The Clavicle, colloquially known as theCollarbone, is a crank-shaped Bone of The Shoulder Girdle that meets the Sternum at its medial end to form the Sternoclavicular Joint and the Acromion of the Scapula at its lateral end to form the Acromioclavicular Joint . Despite relatively small contributions of movement, the Clavicle plays an integral role in the motion and stability of The Shoulder Girdle as it is the only bony link between the axial and appendicular skeleton (SOURCE-25).
The Clavicle has a unique crank-like architecture to facilitate its equally unique functions at The Shoulder Girdle . From an anterior view the Clavicle is convex (orantecurve)in the medial two-thirds and concave (orretrocurve) in the lateral third.
Lateral (Acromial) End- the flattened lateral end forms a variable but reciprocal small oval facet for the Acromion, forming the Acromioclavicular Joint . This articular facet has a slightly inferior bias
Shaft (Diaphysis)- the shaft of the Clavicle is defined by two reciprocal curves (SOURCE-3+4+5+12):
Lateral Two-Fifths- the lateral curve is posteriorly convex with a radius half that of the medial curve. This portion of the shaft is more rectangular and defined by superior and inferior surfaces, distinguished by thinner anterior and posterior borders. The inferior surface houses theConoid Tuberclewhich serves as the attachment site for the Conoid Ligament . Similarly, theTrapezoid Lineis also found on the inferior surface for the attachment of the Trapezoid Ligament . In addition to the muscular attachments (discussed below), the Lateral Two-Fifths also serve as a partial attachment for the Clavipectoral Fascia
Medial Three-Fifths- the larger medial portion of the shaft is anteriorly convex and more cylindrical featuring less prominent surfaces. The sternal end of the inferior surface serves as an attachment site for the Costoclavicular Ligament . Attachment for the Subclavius and Clavipectoral Fascia is made in proximity to theSubclavian Groovewhich courses between the shaft’s medial and lateral portions
Medial (Sternal) End- the medial end is thick and forms the Sternoclavicular Joint through articulation with the Clavicular Notch of the Sternum and superior surface of the neighbouring First Costal Cartilage . Its articular facet has an anteroinferior bias and is often irregular due as it provides a roughened surface for attachment of the Interclavicular Ligament , Sternoclavicular Ligaments and articular disc. A lack of congruency at the Sternoclavicular Joint is compensated for by the fibrocartilaginous articular disc. This end of the Clavicle extends over the Sternum to form the lateral wall of theJugular Notch(SOURCE-3+4+5)
The circumference of the Clavicle’s midpoint is the most prominent feature to represent the sexual dimorphism between males and females. Additionally, a male Clavicle is expected to be longer, rougher and thicker (SOURCE-3).
The Clavicle represents the sole bony link between The Shoulder Girdle and The Axial Skeleton that paradoxically maintains clearance of the Scapula and Upper Limb from the Thorax during motion (SOURCE-3+4+5). Additionally, this link transmits some of the limbs weight to The Axial Skeleton . The inverse curve structure of the Clavicle aids in stress absorption (SOURCE-12).
Slight motions of the Clavicle compliment larger movements of the Scapula . During arm Elevation the Clavicle Rotates ~40-50º, Elevates 11-15º and Retracts 15-30º (SOURCE-2). The majority of this movement occurs at the Sternoclavicular Joint with slight contributions from the Acromioclavicular Joint . (SOURCE-2)
Osteokinematics of the Clavicle are determined by motions at The Shoulder Girdle , which are detailed on their respective pages:
Subclavius - attaches on the middle ~40% of the Clavicles Inferior Surface
Deltoid - inserts onto the anterior border of the Lateral Two-Fifths
Upper Trapezius - inserts onto the posterior border of the Lateral Two-Fifths
Pectoralis Major - attaches on the anterior border of the Medial Three-Fifths
Sternocleidomastoid - attaches to the superior surface of the Medial Half
Sternohyoid - lateral fibres attach to the posterior surface near the Sternal End
The pathomechanics of the Acromioclavicular Joint and Sternoclavicular Joint , which includes ligamentous compromise, instability and dislocation, are detailed on their respective pages.
