the muscles of the shoulder girdle is permitted.
• Phase 2 (2–6 weeks): Activities not involving the injured upper extremity are allowed (stationary cycling, lower‑extremity training without impact, aerobic activity without resistance). Resistance training for the injured arm, overhead exercises, and lifting weights are not permitted.
• Phase 3 (6–9 weeks): Light weight training and body‑weight exercises (planks, push‑ups, burpees) are allowed as tolerated.
• Phase 4 (9–12 weeks): Non‑contact sports is permitted, if entry criteria are met (radiographic evidence of union, pain‑free motion, etc.).
• Phase 5 (beyond 12 weeks): Contact sports and competitive activities are allowed.

Return to contact sports is permitted no earlier than 12 weeks after injury and only when fracture union is radiographically confirmed. Healing and recovery take more time in older adults, patients with metabolic disorders, and those who sustained high‑energy trauma. Children typically heal and recover more quickly.

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Prognosis

The prognosis for clavicle fractures is generally favorable, although outcomes depend significantly on fracture location and treatment strategy.

• Fractures of sternal end of clavicle: These are relatively rare. Medical therapy is associated with a high union rate and minimal complications. Surgical treatment may allow earlier functional recovery of the injured limb.
• Midshaft fractures: When treatment indications are followed, union occurs in approximately 85 % of cases with medical therapy and in more than 95 % of cases with surgical treatment. Surgery provides a faster return to full physical activity.
• Fractures of acromial end of clavicle: Medical therapy is associated with nonunion in up to 30 % of cases. There is also a risk of impaired shoulder function due to reduced deltoid muscle strength. Surgical treatment tends to restore the limb function more quickly and shows high union rates.