Clavicle Fracture

Upper Limb

Overview

Clavicle fracture is one of the most common bone injuries, accounting for 2-3% of all fractures and typically occurring from direct trauma, falls, or indirect axial loading. Most clavicle fractures are mid-shaft fractures with varying degrees of displacement that may be managed conservatively or surgically depending on fracture configuration and patient factors. Osteopathic management focuses on supporting healing, managing secondary restrictions, and restoring functional mobility post-fracture.

Pathophysiology

The clavicle serves as a strut between the sternum and scapula, providing structural support and a broad surface for muscle attachment. Fracture mechanisms include direct blunt trauma to the shoulder, falls onto the lateral shoulder (most common), or indirect forces through axial loading of the arm. The proximal fragment is typically elevated due to pull from the sternocleidomastoid muscle, while the distal fragment is depressed by the weight of the arm and pectoralis major pull. Fracture healing proceeds through inflammation (0-2 weeks), soft callus formation (2-8 weeks), hard callus formation (8-12 weeks), and remodeling (12+ weeks). Non-union or malunion may occur in 5-10% of cases, particularly with displaced mid-shaft fractures.

Patient Education

Clavicle fractures typically heal well with conservative management; early gentle movement within pain tolerance promotes healing and reduces stiffness, while avoiding heavy lifting and impact activities for 8-12 weeks is essential for bony union.

Typical Presentation

Site

Mid-clavicle region (80% of fractures), distal third (15%), or proximal third (5%); pain may radiate to shoulder joint, neck, or anterior chest

Quality

Sharp, acute pain at fracture site with possible aching; may describe grinding or clicking sensations with movement

Intensity

Severe initially (7-9/10) reducing over 2-4 weeks to moderate (4-6/10); pain typically worse with arm movement and shoulder elevation

Aggravating

Horizontal adduction, shoulder shrugging, heavy lifting, load-bearing through affected arm, lying on affected side, rapid arm movement

Relieving

Immobilization or arm sling, rest, ice application in acute phase, gentle pendulum movements after acute phase, anti-inflammatory medication

Associated

Visible deformity or step at fracture site, swelling and bruising, crepitus or clicking with movement, restricted shoulder abduction/elevation, scapular winging if severe, possible brachial plexus irritation symptoms, reduced grip strength

Orthopaedic Tests

Clavicle Compression Test (Cross-Body Adduction)

Procedure

Patient seated or standing. Examiner passively adducts the affected shoulder across the body, bringing the arm toward the opposite shoulder. Alternatively, apply gentle axial compression along the long axis of the clavicle.

Positive Finding

Sharp pain or reproduction of symptoms directly over the fracture site, or visible/palpable deformity at the fracture location

Sensitivity / Specificity

See current literature / See current literature

Interpretation

Suggests clavicle fracture, particularly if focal tenderness is present. High specificity for structural damage but less commonly formally validated in prospective studies.

Clavicular Spring Test

Procedure

Patient supine or seated. Examiner gently applies posteroanterior (PA) pressure over the mid-clavicle or fracture site, then releases. Assess for 'springing' sensation or crepitus.

Positive Finding

Loss of normal spring-back or resilience, palpable crepitus, or increased movement/instability at the fracture site

Sensitivity / Specificity

See current literature / See current literature

Interpretation

Crepitus or loss of mechanical continuity suggests non-union or incomplete healing. Useful for assessment during follow-up rather than acute diagnosis.

Palpation for Step Deformity

Procedure

Patient seated, shoulders relaxed. Examiner visually inspects and palpates the superior and anterior surfaces of both clavicles in the frontal plane, comparing both sides for discontinuity.

Positive Finding

Visible or palpable step-off, bony prominence, or asymmetry compared to the contralateral clavicle

Sensitivity / Specificity

See current literature / See current literature

Interpretation

Indicates displacement of fracture fragments. Common finding in acute displaced fractures and may guide management decisions regarding surgical versus conservative treatment.

Shoulder Shrug Test

Procedure

Patient actively elevates both shoulders toward ears (shoulder shrug). Observe and palpate the clavicles during movement.

Positive Finding

Pain, abnormal movement, crepitus, or visible deformity during active elevation; asymmetrical shoulder height

Sensitivity / Specificity

See current literature / See current literature

Interpretation

Assesses functional integrity and pain response during active upper trapezius engagement. Useful for serial assessment of fracture healing and return to functional movement.

Clavicular Percussion Test

Procedure

Patient seated. Examiner gently percusses (taps) along the length of the clavicle from lateral to medial with a reflex hammer or fingertip.

Positive Finding

Point tenderness or pain at the fracture site; patient guards or withdraws from percussion

Sensitivity / Specificity

See current literature / See current literature

Interpretation

Localizes pain to the fracture site. Simple bedside test to confirm focal pathology and monitor resolution during healing.

Abduction Stress Test (Horizontal Adduction with Resistance)

Procedure

Patient seated. Examiner places affected arm in 90° shoulder flexion and elbow extension, then applies gentle horizontal adduction (cross-body) with patient resistance, or passive overpressure at end range.

Positive Finding

Reproduction of pain at the clavicle, especially with specific load through the distal clavicle

Sensitivity / Specificity

See current literature / See current literature

Interpretation

Stresses the acromioclavicular joint and distal clavicle; may help differentiate AC joint involvement or distal clavicle fractures from midshaft fractures.

