Clavicle fractures account for 2.6–4% of all fractures and are among the most common injuries seen in the ED, most frequently affecting males younger than 30 years. [1-2] The majority (~80%) involve the midshaft, with most nondisplaced fractures managed nonoperatively with sling immobilization and outpatient orthopedic follow-up. [1-2]
1. History
- Mechanism of injury: Fall onto the lateral shoulder (~90% of cases), direct blow, fall onto outstretched hand (2–5%), or high-energy trauma (MVC, cycling, contact sports) [3-4]
- Location and radiation of pain: Shoulder, clavicular region; ask about arm/hand numbness, weakness, or paresthesias suggesting brachial plexus involvement [5]
- Timing: Acute vs. delayed presentation (pseudoaneurysm, expanding hematoma can present days later) [6]
- Associated symptoms: Dyspnea (pneumothorax), swelling, inability to raise arm, crepitus
- Important negatives: No chest pain, no shortness of breath, no hand/arm weakness or color change; in pediatric patients without trauma history, consider malignancy, rickets, or non-accidental trauma [4]
2. Alarm Features
- Open fracture (bone through skin) — emergent orthopedic consultation [1]
- Posteriorly displaced medial (proximal) clavicle fracture — risk of tracheal/esophageal/great vessel compression; requires emergent evaluation [1][5]
- Skin tenting — impending open fracture [5]
- Neurovascular compromise: Absent distal pulses, expanding supraclavicular mass, brachial plexopathy (arm weakness/numbness) — associated with subclavian artery/vein injury [6-7]
- Dyspnea or decreased breath sounds — pneumothorax from displaced fragment [8-9]
- Floating shoulder — ipsilateral clavicle fracture + scapular neck fracture = unstable shoulder girdle [1]
- High-energy mechanism with polytrauma — 76% of polytrauma patients with clavicle fractures have concomitant thoracic injury [10]
3. Medications
- First-line analgesia: Acetaminophen + NSAIDs (ibuprofen, naproxen) as multimodal approach
- Opioids: Short-course for breakthrough pain; use caution with respiratory depression, especially if concern for pneumothorax
- Regional anesthesia in ED: Ultrasound-guided clavipectoral plane block or supraclavicular nerve block provides excellent analgesia with significant pain reduction and opioid-sparing effect; hematoma block is another option [11-15]
- Avoid: Prolonged opioid prescriptions; NSAIDs are sometimes debated regarding fracture healing, though clinical significance remains uncertain
- Bone stimulators (LIPUS): Not recommended per AAOS CPG — no benefit on union rate or time to union [2]
4. Diet
- Ensure adequate calcium and vitamin D intake to support bone healing
- Adequate protein intake for fracture recovery
- Smoking cessation is critical — smoking is a modifiable risk factor for nonunion per AAOS guidelines [2]
- Alcohol moderation — excessive use impairs bone healing
5. Review of Systems
- Respiratory: Dyspnea, pleuritic chest pain (pneumothorax/hemothorax) [8][16]
- Neurologic: Arm/hand weakness, numbness, tingling (brachial plexus injury) [7]
- Vascular: Arm swelling, color change, coolness (subclavian vessel injury) [6]
- MSK: Ipsilateral rib pain, scapular pain (floating shoulder), sternoclavicular joint pain
- Constitutional: If atraumatic, ask about fevers, weight loss, night sweats (pathologic fracture)
6. Collateral History and Family History
- Witnesses to mechanism (especially in pediatric/elderly patients — assess for non-accidental trauma or mechanical fall risk)
- Hand dominance and occupation (manual labor, overhead work, athlete — influences surgical decision-making) [2]
- History of osteoporosis or metabolic bone disease in elderly patients
- Family history of bone disorders or osteoporosis if atraumatic fracture
7. Risk Factors
- Age: Bimodal — young males (sports/trauma) and elderly females (osteoporosis/falls) [3]
- Male sex (higher incidence in younger populations) [2]
- Contact/collision sports: Football, rugby, cycling, skiing, equestrian [3][17]
- Osteoporosis in elderly
- Smoking: Modifiable risk factor for nonunion [2]
- High-energy mechanism: Greater displacement, comminution, associated injuries
Risk factors for nonunion (important for counseling): Displacement >100%, shortening >2 cm, comminution, female sex, smoking, advanced age, open fracture [1][18-19]
