01OverviewDefinition, clinical context and the essential points that orientate the chapter.
The clavicle connects the arm to the axial skeleton and shelters the neurovascular bundle over the first rib. Most fractures involve the middle third. Lateral fractures can be unstable when coracoclavicular support is lost. An AC prominence partly reflects the scapula and arm dropping rather than the clavicle rising. Describe site, displacement, comminution, skin, stability and functional demand rather than relying on one classification label.
Expose both shoulders and chest, palpate gently from sternoclavicular to AC joint and examine elbow and wrist. A road collision or fall from height demands broader trauma assessment. Most isolated closed injuries heal without surgery; urgent indications arise from tissue and limb threat, while elective fixation is selective. Explain likely residual bump, progress movement as pain permits and investigate persistent pain or dysfunction rather than extending immobilisation indefinitely.
For clavicular fractures, specify medial, middle or lateral third and whether the pattern is displaced, shortened, comminuted, segmental or associated with scapular-neck disruption. A lateral fracture may lose coracoclavicular support and behave less predictably than a routine midshaft injury. For AC injury, distinguish a ligament sprain from vertical or posterior instability. Rockwood I and II generally retain enough stability for functional care; III requires individual assessment; IV, V and VI represent greater displacement requiring early shoulder-specialist review. Classification supports communication but skin pressure, neurovascular safety and the patient's work still determine urgency.
Non-operative care is active rather than passive. Fit a broad-arm sling for comfort without compressing the fracture, then maintain hand, wrist and elbow motion immediately. Pendular shoulder exercises begin when pain permits, progressing to assisted and active elevation under the fracture pathway. Heavy lifting, contact sport and overhead work wait for clinical healing and functional control. Routine repeat radiographs are unnecessary for every low-risk injury, but worsening deformity, persistent focal pain, failure of functional progression or new neurological symptoms justifies renewed examination and imaging. Smoking cessation, nutrition and practical sleep positioning can improve recovery experience.
Operative discussion separates emergency indication from preference-sensitive benefit. Open injury, non-viable skin, vascular damage and an unstable shoulder-girdle complex require urgent intervention. For closed midshaft displacement or symptomatic lateral instability, consider age, shortening, comminution, dominant arm, occupation, sport, smoking and tolerance of nonunion versus scar and hardware. Plate fixation may restore length but brings wound, sensory and implant-removal risks. AC reconstruction choices depend on chronicity and direction of instability. Shared decision-making should use expected function rather than promising that a radiographic bump will disappear.
Older adults need a plan that permits self-care and minimises sling-related stiffness. Assess whether cognition, contralateral weakness or walking aids make immobilisation unsafe and involve therapy early. A standing-height injury in an adult aged 50 or older should connect with current fracture-liaison and falls-prevention services; the active 2026 BOAST outpatient standard integrates fracture prevention rather than the archived BOAST 9 document. In pregnancy, indicated radiography is not withheld, oral analgesia is selected for gestation and systemic NSAIDs are avoided from 20 weeks unless necessary and contraindicated from 28 weeks.
Follow-up questions should be functional and time specific. Ask whether the patient can dress, wash hair, sleep, drive safely and resume graded work, then compare active range with the uninjured side. Continuing focal clavicular tenderness, movement at the fracture, deformity progression or pain that stops rehabilitation raises concern for delayed union or nonunion. For AC injury, persistent horizontal instability, pain on cross-body loading and scapular dyskinesis justify specialist reassessment. Neuropathic symptoms require a repeated named-nerve map, not automatic attribution to sling pressure.
Safety-net advice separates expected soreness from urgent change. Increasing breathlessness, chest pain, hand coolness, colour change, new weakness or numbness, skin whitening over the fragment and wound discharge require prompt care. A sling should be removed briefly for hygiene and prescribed exercises while the arm remains supported. Driving resumes only when the patient can control the vehicle and is no longer impaired by the injury, sling or sedating medicines. Contact sport and heavy manual loading wait for clinical union, strength and sport-specific control confirmed through the fracture service.
