Clavicula: Anatomy, Function and Common InjuriesThe clavicle, commonly known as the collarbone and termed “clavicula” in many languages, is a slender, S-shaped long bone that serves as a key connection between the axial skeleton and the upper limb. It is easily palpable beneath the skin and plays critical roles in shoulder mechanics, protection of neurovascular structures, and force transmission. This article covers its anatomy, function, common injuries, clinical assessment, imaging, and basic management principles.
Anatomy
Gross anatomy
- Location: The clavicle extends horizontally across the superior thorax, connecting the manubrium of the sternum medially to the acromion of the scapula laterally.
- Shape: S-shaped (sigmoid) with a convex medial two-thirds and concave lateral third when viewed superiorly.
- Ends:
- Medial (sternal) end: articulates with the clavicular notch of the manubrium at the sternoclavicular (SC) joint.
- Lateral (acromial) end: articulates with the acromion of the scapula at the acromioclavicular (AC) joint.
Bone structure
- The clavicle is a long bone but differs from typical long bones: it ossifies primarily via intramembranous ossification with a secondary center at the sternal end. It has a thin cortex and a small medullary canal.
- Cortical thickness is greater superiorly; the inferior surface has roughened areas for ligament attachment.
Muscular and ligamentous attachments
- Muscles:
- Sternocleidomastoid: attaches to the medial superior surface, elevates the clavicle.
- Pectoralis major: attaches to the anterior midshaft.
- Deltoid: attaches to the lateral anterior surface.
- Trapezius: attaches to the lateral posterior surface.
- Subclavius: runs beneath the clavicle attaching to the inferior midshaft.
- Ligaments:
- Sternoclavicular ligaments (anterior and posterior) stabilize the SC joint.
- Costoclavicular ligament anchors the clavicle to the first rib — major restraint to elevation.
- Coracoclavicular ligament (conoid and trapezoid portions) stabilizes the lateral clavicle to the scapula, crucial for AC joint stability.
- Acromioclavicular ligaments support the AC joint capsule.
Vascular and neural relations
- Subclavian vessels and brachial plexus lie inferior and posterior to the clavicle as they pass into the upper limb — the clavicle protects these structures but fractures may threaten them.
Development and variations
- Ossification: primary center for shaft (intramembranous) appears in utero; the sternal epiphysis appears later and fuses in early adulthood.
- Variations: congenital pseudarthrosis, clavicular length differences, and bipartite clavicle are possible.
Biomechanical Function
- Strut for the shoulder: The clavicle acts as a rigid strut that holds the scapula and upper limb away from the thorax, maximizing range of motion and enabling the arm’s wide arc of movement.
- Force transmission: It transmits forces from the upper limb to the axial skeleton. Compression and tensile forces are absorbed along its length.
- Protection: Shields the subclavian vessels and brachial plexus from direct trauma.
- Muscle leverage: Provides attachment sites that contribute to movements such as elevation, protraction, and rotation of the scapula and arm.
Common Injuries
- Clavicle fractures
- Epidemiology: One of the most common fractures in children and adults, especially from falls onto the shoulder or outstretched hand, sports injuries, and traffic accidents.
- Typical fracture sites:
- Middle third (midshaft): accounts for ~70–80% of clavicle fractures; often displaced due to muscle forces (sternocleidomastoid pulls medial fragment upward; weight of the arm pulls lateral fragment downward and medially).
- Lateral third (distal): ~15–25%; may involve the AC joint and coracoclavicular ligaments.
- Medial third (sternal end): ~2–5%; less common but can be associated with significant mediastinal injury.
- Clinical features: Pain localized to the clavicle, swelling, deformity or “bump,” limited shoulder movement, crepitus. Neurovascular compromise or skin tenting may occur in severe displacement.
- Complications: Nonunion (more common in the lateral third and in older adults), malunion, neurovascular injury, pneumothorax (rare), infection (open fractures), and post-traumatic AC/SC joint dysfunction.
- Acromioclavicular (AC) joint injuries (separations)
- Mechanism: Direct blow to the acromion or fall onto the shoulder. Severity graded I–VI (Rockwood classification) based on ligament injury and displacement.
- Grade I: sprain of AC ligaments, intact coracoclavicular (CC) ligaments.