⚠ Red Flags

  • •Open/compound fracture with skin penetration
  • •Neurovascular compromise: absent distal pulses, paresthesia/paraesthesia in hand, color changes or temperature differences
  • •Severe soft tissue injury or wounds requiring surgical intervention
  • •Multiple injuries suggesting high-velocity trauma (assess for pneumothorax, rib fractures, spinal injury)
  • •Signs of non-union or malunion persisting beyond 12 weeks with functional impairment
  • •Reflex sympathetic dystrophy/Complex Regional Pain Syndrome development

⚡ Yellow Flags

  • •Delayed healing or non-compliance with immobilization suggesting possible secondary gain
  • •Catastrophic thinking about permanent disability or cosmetic concerns
  • •High anxiety or fear-avoidance behavior disproportionate to injury severity
  • •Workplace or litigation involvement affecting rehabilitation motivation
  • •History of non-union or delayed healing in previous fractures
  • •Poor coping strategies or limited social support

Osteopathic Techniques

Region

Sternoclavicular joint and proximal clavicle

Technique

Soft Tissue

Rationale

Gentle soft tissue mobilization reduces muscular splinting around the sternoclavicular joint and anterior chest wall, promoting venous and lymphatic drainage to support healing while respecting fracture immobilization

Region

Shoulder girdle (scapula, trapezius, rhomboids)

Technique

Soft Tissue

Rationale

Addresses secondary muscle tension and spasm in supporting muscles, preventing postural dysfunction and scapular dyskinesis that commonly develops during immobilization period

Region

Cervical spine and neck musculature

Technique

MET

Rationale

Gentle muscle energy techniques to cervical spine and upper trapezius maintain cervical mobility and reduce secondary neck tension that develops from protective posturing and immobilization

Region

Acromioclavicular joint and distal clavicle

Technique

Articulation

Rationale

Once acute phase is complete (typically 6+ weeks), gentle articulation of the AC joint maintains mobility and prevents secondary joint dysfunction and post-traumatic arthritis

Region

Glenohumeral joint and shoulder complex

Technique

Functional

Rationale

Functional technique and gentle mobilization in neutral positions maintains shoulder joint mobility during immobilization, preventing adhesions and restoring scapulohumeral rhythm post-immobilization

Region

Thoracic spine and rib cage

Technique

Articulation

Rationale

Maintains thoracic mobility and rib mechanics, preventing compensatory restrictions that develop from protective splinting and limited arm movement

Add-On Approaches

Chinese Medicine

TCM approaches focus on promoting Qi and blood circulation to the injury site using acupuncture points such as LI-15 (Jianyu), LI-14 (Binao), and local ahshi points; herbal formulas like Tuo Li Xiao Yao San support bone healing and reduce inflammation during recovery phases

Chiropractic

Chiropractic management includes high-velocity low-amplitude (HVLA) adjustment to cervical and thoracic spine to restore normal segmental mechanics and prevent secondary dysfunction; soft tissue techniques address muscular compensation patterns

Physiotherapy

Progressive rehabilitation program including pendulum exercises (weeks 1-2), passive-assisted range of motion (weeks 2-4), active range of motion (weeks 4-8), and strengthening exercises (weeks 8+); proprioceptive training and functional activity retraining are essential for return to sport/work

Remedial Massage

Gentle remedial massage to surrounding musculature (avoiding direct fracture site) promotes circulation, reduces muscle splinting, and addresses myofascial restrictions in trapezius, pectoralis, and scapular stabilizers; trigger point therapy may address referred pain patterns

Rehabilitation Exercises

Pendulum Shoulder Circles (Codman's Pendulum Exercises)

Range of MotionBeginner

Supine Passive Shoulder Elevation (Wall Slide Progression)

Range of MotionBeginner

Cross-Body Shoulder Stretch (Horizontal Adduction Stretch)

StretchingBeginner

Doorway Pectoral Stretch (Corner Stretch)

StretchingBeginner

Scapular Retraction (Prone Shoulder Blade Squeeze)

StrengtheningIntermediate

Quadruped Shoulder Stabilization (Quadruped Hold with Arm Lift)

StrengtheningIntermediate

Side-Lying Shoulder External Rotation (Prone Press-Out)

StrengtheningIntermediate

Resistance Band Shoulder Abduction (Standing Side Raise)

StrengtheningIntermediate

Scapular Setting and Posture Retraining (Standing Wall Posture)

PosturalBeginner

Single-Arm Balance on Stability Ball (Core and Shoulder Stability)

BalanceAdvanced

Push-Up Progression (Modified to Standard Push-Up)

StrengtheningAdvanced

Stationary Cycling or Lower Body Cardiovascular Work (Protected Upper Limb)

CardiovascularIntermediate

Referral Criteria

  • •Initial presentation with suspected clavicle fracture should be referred for radiographic imaging (X-ray: AP, lateral, and axial views) to confirm diagnosis and assess fracture configuration
  • •Displaced or comminuted mid-shaft fractures should be referred to orthopedic surgeon for assessment of operative versus conservative management
  • •Signs of neurovascular compromise or open fracture require immediate emergency department referral
  • •Fracture with associated brachial plexus injury requires specialist neurological assessment and orthopedic consultation
  • •Lack of callus formation or persistent severe pain beyond 8 weeks warrants re-referral to orthopedics to assess for non-union or malunion
  • •Development of Complex Regional Pain Syndrome or reflex sympathetic dystrophy requires specialist pain management and physiotherapy referral
  • •Distal clavicle fractures with acromioclavicular joint disruption may require orthopedic evaluation for surgical stabilization
  • •Patient unable to comply with conservative management or develop significant psychological distress requires mental health or pain psychology referral