History and exam
Key diagnostic factors
common
presence of risk factors
Strong risk factors for clavicle fractures are acute trauma to the clavicle or shoulder, male sex, and age over 65 years or under 30 years.
pain over clavicle
Omnipresent unless mental status altered, intoxication, or distracting injury present.
Acute fractures usually cause moderate to severe pain at the fracture site.
The patient may report pain with attempted range of motion of shoulder or lifting a weight with the ipsilateral arm.
Pathologic and insufficiency fractures usually cause a sudden onset of pain at the fracture site.
Assess the patient’s pain regularly.
guarding
Omnipresent unless mental status altered, intoxication, or distracting injury present.
Look for impaired movement of the shoulder and guarding against movement of the upper limb. Patients tend to keep the injured arm at their side, and often try to support the weight of the injured extremity with their contralateral hand or by resting it on a table or the arm of a chair.
point tenderness over site of fracture
Omnipresent on physical exam unless mental status altered, intoxication, or distracting injury present.
soft tissue swelling at site of fracture
Inspection usually reveals soft tissue swelling around the injured area. A nonspecific sign.
deformity or step-off at site of fracture
Indicates displacement; present in up to 90% of midshaft clavicle fractures.[5]
crepitus
The patient may report audible and/or palpable crepitus, especially during attempted range of motion of the shoulder.
Other diagnostic factors
common
ecchymosis at site of fracture
Ecchymosis is often present within a day or two after the injury, gradually fading over time. A nonspecific sign.
uncommon
wound overlying site of fracture
If a wound is noted at or near the fracture site, treat the injury as an open fracture and refer for immediate orthopedic consultation.
skin tenting
Carefully look for skin tenting. Although this is uncommon (with studies showing an incidence of 4% to 9% in patients with displaced midshaft clavicle fracture) skin tenting is a risk factor for skin necrosis and may lead to an open injury.[22][23][24] It therefore requires urgent orthopedic consultation.
Risk factors
strong
acute trauma to the clavicle
Almost all clavicle fractures are caused by acute trauma; stress fractures of the clavicle are rare.
A direct fall on the shoulder (e.g., while playing sports) is the most common mechanism of injury in the population as a whole (87%), and particularly in younger age groups (<30 years) and in males.[5][6][14][15][16]
Road traffic accidents are another common cause.[5][6][16] In one study of clavicle fractures, of those resulting from a road traffic accident, 39% occurred in cyclists, 26% in car drivers or their passengers, 17% in motorcyclists, and 17% in pedestrians.[3]
A direct blow to the clavicle is a less common mechanism of injury, but if this is reported by the patient then it would have a strong association with a clavicle fracture.
A fall on the outstretched hand is a less common mechanism in adults (6%).[14][15]
male sex
age <30 years
age ≥65 years in females
Older age is a risk factor for clavicle fracture due to a low-energy mechanism (i.e., ground-level falls). Clavicle fractures are more common in women than in men in this age group.[5]
weak
osteoporosis (pathologic fractures)
People with osteoporosis are at increased risk for pathologic fracture, which may occur with what appears to be minimal trauma or trivial provocation. This is not specific for clavicle fractures.
bone tumor (pathologic fractures)
People with bone tumors of the clavicle are at increased risk for acute pathologic fracture with relatively minor trauma.[18] This is not specific for clavicle fractures.
low BMI (insufficiency fractures)
Weak risk factor for an insufficiency fracture in general, not specifically a clavicle fracture. May be helpful in understanding why a patient sustained a clavicle fracture in a given situation.
prior fracture (insufficiency fractures)
Weak risk factor for an insufficiency fracture in general, not specifically a clavicle fracture. May be helpful in understanding why a patient sustained a clavicle fracture in a given situation.
prolonged corticosteroid use (insufficiency fractures)
Weak risk factor for an insufficiency fracture in general, not specifically a clavicle fracture. May be helpful in understanding why a patient sustained a clavicle fracture in a given situation.
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