Current Problems in Diagnostic Radiology 49 (2020) 199 204

Current Problems in Diagnostic Radiology

journal homepage: www.cpdrjournal.com

Clavicle Fractures: Review and Update for Radiologists

Kimia Khalatbari Kani, MD*
Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD

Clavicle fractures are relatively common injuries that are typically diagnosed and followed with plain radiography. The goals of this article are to review the
imaging evaluation, common classification systems, and relative surgical indications for clavicle fractures.
© 2019 Elsevier Inc. All rights reserved.

Introduction permits comparison for symmetry and assessment of degree of cla-

The clavicle is a relatively thin S-shaped bone that articulates
with the sternum and acromion at its medial and lateral expan-
sions, respectively. Clavicle fractures are relatively common injuries
and account for approximately 2%-5% of all fractures in adults.1
These fractures demonstrate a bimodal age distribution, with indi-
viduals younger than 30 years of age and older than 70 years being
at highest risk.1
Clavicle fractures most commonly result from a direct blow to the
point of the shoulder (eg, fall from a vehicle, bicycle, or height and
sports injuries) and less commonly from direct blows to the clavicle
or fall onto an outstretched hand.2 Although less common, stress,
pathologic, and fragility fractures may also occur. Most fractures
(80%-85%) involve the midshaft of the clavicle where the bone is nar-
rowest, and the soft-tissue support is the least.2 Fifteen percent to
20% of clavicle fractures involve the distal third (fragility fractures in
the elderly typically occur at this level).2 Proximal third clavicle frac-
tures are the least common type (0%-5%) and are usually secondary to
high-energy motor vehicle accidents.3
The goals of this article are to review the imaging evaluation,
classification systems, and relative surgical indications for clavicle
fractures.
Imaging
Clavicle fractures are well depicted on radiographs. In the trauma
setting, these fractures may be first detected on anteroposterior (AP)
chest radiographs. Dedicated radiographs are recommended for the
evaluation of clavicle fractures and include a horizontal AP view and
an apical oblique projection of the clavicle obtained with 10°-40° of
cephalic angulation (the location of the clavicle precludes its assess-
ment with true orthogonal radiographic projections).4 Clavicle frac-
tures are best characterized on standing radiographs that include the
clavicles and acromioclavicular joints bilaterally. Gravity will demon-
strate maximal deformity, while inclusion of the contralateral side
*Reprint requests to Kimia Khalatbari Kani, MD, Department of Diagnostic Radiology
and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD.
E-mail addresses: khalatbarik@live.com, kimia.kani@umm.edu
vicular shortening (Fig 1).2 Stress views (a comparative AP view that
is obtained in a standing position with the patient either holding or
suspending 5-15 lbs of weights from each wrist) may occasionally be
obtained for determination of the integrity of the coracoclavicular
(CC) ligament in distal clavicle fractures.
Fractures of the middle and distal thirds of the clavicle are well
evaluated by radiographs and CT is rarely required for the assessment
of these fractures.2 In contrast, accurate radiographic assessment of
fractures of the medial third of the clavicle is difficult, and CT may be
necessary for precise delineation of these fractures.2,3 The medial cla-
vicular epiphysis does not ossify until 18-20 years of age and the
medial clavicular physis is the last to fuse, typically between 22 and
25 years of age.5 CT is especially useful in distinguishing medial phys-
eal fracture-separations from true sternoclavicular joint dislocations
in individuals who are younger than 25 years of age.3
Classification
Multiple classification systems exist for clavicle fractures, none of
which have proven to be ideal. Allman originally classified these frac-
tures based on location and decreasing order of frequency as: Group I
(middle third clavicular shaft fractures) (Fig 1), group II (fractures dis-
tal to the CC ligament), and group III (proximal third fractures).6 Mus-
cular, ligamentous, and gravitational forces acting on the fractured
clavicle may result in displacement of the fracture fragments with
resultant deformity and shortening of the clavicle, especially in mid-
shaft fractures (Fig 1). The proximal fracture fragment is typically ele-
vated, while the distal fracture fragment is translated medially,
inferiorly, and anteriorly and rotated anteriorly. The distal fracture
fragment is attached to the scapula via the acromioclavicular joint,
and its displacement results in protraction of the scapula (this may be
clinically detectable as a winged scapula). Most of the fractures
involving the proximal and distal thirds of the clavicle are nondis-
placed and extra-articular.
Fractures of the distal clavicle were further subdivided by Neer
and subsequently modified by Craig into 5 types based on absence or
presence of displacement, articular extension, relationship to CC liga-
ment and CC ligament integrity (Figs 2 and 3).7 This widely used clas-
sification system demonstrates a fair interrater agreement.8