The shaft of the Clavicle is often subject to Fracture s, representing approximately 2-10% of all fractures and 44% of those that affect The Shoulder Girdle (SOURCE-10+11). Fractures of the Clavicle are grouped according to which third of the shaft was affected (SOURCE-11). These injuries may be further categorised based on if they were undisplaced (a), displaced (b) or comminuted (c) (SOURCE-11). Fractures of the middle-third (group I) are the most common (~81%) and displaced in 48% of cases and comminuted in 19% (SOURCE-11). Fractures of the most medial-third (group III) are the least common but most likely to be displaced when they do occur (SOURCE-11). Fractures of the lateral-third of the Clavicles shaft occur equally displaced and undisplaced (SOURCE-11). The vast majoirty of Clavicular fractures are traumatic, resulting from a direct fall on the lateral shoulder or a FOOSH mechanism (SOURCE-10+14).
Altered tone of the several attaching soft-tissues form the basis for changes in mechanics which directly influence Scapulohumeral Rhythm . Although no muscles directly cross the Sternoclavicular Joint , several attach to the medial Clavicle and could impact joint mechanics (SOURCE-7):
Subclavius - through connection with Costoclavicular Ligament , First Ribs mobility may impact motion of the Clavicle (SOURCE-3+7)
At the lateral end of the Clavicle, Trapezius insufficiency or Clavicular fracture may lead to depression of the Clavicle (SOURCE-13). This may encroach on a passage for neurovascular structures, known as theThoracic Outlet, leading to their impingement (SOURCE-13). This form of impingment is considered secondary Thoracic Outlet Syndrome (SOURCE-13).
The Clavicle is related to the following pathologies:
Fractures of the Clavicle account for roughly 44-66% of all Shoulder fractures and 2.6%-12% of all fractures body-wide (SOURCE-4+9), making it the most commonly fractured bone in the human body (SOURCE-5). Fractures to the middle-third of the shaft (~80%) are considerably more common than the lateral-third (~15%) and medial-third (~5%) (SOURCE-4). Additionally, displacement following a fracture is more common at its shaft than polar ends and can lead to structural shortening of the bones length. This shortening has been associated with pathomechanics at the Acromioclavicular Joint , Sternoclavicular Joint and Scapular Winging (SOURCE-4)
Thoracic Outlet Syndrome / Pectoralis Minor Syndrome - the neurovascular bundle that extends to the upper extremity is subject to compression near the Clavicle. When it occurs proximally of the Clavicle it is known as Thoracic Outlet Syndrome and distally as Pectoralis Minor Syndrome (SOURCE-8).
Acromioclavicular Joint or Sternoclavicular Joint Instability - either joint may be subject to a sliding scale of instability from capsuloligamentous laxity to full dislocation as described on their respective pages.
Acromioclavicular Joint or Sternoclavicular Joint Degeneration - either joint may be subject to degeneration of their articular surface and consequentail compromise of their function. These mechanisms are described on their respective pages. Degeneration arthritis may also be a complication of nonunion fractures (SOURCE-15).
The following observations may be visualised with Clavicle pathology:Resting Posture:
Symmetry - as the Clavicle is the superficial structure along its length, a comparison to the asymptomatic side may be visualised and/or palpable
Fractures - the patient often presents with a pain -avoidance posture ( GH Joint - Adduction , bringing the arm towards the torso) and may support the weight of the limb with the opposing arm (SOURCE-14+15). A step deformity may also be palpable (SOURCE-15)
Decreased Distal Pulses - or other vascular symptoms indicate subclavian vessel injury (SOURCE-15)
Local swelling, Inflammation and/or Pain - along the shaft may indicate a fracture , while at either the Sternoclavicular Joint or Acromioclavicular Joint may indicate capsuloligamentous compromise (SOURCE-15+16+17+18)
Motion:
Acromioclavicular Joint or Sternoclavicular Joint Pathology - joint instability or degeneration may limit both Shoulder - Active Range of Motion and Shoulder - Passive Range of Motion , in particular GH Joint - Abduction (SOURCE-16+17+19+20+21). For the Acromioclavicular Joint , a Painful Arc is described in the final ~10º of Scapulohumeral Rhythm (SOURCE-16+17+20+21). Movement may be accompanied by crepitis/ audible click and grinding (SOURCE-16+19)
Clavicle Fracture - in the acute phase is likely to impact all shoulder ranges, with the weight of the arm alone often pain ful (SOURCE-14+15). Malunion fractures that result in a shortened Clavicle length (SOURCE-22):
Limit arm elevation range of motion
Cause GH Joint - External Rotation and Lower Trapezius Weakness
Produce a more forwards shoulder posture and Anterior Tilt of the Scapula
The Clavicle is palpated along its entire length for tenderness and abnormal structure, a typical finding being callus formation following a fracture. Findings should be compared to the unaffected side as the relative resting position can change and alter the mechanics of the bone at its joints.