8. Differential Diagnosis
- AC joint separation — tenderness at AC joint, positive cross-body adduction test; deformity more lateral
- Sternoclavicular joint dislocation — medial tenderness/deformity; posterior dislocation is a surgical emergency
- Proximal humerus fracture — more lateral pain, different mechanism
- Scapula fracture — posterior shoulder pain; consider floating shoulder if concurrent
- Rib fracture — chest wall tenderness, pleuritic pain
- Pathologic fracture — atraumatic or minimal trauma in setting of malignancy or metabolic bone disease
- Shoulder dislocation — loss of deltoid contour, limited ROM
- Non-accidental trauma (pediatric) — inconsistent history, multiple fractures in various stages of healing [4]
9. Past Medical History
- Prior clavicle fractures or shoulder injuries (refracture is a risk factor for nonunion) [18]
- Osteoporosis, metabolic bone disease, malignancy
- Prior shoulder surgery
- Chronic conditions: Diabetes, peripheral vascular disease (affect healing)
- Smoking history, substance use
- Anticoagulant use (bleeding risk, hematoma expansion)
10. Physical Exam
- Inspection: Visible deformity ("Z" deformity with displaced midshaft fractures), swelling, ecchymosis, skin tenting, open wound [2][5]
- Palpation: Point tenderness over fracture site, crepitus, step-off; palpate entire clavicle including SC and AC joints
- Neurovascular exam (critical):
- Distal pulses (radial, ulnar), capillary refill
- Motor/sensory exam of the upper extremity (brachial plexus — C5-T1 distributions)
- Brachial-brachial index if concern for vascular injury [7]
- Respiratory: Auscultate bilateral lung fields — decreased breath sounds suggests pneumothorax [8]
- Shoulder: Assess ipsilateral scapula, AC joint, glenohumeral joint for associated injuries
- Skin: Assess for tenting or impending open fracture
11. Lab Studies
- Routine labs are generally not indicated for isolated clavicle fractures
- Consider CBC, BMP, coagulation studies in polytrauma or if surgical intervention is anticipated
- Type and screen if concern for vascular injury or significant hemorrhage
- In elderly or atraumatic fractures: Consider calcium, vitamin D, PTH, TSH to evaluate for metabolic bone disease
- If pathologic fracture suspected: ESR, CRP, serum protein electrophoresis, alkaline phosphatase
12. Imaging
- First-line: AP clavicle radiograph — confirms diagnosis in most cases [3]
- Additional views: AP with 45° cephalic tilt (Zanca view) to better characterize displacement and shortening; can help evaluate distal third fractures [3]
- Chest X-ray: Should be obtained with significantly displaced fractures or any respiratory symptoms to evaluate for pneumothorax, hemothorax, or intrathoracic displacement [8][10]
- CT scan: Indicated for:
- Medial (proximal) clavicle fractures — to assess posterior displacement toward mediastinal structures [1]
- Suspected intrathoracic fragment displacement [8]
- Preoperative planning for complex/comminuted fractures
- CT angiography: If concern for subclavian artery/vein injury (expanding hematoma, pulse deficit, brachial plexopathy) [6]
- Imaging is unnecessary: Ultrasound can be used as a bedside adjunct but is not standard for fracture characterization
13. Special Tests
- Allman Classification: [4][20]
- Group I: Middle third (~80%)
- Group II: Lateral/distal third (~15%)
- Group III: Medial/proximal third (~5%)
- Robinson Classification: Incorporates displacement and comminution for prognostic value [18]
- Point-of-care ultrasound (POCUS): Can identify fracture at bedside; also useful for guiding nerve blocks and assessing for pneumothorax [11][14]
- Brachial-brachial index: Ratio of bilateral brachial artery pressures — abnormal if <0.9, suggests axillosubclavian vessel injury [7]
14. ECG
- Not routinely indicated for isolated clavicle fractures
- Consider ECG in:
- High-energy/polytrauma — to evaluate for myocardial contusion [10]
- Elderly patients with fall — rule out syncope as cause of fall
- Posteriorly displaced medial clavicle fracture with chest pain
15. Assessment