- Grade II: rupture of AC ligaments, partial CC injury.
- Grade III: rupture of both AC and CC ligaments with clavicle displacement.
- Grades IV–VI: increasing displacement and soft-tissue disruption.
- Symptoms: Local pain, swelling, visible prominence of distal clavicle in higher grades, reduced shoulder strength and motion.
- Sternoclavicular (SC) joint injuries
- Less common. Can be anterior or posterior dislocations; posterior dislocations are dangerous due to risk to mediastinal structures (trachea, esophagus, vessels).
- Presentation: Pain at the sternoclavicular area, deformity; posterior dislocation may cause respiratory or vascular symptoms.
- Clavicular osteolysis and stress reactions
- Seen in weightlifters or with repetitive microtrauma — pain over the distal clavicle, radiographic signs of resorption or degenerative change.
Clinical Assessment
History
- Mechanism of injury (direct blow, fall, traffic collision), onset and location of pain, functional limitation, numbness/tingling, prior shoulder pathology.
Inspection
- Swelling, bruising, step-off deformity, skin tenting (urgent if at risk of open fracture).
Palpation
- Point tenderness along clavicle, crepitus with movement, assess distal pulses and motor/sensory exam of the ipsilateral limb.
Range of motion
- Active and passive shoulder movement (abduction, flexion, rotation) — movement may be limited by pain.
Special tests
- Cross-body adduction test and other provocative tests for AC joint pathology.
- Neurovascular tests for brachial plexus or subclavian involvement.
Imaging
- Plain radiographs: AP and 45° cephalic tilt views for clavicle; Zanca view for AC joint; serendipity view for SC joint. Chest X-ray if concern for pneumothorax.
- CT scan: helpful for medial-third injuries, complex fractures, or preoperative planning.
- MRI/Ultrasound: evaluate soft-tissue structures (ligaments, rotator cuff) and occult fractures.
Management Principles
Clavicle fractures (general)
- Nonoperative treatment: Most midshaft fractures are treated conservatively with a sling or figure-of-eight bandage, analgesia, and early gentle mobilization as pain permits. Regular radiographic follow-up to assess healing.
- Indications for surgical fixation:
- Open fractures, skin compromise, neurovascular injury, significant displacement or shortening (>2 cm commonly cited), comminution, floating shoulder (associated scapular neck fracture), or symptomatic nonunion.
- Surgical options: Plate fixation (precontoured locking plates) and intramedullary fixation (elastic nails, pins) each have pros/cons regarding soft-tissue irritation and implant prominence.
Distal clavicle fractures and AC separations
- Management depends on fracture location and ligamentous injury.
- Many low-grade AC separations and minimally displaced distal clavicle fractures are treated conservatively.
- Surgical repair or reconstruction (AC and/or CC ligaments, distal clavicle resection, or fixation) indicated for high-grade separations (e.g., Rockwood IV–VI), significantly displaced distal fractures, or chronic symptomatic instability.
SC joint injuries
- Anterior dislocations can often be managed conservatively; posterior dislocations usually require urgent reduction and possibly surgical stabilization given risk to mediastinal structures.
Rehabilitation
- Early passive and active-assisted range-of-motion progressing to strengthening once union and pain allow — focus on scapular stabilizers and rotator cuff.
- Return-to-sport/work decisions guided by radiographic healing, strength, and functional demands.
Prognosis and Complications
- Most clavicle fractures heal uneventfully with conservative care, especially in children.
- Middle-third fractures generally have good outcomes; lateral-third and medial-third fractures carry higher risk of nonunion or complications.
- Complications include nonunion, malunion with cosmetic deformity or functional limitation, implant irritation when surgically fixed, neurovascular injury (rare), and post-traumatic osteoarthritis of the AC joint.
Prevention
- In sports: protective techniques, appropriate protective gear, strength and conditioning focusing on shoulder girdle stability.
- Fall prevention in older adults: home safety, strength and balance training to reduce fall risk.
Key takeaways
- The clavicle is an S-shaped bone connecting the sternum to the scapula and functions as a strut for the shoulder.
- Middle-third (midshaft) fractures are the most common clavicle injuries.
- AC separations vary in severity; high-grade injuries often require surgical management.