The following details imaging techniques related to the Clavicle:
Radiography (X-Rays)- is typically the first line of imaging obtained for uncomplicated Clavicular or Acromioclavicular Joint injury (SOURCE-14+27+28). The image should include view of the Acromioclavicular Joint and Sternoclavicular Joint to assess for concomitant injury (SOURCE-14+28):
Standard Anterior-Posterior (AP) View
Cephalic Tilt (axial) View - reduces apparent overlap of the Ribs and Scapula to better assess superoinferior displacement
Computed Tomography (CT-Scan)- while not routinely used to evaluate Clavicular fracture s, may be used to evaluate suspected neurovascular injury or for preoperative planning of displaced/ non-union fractures (SOURCE-27+28). Thin section CT scans have value in the detection of subtle medial Clavicular fractures in the young with open growth-plates or Sternoclavicular Joint Dislocation (SOURCE-27).
Magnetic Resonance Imaging (MRI)- while not routinely used to evaluate Clavicular fracture s, clear visualisation of soft-tissues allows for the evaluation of concomitant injury to the associated ligaments or neurovascular structures (SOURCE-27+28).
For treatment of Acromioclavicular Joint or Sternoclavicular Joint pathology, see their respective pages. The following details treatment approach for Clavicular fracture s. The majoirty of these injuries are managed conservatively, initially with immobilisation of the affected limb through the use of a sling or figure-of-eight brace until bone union is achieved (anywhere from 3-12 weeks, depending on age) (SOURCE-14+15). Nonunion is the most common complication where the Clavicle heals with an irregular angulation or appearance that may result in a structural shortening of the bone’s shaft (SOURCE-15). Due to their proximity to and frequent involvement with the vertically stabilising Coracoclavicular Ligament s, nonunion is considerably more prevalent in the distal (lateral) Clavicle (SOURCE-14). Following immobilisation, treatment should focus on improving Range of Motion and Strength (SOURCE-15). A return to daily activities is expected around the 6 week mark, with a full return to contact sports delayed for 2-4 months (SOURCE-14+15).
During the immobilisation period (4-6weeks) it is recommended to restrict Shoulder - Passive Range of Motion to 90º of GH Joint - Flexion (SOURCE-25). After this period Range of Motion and Strength training should progressively introduced (SOURCE-15). Some authors recommend avoiding weight-bearing activities for up to 3 months, although given a return to daily activities and possibly contact sport fall within this time period, this may be overly cautious (SOURCE-14+15+25). The following details exercises that progressively load the Clavicle:
Intial Phase - low load and range exercises that emphasise rudimentary muscle activity
Shoulder Sling - Scapula setting exercise
Rotator Cuff Pendulums - oscillatory motion that afford a distracting glide to the Humeral Head
Prone Cobra - isometric exercise that emphasises Middle and Lower Trapezius
Rotator Cuff Banded Rotations - light low range isotonic rotation exercises
Isometric Chest Squeezes - isometric exercise that isolates Chest
Band Pull-Apart - basic isotonic exercise for Scapular Retractors
Banded Unilateral Lat Activations - activate lat, posteroinferior drawer on Humerus
Mid-Phase - restoring pain -free range of motion and basic Strength
Seated Row - rudimentary weighted isotonic horizontal pull movement
Push-Up - bodyweight isotonic horizontal push exercise
Inverted Rows - rudimentary isotonic horizontal pull exercise that utilises bodyweight
Push-Up Plus - push-up variation with additional Scapulothoracic Joint - Protraction
One Arm Row - unilateral DB version of Seated Row
Face Pulls - bilateral isotonic horizontal pull exercise that emphasises GH Joint - External Rotation
Lat Pulldown - rudimentary weighted isotonic vertical pull movement with a high range of motion
Straight Arm Lat Pulldown - isotonic motion that emphasises Lats and straight arm strength
Overhead Press - isotonic vertical push exercise with large overhead range
DB Shoulder Press - unilaterally loaded overhead press variation
Late Phase - the continued pursuit of Strength and Range of Motion can be complimented by exercises that are increasingly intense or reflective of the patients functional demands