Clavicle fractures are classified by location (midshaft most common), displacement, comminution, and shortening. [1-2] Most are low-energy injuries in young active patients and heal well with conservative management. Key clinical decisions center on identifying fractures requiring emergent consultation (open fractures, posterior SC dislocations, neurovascular compromise) versus those needing urgent orthopedic referral (>100% displacement, >2 cm shortening, comminution, floating shoulder) versus those safe for outpatient follow-up. [1]
Complications to consider
- Nonunion (3–15% depending on displacement) [2][18]
- Symptomatic malunion with shoulder dysfunction
- Pneumothorax/hemothorax (rare but dangerous) [8-9]
- Neurovascular injury (<1% but high morbidity) [7][21]
- Hardware complications if surgically treated (reoperation rate ~25%, mostly implant removal) [19]
16. Treatment Plan
Initial stabilization (ED)
- Sling immobilization — preferred over figure-of-eight bandage (better comfort, equivalent outcomes) [22]
- Multimodal analgesia: Acetaminophen + NSAID ± short-course opioid for breakthrough pain
- Regional anesthesia: Consider US-guided clavipectoral plane block or supraclavicular nerve block for severe pain [11][13]
- Ice, elevation of head of bed
Nonoperative management (majority of fractures)
- Sling for 2–6 weeks for comfort [3][18]
- Pendulum exercises beginning at 1–2 weeks as pain allows
- Progressive ROM and strengthening after clinical and radiographic healing
Surgical indications: [1][22]
- Emergent: Open fracture, posteriorly displaced proximal fracture, neurovascular compromise
- Urgent/elective: >100% displacement, >2 cm shortening, comminuted fractures, floating shoulder, skin tenting, high-demand patient/athlete (shared decision-making)
- Per AAOS CPG: Surgical treatment of displaced midshaft fractures yields higher union rates and better early outcomes, though long-term outcomes are similar to nonoperative treatment [2][22]
- Fixation options: Plate osteosynthesis (superior or anterior) or intramedullary fixation [2]
Pediatric considerations: Generally managed conservatively due to high healing and remodeling potential; adult algorithms apply for adolescents >9 years (girls) and >12 years (boys) [1][5]
17. Disposition
Discharge (majority of patients)
- Nondisplaced or minimally displaced fractures with no neurovascular compromise
- Adequate pain control achieved
- Sling immobilization with orthopedic follow-up in 1–2 weeks [1]
Emergent orthopedic consultation in ED
- Open fracture
- Posteriorly displaced medial clavicle fracture
- Neurovascular compromise
- Intrathoracic fragment displacement [1][8]
Urgent orthopedic referral (within days)
- 100% displacement, >2 cm shortening
- Comminuted fractures
- Floating shoulder
- Skin tenting/impending open fracture [1]
Admission
- Associated pneumothorax/hemothorax requiring chest tube
- Polytrauma
- Vascular injury requiring intervention
18. Follow-Up / Return Precautions
Follow-up timing
- Orthopedic follow-up in 1–2 weeks for repeat radiographs and reassessment
- Serial radiographs at 6 and 12 weeks to assess union
- Typical healing time: 6–12 weeks in adults; faster in children
Return-to-activity criteria: [5][17]
- Radiographic evidence of healing
- No tenderness at fracture site
- Full ROM and strength
- Resolution of neurologic symptoms
- Conservatively managed adolescent athletes return to sport in ~61 days on average [17]
Return precautions (instruct patient to return immediately for):
- Increasing arm/hand numbness, weakness, or color change
- New or worsening shortness of breath or chest pain
- Increasing swelling or expanding mass over the fracture site
- Skin breakdown over the fracture
- Fever (if post-surgical)
Patient counseling
- Prominent callus formation is normal and expected, especially in children [4]
- Avoid lifting, overhead activity, and contact sports until cleared
- Smoking cessation strongly advised — significantly increases nonunion risk [2]
- Most patients achieve excellent functional outcomes with either treatment approach [2][22]
References
1. The Emergency Medicine Management of Clavicle Fractures. — Serpico M, Tomberg S. The American Journal of Emergency Medicine. 2021.
2. American Academy of Orthopaedic Surgeons Clinical Practice Guideline Summary on the Treatment of Clavicle Fractures. — Wright M, Della Rocca GJ. The Journal of the American Academy of Orthopaedic Surgeons. 2023.
