Anatomy Msk · Year 1 · from Anatomy Msk
Case 2: Clavicle Fracture
Clinical Image
Source: Wikimedia Commons - Clavicle Fracture X-ray - CC BY-SA 3.0
Case Presentation
A 19-year-old cyclist is brought to the emergency department after a crash during a race. He went over his handlebars and landed directly on his left shoulder. He reports immediate pain over his left clavicle and is holding his left arm against his body for support. Physical examination reveals obvious deformity over the middle third of the left clavicle with visible tenting of the skin. There is significant swelling, tenderness, and palpable crepitus at the fracture site. The distal fragment is displaced inferiorly and medially due to the weight of the arm, while the proximal fragment is elevated by the sternocleidomastoid. Neurovascular examination of the left upper extremity is intact with normal radial pulse, sensation, and motor function. Chest examination is clear, and there is no subcutaneous emphysema. Radiographs confirm a displaced, comminuted fracture of the middle third of the clavicle with shortening greater than 2 cm. Given the significant displacement, comminution, and shortening (risk factors for nonunion), he undergoes open reduction and internal fixation with a superior clavicle plate. At 3-month follow-up, the fracture has healed with full return to cycling.
Key Learning Points
- The clavicle is the most commonly fractured bone in the body; 80% occur in the middle third
- Middle third is the weakest point, lacking ligamentous attachments and having a transition in cross-section
- The sternocleidomastoid elevates the proximal fragment; arm weight pulls the distal fragment inferiorly and medially
- The subclavian vessels and brachial plexus lie posterior to the middle third clavicle and can be injured
- Operative indications include significant displacement, shortening >2cm, open fracture, and neurovascular injury