Key points
- Assess mechanism and perform ABCDE after high energy because clavicle fracture can coexist with chest, scapular, head and cervical injury.
- Inspect the whole clavicle and AC joint for wounds, abrasion, blanching and tenting without repeatedly pressing a sharp fragment.
- Record radial pulse, refill and axillary, radial, median and ulnar motor and sensory function before and after sling or manipulation.
- Obtain an AP clavicle view with an additional angled view when needed and image the chest or shoulder girdle when associated injury is suspected.
- A sling, analgesia and early guided movement suit most closed uncomplicated midshaft fractures and Rockwood I or II AC injuries.
- Open injury, threatened skin, vascular compromise, progressive neurology or unstable high-energy girdle injury needs urgent specialist treatment.
- Rockwood III AC injury is individualised by occupation, sport, symptoms and instability; types IV to VI generally need early specialist review.
- After low-trauma fracture, integrate falls and bone-health action through current outpatient and fracture-liaison services.
02AetiologyUnderlying causes, associations and risk factors, with why each one matters.
Direct shoulder impact
A fall or collision onto the lateral shoulder compresses the girdle medially, commonly fracturing the clavicular midshaft or disrupting acromioclavicular and coracoclavicular restraints.
Outstretched-hand force
Axial load transmitted from the hand can injure the clavicle or AC joint, although direct lateral impact is the more characteristic mechanism.
Fragility or pathology
Low-energy fracture in an older adult may indicate osteoporosis, while preceding pain or a destructive lesion raises concern for pathological bone.
03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.
- 1Midshaft deforming forces
Sternocleidomastoid elevates the medial fragment while arm weight pulls the lateral fragment down, forward and medially, creating shortening and a palpable step.
- 2Ligamentous instability
AC injury ranges from ligament sprain with preserved alignment to complete AC and coracoclavicular disruption with vertical or posterior displacement.
- 3Soft-tissue vulnerability
A sharp fragment can stretch thin superior skin, while deeper displacement may injure pleura, subclavian vessels or brachial plexus.
- 4Healing mechanics
Callus usually restores continuity, but marked shortening, instability, nonunion or scapular dyskinesis can leave pain and reduced overhead endurance.
04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.
Local tenderness, crepitus, drooping shoulder, palpable step and pain supporting the arm are typical.
Superior-shoulder tenderness, swelling, pain on cross-body adduction and distal-clavicle prominence follow lateral impact.
Pale non-blanching pressure, progressive tenting or an open wound signals impending or established tissue failure.
Hypoxia, chest pain, reduced breath sounds or surgical emphysema requires immediate pleural assessment.
Pulse change, coolness, haematoma, paraesthesia or weakness suggests subclavian-vessel or brachial-plexus damage.
05InvestigationsWhat to request, why it matters and how to interpret it.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
AP and angled clavicle radiographsFirst step - Why
- Define location, displacement, shortening and comminution across the whole clavicle.
- Interpretation and limitations
- Radiographic displacement does not replace direct skin and neurovascular assessment.
- 02
Shoulder and AC-joint radiography - Why
- Assess joint alignment and exclude proximal humeral or glenohumeral injury.
- Interpretation and limitations
- Specialised or bilateral views may support specialist classification; painful weighted views are not routine emergency tests.
- 03
Chest radiograph or trauma CT - Why
- Detect pleural, rib, scapular and mediastinal injury after concerning mechanism or examination.
- Interpretation and limitations
- Use the major-trauma pathway and do not rely on normal saturation to exclude evolving pneumothorax.
- 04
CT angiography - Why
- Define suspected arterial injury in a stable enough patient with concerning vascular findings.
- Interpretation and limitations
- Imaging must not delay haemorrhage control or coordinated orthopaedic and vascular treatment.
06Differential diagnosisRealistic alternatives and the features that help distinguish them.
Glenohumeral dislocation
Loss of shoulder contour, fixed arm position and restricted rotation suggests dislocation; document axillary-nerve function and obtain appropriate views.
Proximal humeral fracture
Diffuse upper-arm bruising, pain with all shoulder movement and tenderness below the joint line favours proximal humeral injury.
