Characteristics

• The majority are caused by direct force to the shoulder, e.g. fall. Less commonly the fracture is secondary to transmitted force from falling onto an outstretched hand.

• The most common site is the junction of middle and outer third (80%).

• May be associated with a sternoclavicular or acromioclavicular dislocation.

Clinical features

• Patients will complain of pain at the site of the fracture and will be reluctant to move their shoulder or arm.

• There may be anterior, inferior and medial displacement of the shoulder in mid clavicular fractures due to the action of attached muscles.

• A palpable step and fracture crepitus can often be felt.

• Rarely these are open injuries.

• Occasionally the skin can be tethered on fracture ends; as long as the skin is not jeopardized it is safe to treat this as a closed fracture. The skin usually separates off from the fracture ends, as a sling is applied.

• Pressure necrosis of the overlying skin is a rare but serious complication.

• Rarely there may be an associated pneumothorax or neurovascular injury.

Radiological features

• A single AP view is usually adequate.

• Often the fracture line is obvious, although in children a greenstick fracture can be difficult to see, but treat as below and review at 2 weeks will distinguish the fractures.

• Beware subtle pneumothorax secondary to a bony fragment.

• In a patient with a history of malignancy, or when the history does not support the presence of a traumatic injury, a pathological fracture should be considered.

• This may be secondary to recurrent disease but always ask for a history of radiotherapy as radionecrosis can mimic metastasis.

Management

• ABCs, assess soft tissues and neurovascular status and immobilise.

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