3. Surgical Versus Conservative Interventions for Treating Fractures of the Middle Third of the Clavicle. — Lenza M, Buchbinder R, Johnston RV, Ferrari BA, Faloppa F. The Cochrane Database of Systematic Reviews. 2019.
4. Clavicle Fractures. — Pecci M, Kreher JB. American Family Physician. 2008.
5. The Adolescent Athlete and the Team Physician: A Consensus Statement. 2025 Update. — Putukian M, Leclere LE, Herring SA, et al. Medicine and Science in Sports and Exercise. 2026.
6. Emergency Bedside Sonographic Diagnosis of Subclavian Artery Pseudoaneurysm With Brachial Plexopathy After Clavicle Fracture. — Gullo J, Singletary EM, Larese S. Annals of Emergency Medicine. 2013.
7. Brachial Plexus Injury Significantly Increases Risk of Axillosubclavian Vessel Injury in Blunt Trauma Patients With Clavicle Fractures. — Tay E, Grigorian A, Schubl SD, et al. The American Surgeon. 2021.
8. Clavicle Fracture With Intrathoracic Displacement. — Lohse GR, Lee DH. Orthopedics. 2013.
9. Pneumothorax Complicating a Closed Fracture of the Clavicle. A Case Report. — Dugdale TW, Fulkerson JP. Clinical Orthopaedics and Related Research. 1987.
10. Associated Thoracic Injury in Patients With a Clavicle Fracture: A Retrospective Analysis of 1461 Polytrauma Patients. — van Laarhoven JJEM, Hietbrink F, Ferree S, et al. European Journal of Trauma and Emergency Surgery : Official Publication of the European Trauma Society. 2019.
11. Clavipectoral Plane Block Performed in the Emergency Department for Analgesia After Clavicular Fractures. — Ashworth H, Martin D, Nagdev A, Lind K. The American Journal of Emergency Medicine. 2023.
12. Ultrasound-Guided Nerve Blocks for Patients With Clavicle Fracture in the Emergency Department. — Chen CC, Su EH, Li H, et al. Journal of Clinical Medicine. 2026.
13. Ultrasound-Guided Supraclavicular Nerves Block for Acute Pain Management in Clavicular Fractures-a Pragmatic Randomized Trial. — Schöll E, Gerbershagen MU, Vach W, Rösli M, Litz RJ. Journal of Clinical Medicine. 2025.
14. Ultrasound-Guided Hematoma Block for a Clavicular Fracture. — DeJulio P, Korn R, Oswald J. The Journal of Emergency Medicine. 2021.
15. Optimizing Pain Relief in Clavicle Fractures: A Case Series on Ultrasound Guided Hematoma Block. — Abhiraj R, Raj AS, Chandran Karapparambil V, Bhoi SK. The American Journal of Emergency Medicine. 2025.
16. Clavicle Fracture With Thoracic Penetration and Hemopneumothorax but Without Neurovascular Compromise. — Tjoumakaris FP, Matzon JL, Williams GR. Orthopedics. 2011.
17. Factors Influencing Time to Return to Sport Following Clavicular Fractures in Adolescent Athletes. — Ahearn BM, Shanley E, Thigpen CA, Pill SG, Kissenberth MJ. Journal of Shoulder and Elbow Surgery. 2021.
18. Conservative Interventions for Treating Middle Third Clavicle Fractures in Adolescents and Adults. — Lenza M, Faloppa F. The Cochrane Database of Systematic Reviews. 2016.
19. Rate of and Risk Factors for Reoperations After Open Reduction and Internal Fixation of Midshaft Clavicle Fractures: A Population-Based Study in Ontario, Canada. — Leroux T, Wasserstein D, Henry P, et al. The Journal of Bone and Joint Surgery. American Volume. 2014.
20. Acute Shoulder Injuries in Adults. — Simon LM, Nguyen V, Ezinwa NM. American Family Physician. 2023.
21. Clavicle Fractures With Associated Acute Neurovascular Injury. — Meyer MA, Zhang D, Price MD, et al. Orthopedics. 2021.
22. Treatment of Clavicle Fractures: Evidence-Based Clinical Practice Guideline. — American Academy of Orthopaedic Surgeons (2022). 2022.