Scapular or rib fracture
High-energy posterior shoulder or chest tenderness and respiratory symptoms should broaden trauma imaging beyond the clavicle.
Sternoclavicular dislocation
Medial prominence or depression with dysphagia, dyspnoea or venous congestion suggests injury that can compromise mediastinal structures.
07ManagementImmediate care, first-line treatment, alternatives and escalation.
01First assessmentExclude chest, skin and limb threatFirst stepA patient presents after impact to the shoulder girdle.+
- 1Perform ABCDE and examine chest, neck and scapula according to mechanism.
- 2Document wounds, blanching, pulses, refill and named peripheral-nerve functions.
- 3EscalationProvide analgesia and support, image appropriately and escalate tissue or vascular threat immediately.
02Stable injuryProtect briefly and restore motionExamination and imaging show a closed uncomplicated fracture or low-grade AC injury.+
- 1Use a broad-arm sling for comfort and encourage hand, wrist and elbow movement.
- 2Begin pendular and assisted shoulder movement as pain and local guidance permit.
- 3Provide warning signs and defined follow-up for persistent pain, instability or neurological change.
03Complex patternIndividualise specialist treatmentThere is major displacement, unstable lateral fracture or Rockwood III to VI injury.+
- 1Describe pattern and horizontal and vertical instability accurately and protect skin.
- 2Discuss occupation, sport, smoking, function, appearance and operative risks through early specialist review.
- 3After surgery, follow explicit wound, weight-bearing and rehabilitation restrictions and repeat neurovascular findings.
Key medicines and prescribing safety1 treatment · regimens, roles and cautions+
Paracetamol for adult shoulder-girdle pain
Give 500 mg to 1 g orally when required, leaving at least 4 hours between doses and not exceeding four doses or 4 g in 24 hours.Count combination products and reduce the ceiling below 50 kg or with hepatic impairment, malnutrition or harmful alcohol use.
08ComplicationsImportant consequences, why they occur and why they matter clinically.
Nonunion or malunion
Persistent motion, pain, shortening or weakness after expected healing can follow displacement, comminution and smoking and requires reassessment.
Skin and neurovascular injury
Progressive tenting can convert to an open wound, while deeper damage causes haemorrhage, ischaemia, paraesthesia or weakness.
Shoulder stiffness
Pain and prolonged sling use restrict movement, especially in older adults, so stability-guided early elbow and shoulder exercises matter.
Persistent AC symptoms
Prominence, pain with cross-body loading, scapular dyskinesis or later AC arthritis may continue despite acceptable early recovery.
09Monitoring and follow-upTreatment response, safety checks and longer-term review.
- Recheck skin colour and pressure after sling fitting and after swelling changes.
- Repeat pulse, refill and named nerve functions after manipulation or new symptoms.
- Assess pain, focal tenderness, active motion and functional recovery at follow-up.
- Investigate persistent pain, motion or weakness for nonunion, malunion or another shoulder injury.
- Confirm falls and bone-health actions have reached the responsible service after fragility fracture.
10Special situationsVariants, exceptions and circumstances that change the usual approach.
The shoulder falls
The AC step partly reflects downward scapular displacement, explaining why pushing on the clavicle is not a useful stability test.
Skin is an endpoint
Fixed blanching can precede necrosis; waiting for an actual wound adds preventable harm.
Medial means mediastinal
Medial clavicle injury with breathing, swallowing or venous symptoms needs cross-sectional specialist assessment.
Grade is not outcome
Displacement, horizontal instability, work and symptoms interact, so a type III label alone does not dictate surgery.
11Common pitfallsFrequent interpretation and management errors.
- 01
Focusing on the fracture and failing to examine chest, scapula, neck and sternoclavicular joint.
- 02
Describing skin as intact without recording blanching, tenting or abrasion.
- 03
Recording hand sensation without pulses and named motor functions.
- 04
Treating every Rockwood III injury as automatically operative or automatically benign.
- 05
Keeping an older adult in a sling until avoidable stiffness develops.