https://doi.org/10.1067/j.cpradiol.2019.02.010
0363-0188/© 2019 Elsevier Inc. All rights reserved.

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200 K.K. Kani / Current Problems in Diagnostic Radiology 49 (2020) 199 204

TABLE 1
Robinson classification of clavicle fractures9

Type I: Fractures of the medial fifth

1A. Nondisplaced fractures

1A1. Extra-articular
1A2. Intra-articular
1B. Displaced fractures
FIG 1. Upright bilateral clavicle radiograph. Apical oblique projection of the clavicles in a 1B1. Extra-articular
69-year-old male shows a comminuted and displaced z-shaped left midclavicular shaft 1B2. Intra-articular
fracture. The proximal fracture fragment is elevated, and the distal fracture fragment is
Type II: Fractures of the intermediate three-fifths
translated medially and inferiorly with resultant shortening of the left clavicle.
2A. Cortical alignment fractures with residual bony contact
2A1. Nondisplaced
Robinson developed an alternative classification based on a pro- 2A2. Angulated
spective review of 1000 consecutive clavicle fractures (Table 1).9 In 2B. Displaced fractures
2B1. Simple or wedge comminuted fractures
this classification scheme, fractures of the clavicle are categorized as
2B2. Isolated segmental or segmental comminuted fractures
type I (medial fifth), type II (intermediate three-fifths), and type III
(lateral fifth) fractures. Each type is subdivided into subgroups A or B, Type III: Fractures of the lateral fifth

according to degree of displacement: Subgroup A demonstrates less
than one full-shaft width (<100%) translation and subgroup B >100%
translation of the fracture fragments. Fractures involving the ends of
the clavicle are further subdivided into intra-articular and extra-artic-
ular fractures, while clavicle shaft fractures are further subdivided
based on fracture morphology along with presence and extent of frac-
ture comminution. This classification scheme can help predict out-
come and guide management decisions. The most commonly used
classification system for clavicle fractures in fracture registries is the
AO and Orthopaedic Trauma Association alphanumeric classification
system (Figs 4-6).10
Pertinent features for describing clavicle fractures can be partially
construed from the above classification systems and include: fracture
location (including location relative to the CC ligament in distal clavi-
cle fractures), fracture morphology (including presence and degree of
comminution as well as description of segmental fracture fragments),
articular extension, and degree of displacement of fracture fragments
and clavicular shortening.
3A. Cortical alignment fractures with residual bony contact
3A1. Extra-articular
3A2. Intra-articular
3B. Displaced fractures
3B1. Extra-articular
3B2. Intra-articular
injuries with clavicle fractures are rare, despite the proximity of the
clavicle to the subclavian vessels and brachial plexus. Neurovascular
injuries may occur at the time of initial injury, during surgery or in a
delayed fashion (due to encroachment from inferior clavicular callus
formation or deformity of the thoracic inlet from a fracture malunion or
nonunion).2 Refracture after healing of a clavicle fracture occurs rarely.2
Intraarticular fractures of the distal clavicle may be complicated by
acromioclavicular joint osteoarthritis.11 Discussion of surgical and hard-
ware related complications in surgically treated clavicle fractures is
beyond the scope of this article.

