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Clavicle Fracture

  1. It is the first bone to start ossifying and only long bone which ossifies in membrane and has two primary centre of ossification
  2. The central transition represents a weak link in clavicular structure. The mid-clavicle (middle third) therefore is the most common site of fracture. Mid clavicular (middle 1/3) fractures account for 8O%, distal fractures for 15%, and proximal (medial) fractures for 5% of cases
Fig: Displacement of Clavicle Fracture
The outer fragment displaces medially and downwards because of the gravity and pull by the pectoralis major muscle attached to it. The inner fragment displaces upwards because of the pull by the sterno-cleidomastoid muscle attached to it.
  1. Mechanism of Injury
    1. Fall on shoulder or out stretched hand.
    2. During extraction of hand in breech delivery
  2. Other Features
    1. Bone usually breaks into two fragments comminuted fractures are extremely rare
    2. Clavicle is the most common fractured bone (over all) in adults.
    3. Clavicle is the most common bone fractured during birth.
    4. Malunion is the most common complication.
  3. Treatment
    1. Perfect reduction is neither possible nor essential as fracture with even moderate displacements unite & give good functional results.
    2. Mid & proximal clavicular fractures are usually treated using “figure of eight” strapping with tightening
    3. periodically and instruction to keep the shoulder from sagging forward. A sling may be used to support limb in the first few days.
    4. Open reduction & internal fixation is required in very specific conditions as nonunion, neurovascular
    5. involvement, fracture of lateral end with torn coracoclavicular ligaments in an adult, persistent wide separation of fragment with interposition of soft tissue, and floating shoulder.
    6. Valpeau bandage (dressing) cart be used in acromioclavicular dislocation, fracture clavicle and shoulder dislocation but it is most effective in acromioclavicular dislocation as it pushes lateral end of shoulder down wards and arm upwards, and thus helps maintaining reduction.

Fractures of Surgical Neck Humerus

  1. Usually occur after middle age, most commonly in osteoporotic post menopausal women .
  2. The most widely accepted Neer classification, classifies proximal humerus fractures as one part, two part, three part or four part depending upon the number of displaced fragments with displacement defined as 45 degree of angulation or 1 cm of seperation. And the four major fragments involved in these injuries are head of humerus (i.e fracture anatomical neck), greater tuberosity, lesser tuberosity and shaft (i.e. fracture surgical neck humerus).
  3. Clinical presentation of fracture surgical neck humerus
    1. Mostly the fracture is firmly impacted (not displaced or minimally displaced).
    2. Pain may not be severe & patient may be able to move the shoulder. So the diagnosis is often missed
  4. Complication
    1. Axillary nerve is at particular risk, both from injury & from surgery
    2. Stiffness of shoulder & malunion are common
    3. AVN of humerus head occurs in three part or four part fracture.
  5. Management of fracture surgical neck of humerus
    1. The results of conservative treatment are generally satisfactory as most of the patients are elderly with less
    2. functional demands & most of the fractures are impacted.
    3. Young demanding patient - reduction & fixation is done

Extra Edges


  Injury Common Nerve Involvement
a. Anterior shoulder dislocation Axillary (circumflex humeral) nerve
b. Fracture surgical neck humerus Axillary nerve
c. Fracture shaft humerus Radial nerve
d. Fracture supracondylar humerus AIN > median nerve
e. Medial condyle humerus Ulnar nerve
f. Monteggia fracture dislocation Posterior interosseous nerve
g. Vockman’s ischemic contracture Median nerve
h. Lunate dislocation Median nerve
i. Hip dislocation Sciatic nerve
j. Knee dislocation Peroneal nerve

Fracture Shaft Humerus

Conservative (non surgical) treatments of shaft humerus include — hanging arm cast, “Sugar tong” or coaptation splints, sling & swathes, long arm cast, shoulder spica cast, olecranon pin traction, and functional bracing.

Cast/ Brace

Used In

Hanging cast & “Sugar tong” or Coaptation splints

Fracture shaft humerus

Minnerva cast, Halo device

Cervical spine

Risser’s cast, Milwaukee brace

Boston brace


Palvic harness, Von Rosen splint

Ilfeld or Craig splint

Congenital (Developmental) Dysplasia of Hip

Broom stick (Petrie) cast

Legg Calve-Perthes Disease

Cylinder cast/Tube cast

Fracture patella

Hanging cast
Indications for Primary Operative Treatment Of Fracture Shaft Humerus
  1. Fracture Indications
    1. Pathological fracture
    2. Segmental fracture
      • Failure to obtain or maintain adequate closed reduction (i.e.)
      • Shortening > 3cm
      • Angulation > 20°
      • Rotation > 30°
  2. Associated Injuries
    1. Open wound
    2. Vascular injury
    3. Brachial plexus injury
    4. Burns
    5. High velocity gun shot injury
    6. Ipsilateral forearm, shoulder or elbow fractures
    7. B/L humeral fracture
    8. Lower extremity fractures requiring upper extremity weight bearing
    9. Chronic associated joint stiffness — elbow & shoulder.
  3. Patient Indication
    1. Polytrauma
    2. Head injury (GCS 8)
    3. Poor patient tolerance & compliance
    4. Unfavourable body habitus
    5. Morbid obesity
    6. Large breast
Fracture shaft humerus is the easiest of major long bone fractures to be treated by conservative methods and the most common cause of delayed union or nonunion is distraction at fracture site due to gravity and weight of plaster.
Radial nerve injury with fracture shaft of humerus.
Holstein Lewis syndrome: it is radial nerve injury associated with spiral fracture of shaft of humerus.
Indication to explore radial nerve when associated with fracture shaft of humerus.
  1. Open fracture shaft of humerus with radial nerve injury.
  2. Radial nerve injury after attempt of closed reduction of shaft of humerus.

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