Push Press - wholebody, explosive variation of the Overhead Press
Bottoms-Up Kettlebell Walk - typically isometric exercise for entire arm musculature with perturbation from walking
Pull-Up - bodyweight or greater load through large overhead motion
Half DB Bench Press - unilateral isotonic horizontal pressing motion that emphasises the Anterior Sling
Medball Pullover Throw - plyometric Pullover variation
Medicine Ball Chest Press - plyometric horizontal pressing motion, often sports relevant
DB Snatch - unilateral isotonic, explosive shoulder exercise with large overhead range
DB Hang Clean - unilateral clean progression, often performed explosively
Farmers Carry - upperbody/ Core isometric exercise with perturbation of walking
Mobilisations can be applied directly to the Clavicle at its polar ends or indirectly at the Scapula : Joint Play - techniques applied with the patient at rest
Acromioclavicular Anterior Glide - can be used to treat general Pain (SOURCE-6)
Acromioclavicular Posterior Glide - appropriate for Pain following injury, Subluxation or Fracture of Clavicle (SOURCE-6)
Acromioclavicular Inferior Glide - advocated by Maitland for general joint Pain or restriction (SOURCE-6)
Acromioclavicular Superior Glide - recommended when the other joint play motions fail to alleviate symptoms (SOURCE-6)
Mobilisation with Movement - techniques applied through an affected motion
Shoulder - MWM 1 - applied to the Clavicle and Scapula
Shoulder - MWM 2 - applied to the medial Clavicle and Scapula
Shoulder - MWM 3 - applied to the Scapula and Humerus
Shoulder - MWM 4 - applied to the Scapula and Humerus
Shoulder - MWM 5 - applied to the Scapula and Humerus
There is continued debate as to whether surgical interventions lead to better outcomes when compared to their conservative counterparts for the management of Clavicle Fracture s. Irrespective of location along the shaft, non-displaced fractures are typically managed non-operatively as they have a lower incidence of nonunion (SOURCE-12+24). For instances where conservative management fails (malunion and/or shortening of the Clavicle) or more severe injury where there may be greater displacement and/or concomitant injury (including Coracoclavicular Ligament compromise), surgery may be indicated (SOURCE-12+23+24). Even in these instances, it is not clear surgical intervention provides a significant benefit over conservative treatment (SOURCE-9+23+24). The aforementioned factors and patients circumstances help determine the most suitable surgical intervention:
Open Reduction and Plate Fixation - through open surgery, bone fragments are realigned to restore the Clavicle’s natural length and fixed using a compression plate and screws (SOURCE-9). This is the most common technique for fractures of the middle-third (Group I) (SOURCE-9). A comprehensive high-quality review found surgical techniques (such as Open Reduction and Plate Fixation or Intramedullary Devices) to have slightly better union rates (~ 8%) and insignificant improvements on functionality but with the added risks of complications following surgery (SOURCE-9). Anterior or Anterosuperior plates are reported to have the best union rates (99.3%) (SOURCE-9)
Coracoclavicular Ligament (CC) Stabilisation - are relevant for fractures of the lateral-third (group II) of the Clavicle, where the stabilising ligaments are often compromised. CC stabilisation is particularly relevant where the size/ quality of fracture may not be sufficient for plate application (SOURCE-24). See Acromioclavicular Joint for further information.
Intramedullary Devices - are an alternative to plate fixation, where typically an internal (intramedullary) device unites the disrupted bone fragements (SOURCE-26). Several devices exist with distinct mechanical properties such as rigig stainless steel or flexible titanium alloys (SOURCE-26). These same devices may also fixed externally (extramedullary) on the Clavicle’s surface (SOURCE-26). While all devices appear to boast good functional outcomes and union rates, each may pose its own unique set of implant-related complications (SOURCE-26).
Surgery presents its own set of complications including, risk of infection, wound healing and hardwear irritation (SOURCE-9+23).
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