Complications
Delayed union, nonunion, and malunion may occur with clavicle
fractures. Delayed union is defined as radiographic healing between
12 and 24 weeks postinjury, while nonunion is defined as lack of
radiographic healing 6 months postinjury.9 Nonunion may be asymp-
tomatic, minimally symptomatic, or symptomatic (Fig 7).
Malunion is ubiquitous with conservatively treated displaced frac-
tures (Fig 8) and may be asymptomatic or symptomatic. Neurovascular
Management
Multiple factors (including fracture pattern, patient factors, and sur-
geon's preference) affect the management of clavicle fractures.2,9,11,14,15
Most clavicle fractures are treated conservatively with relatively good
results and high union rates. Nondisplaced clavicle fractures are typi-
cally treated conservatively. Surgical intervention is considered in cer-
tain patient populations with displaced clavicle fractures that are at

FIG 2. Pertinent anatomy for classification of distal clavicle fractures according to the Neer-Craig classification on (A) Coronal T1-weighted shoulder MR image in a 48-year-old
female and, (B) Axial oblique projection of the clavicle in a 31-year-old female. The V-shaped coracoclavicular ligament extends between the coracoid base and the inferior surface
of the clavicle and is composed of 2 parts: the triangular conoid ligament (black arrow) posteromedially and the quadrilateral-shaped trapezoid ligament (short white arrow)
anterolaterally.12 The conoid and trapezoid ligaments are separated by fat or bursa.12 Superiorly, the conoid ligament attaches to the conoid tubercle, which is a variably sized tuber-
cle along the inferior aspect of the distal clavicle (long white arrow). The conoid tubercle is usually discernible on radiographs and is located at the level of the coracoid process
approximately 4 cm proximal to the acromioclavicular joint.4 The trapezoid ligament attaches onto the neighboring trapezoid line which is not visible radiographically. Vertical dis-
placement of the clavicle is opposed primarily by the coracoclavicular ligament.4

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FIG 3. Neer-Craig classification of distal clavicle fractures. (A) Type I: Minimally displaced, extra-articular fracture distal to an intact coracoclavicular (CC) ligament. (B) Type IIA: Displaced
fracture medial to the CC ligament (the CC ligament is attached to the distal fracture fragment). (C) Type IIB: Displaced fracture occurring between the conoid and trapezoid ligaments:
The conoid ligament is torn, while the preserved trapezoid ligament is attached to the distal fragment. (D) Type III: Minimally displaced intra-articular fracture distal to the CC ligament.
(E) Type IV: Distal clavicular Salter-Harris type I or II injuries. In children and adolescents, the distal clavicular physis is located medial to the acromioclavicular joint capsule (the lateral
epiphysis of the clavicle fuses at approximately 19 years of age). In this age group distal clavicle fractures are typically a Salter-Harris type I or II injury, with an intact acromioclavicular
joint and a distal clavicular metaphysis that is superiorly displaced through a tear in the periosteal sleeve.2 The CC ligament is intact and remains attached to the periosteal sleeve. With
epiphyseal-metaphyseal separation, the unossified distal clavicular epiphysis (ie, distal fracture fragment) together with the displaced distal clavicular metaphysis (ie, proximal fracture
fragment) simulate a complete acromioclavicular joint dislocation. This appearance is referred to as pseudodislocation of the acromioclavicular joint.4 (F) Type V: Comminuted fracture
with CC ligament attached to an inferior fracture fragment.

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202 K.K. Kani / Current Problems in Diagnostic Radiology 49 (2020) 199 204

FIG 4. AO/OTA classification of clavicle fractures. The clavicle is designated as bone 15 and is divided into: (A) A proximal (medial) end segment (15.1) that is defined as an approxi-
mate square with sides equaling the widest portion of the medial clavicle (illustrated by a dashed line); (B) A diaphyseal segment (15.2), and; (C) A distal (lateral) end segment
(15.3) that is located at and lateral to a line drawn perpendicular to the medial edge of the coracoid process (black line). Fractures in the end segments (A, C) are subdivided as
extra-articular, partial articular and complete articular types of fractures (partial articular fractures have some portion of intact bone between the diaphysis and articular surface
while complete articular fractures have none). Optional qualifications can be added to distal clavicle fractures based on whether the coracoclavicular (CC) ligament is intact (a), par-
tially disrupted (b) or completely disrupted (c). Qualifications are added to the end of the fracture code as a lower-case letter in rounded brackets. Diaphyseal segment fractures are
subdivided based on fracture morphology into simple, wedge and multifragmentary types of fractures.

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FIG 5. Distal clavicle fracture. Zanca view in a 69-year-old female shows a minimally
displaced extra-articular fracture of the distal clavicle (Neer-Craig type I, Robinson
type 3A1 and AO/OTA type 15.3A(a) fracture). The fracture line is located 14 mm
medial to the distal clavicular articular surface (the acromioclavicular ligaments attach
approximately 6 mm medial to the acromioclavicular joint13) and the coracoclavicular
ligament is intact (there is no evidence of widening of the coracoclavicular interval).

FIG 7. Nonunion. (A) Zanca view of the right shoulder in a 69-year-old man demon-
strates nonunion of a fracture of the distal third of the clavicle. This very active gentle-
man had persistent pain and discomfort in his lateral clavicle, and after failure of
conservative measures, elected to proceed with surgical intervention. (B) Zanca view
obtained after open reduction and internal fixation as well as autologous bone grafting,
shows a malleable clavicle plate transfixing the fracture.

FIG 6. Distal clavicle fracture. Anteroposterior view of the clavicle in a 26-year-old

male shows a comminuted fracture of the distal clavicle (Neer-Craig type V, Robinson
type 3B1 and AO/OTA type 15.3A fracture). The conoid tubercle (arrow) fracture frag-
ment is separated from the proximal and distal fracture fragments. Therefore, this frac-
ture pattern is equivalent to a coracoclavicular ligament disruption.

TABLE 2
Relative indications for surgical fixation of clavicle fractures2,9,11,14,15

Fractures of the middle third*

>2 cm displacement of fracture fragments

≥1.5-2 cm shortening of the clavicle FIG 8. Malunion. Anteroposterior clavicle radiograph in a 43-year-old female shows
Increasing comminution (>3 fragments) malunion of a midclavicular shaft fracture without hardware fixation.
Segmental fracture
Open or impending open fractures (virtually all open fractures must be considered
for surgery) higher risk for suboptimal outcomes (such as symptomatic nonunion or
Associated neurovascular injuries malunion) with conservative management (Table 2; Fig 9).
Multiple injuries (e.g., polytrauma patient requiring the upper extremites for early
weight-bearing)
Professional athletes

Fractures of the distal third**, ***

Neer-Craig types II and V displaced distal clavicle fractures in young adults or high-
demand patients
Fractures of the proximal third
Significantly displaced (especially with posterior displacement) fractures
*Primary fixation of fractures of the middle third of the clavicle is generally reserved
for young and physically active patients without medical comorbidities who stand to
benefit the most from a rapid return to function
**Neer-Craig type IV distal clavicle fractures are typically treated conservatively
***Middle aged and elderly patients with displaced distal clavicle fractures are typi-
cally treated conservatively
Conclusion
Clavicle fractures are relatively common injuries and are typically
diagnosed and followed with radiography. Understanding the con-
cepts underlying the most common classification systems along with
knowledge of the relative surgical indications for these fractures,
improves the targeted description of clavicle fractures in radiology
reports. Pertinent features for describing clavicle fractures on imaging
include: fracture location (including location relative to the CC liga-
ment in distal clavicle fractures), fracture morphology (including
presence and degree of comminution as well as description of

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204 K.K. Kani / Current Problems in Diagnostic Radiology 49 (2020) 199 204
FIG 9. Surgical fixation of distal clavicle fracture. (A) Anteroposterior view of the
clavicles in a 25-year-old female demonstrates a comminuted extra-articular fracture
of the left distal clavicle (Neer-Craig type V, Robinson type 3B1 and AO/OTA type 15.3A
fracture). The fracture is significantly displaced with the proximal fracture fragment
tenting the skin. (B) Postoperative Zanca view of the left clavicle shows reduction as
well as plate and interfragmentary screw fixation of the distal clavicle fracture.
segmental fracture fragments), articular extension, and degree of dis-
placement of fracture fragments and clavicular shortening.
Conflict of Interest
The author declares that she has no conflict of interest.
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References
1. Van der Meijden OA, Gaskill TR, Millett PJ. Treatment of clavicle fractures: Current
concepts review. J Shoulder Elbow Surg. 2012;21:423–9, https://doi.org/10.1016/j.
jse.2011.08.053.
2. McKee MD, et al. Clavicle fractures. In: Tornetta P, Court-Brown C, Heckman JD,
eds. Rockwood and Green's Fractures in Adults, Philadelphia: Wolters Kluwer;
2015:1428–73.
3. Sewell MD, Al-Hadithy N, Le Leu A, et al. Instability of the sternoclavicular joint:
Current concepts in classification, treatment and outcomes. Bone Joint J 2013;95-
B:721–31, https://doi.org/10.1302/0301-620X.95B6.31064.
4. Sandstrom CK, Gross JA, Kennedy SA. Distal clavicle fracture radiography and
treatment: A pictorial essay. Emerg Radiol 2018;25:311–9, https://doi.org/
10.1007/s10140-018-1586-y.
5. Ozer UE, Yalcin MB, Kanberoglu K, et al. Retrosternal displacement of the clavicle
after medial physeal fracture in an adolescent: MRI. J Pediatr Orthop B
2014;23:375–8, https://doi.org/10.1097/BPB.0000000000000043.
6. Allman FL Jr. Fractures and ligamentous injuries of the clavicle and its articulation.
J Bone Joint Surg Am 1967;49:774–84.
7. Craig E. Fractures of the clavicle. In: Rockwood C, Matsen F, eds. The Shoulder,
Philadelphia: WB Saunders; 1990:367–412.
8. Cho CH, Oh JH, Jung GH, et al. The interrater and intrarater agreement of a modified
neer classification system and associated treatment choice for lateral clavicle frac-
tures. Am J Sports Med 2015;43:2431–6, https://doi.org/10.1177/0363546515593949.
9. Robinson CM. Fractures of the clavicle in the adult. Epidemiology and classifica-
tion. J Bone Joint Surg Br 1998;80:476–84.
10. Fracture and dislocation classification compendium-2018: International compre-
hensive classification of fractures and dislocations committee. https://classifica-
tion.aoeducation.org/compendium.html; Updated 2018. Accessed 12/20/2018.
11. Sambandam B, Gupta R, Kumar S, et al. Fracture of distal end clavicle: A review.
J Clin Orthop Trauma 2014;5:65–73, https://doi.org/10.1016/j.jcot.2014.05.007.
12. Alyas F, Curtis M, Speed C, et al. MR imaging appearances of acromioclavicular
joint dislocation. Radiographics 2008;28:463–79, quiz 619, https://doi.org/
10.1148/rg.282075714.
13. Renfree KJ, Riley MK, Wheeler D, et al. Ligamentous anatomy of the distal clavicle.
J Shoulder Elbow Surg 2003;12:355–9, https://doi.org/10.1016/mse.2003.
S1058274603000296.
14. McKee RC, Whelan DB, Schemitsch EH, et al. Operative versus nonoperative care of
displaced midshaft clavicular fractures: A meta-analysis of randomized clinical tri-
als. J Bone Joint Surg Am 2012;94:675–84, https://doi.org/10.2106/JBJS.J.01364.
15. Naveen BM, Joshi GR, Harikrishnan B. Management of mid-shaft clavicular frac-
tures: Comparison between non-operative treatment and plate fixation in 60
patients. Strategies Trauma Limb Reconstr 2017;12:11–8, https://doi.org/10.1007/
s11751-016-0272-4.