Documenting a Clavicle Fracture Examination in Orthopedics

1. SUBJECTIVE (History)

Chief Complaint

• Location and character of pain (anterosuperior shoulder, clavicle region)
• Onset: traumatic (specific event) vs. atraumatic
• Laterality: document in every section (right/left) - wrong-site surgery is a "never event"

Mechanism of Injury

Per Rockwood & Green: "Medial clavicle fractures usually occur from higher-impact mechanisms, and should prompt a high index of suspicion for associated injuries, warranting careful physical examination and possibly additional CT scanning."

Pertinent History Items

• Dominant hand (document which side is affected vs. dominant)
• Occupation (manual labor, overhead work, throwing athletes - influences surgical decision-making)
• Activity level / recreational demands
• Prior shoulder injuries or surgery
• Comorbidities: osteoporosis, diabetes, seizure disorder, psychiatric conditions, alcohol/drug use
• Current medications (anticoagulants, steroids)
• Time of injury (helps assess swelling progression)
• Pain score (0-10 VAS)
• Ability to use the arm since injury

2. OBJECTIVE (Physical Examination)

Inspection (Look)

• Shoulder "ptosis" - droopy, medially displaced, shortened shoulder (classic sign of completely displaced midshaft fracture)
• Scapular protraction - best seen from behind; the inferior scapular angle may be prominent as it follows the distal fragment anteriorly
• Examine the patient from above to detect posterior translation of the distal clavicle (important to distinguish AC injuries from clavicle shaft fractures)

• Swelling / edema at fracture site
• Bruising / ecchymosis (may track inferiorly toward chest wall)
• Skin tenting - displaced fragment pushing on skin; requires urgent surgical referral
• Skin abrasion over posterior clavicle (common in midshaft fractures)
• Open wounds

• Visible step-off or angulation of clavicle
• Note direction: typically the medial fragment displaces superiorly (pulled by sternocleidomastoid) and the distal fragment drops inferiorly and anteriorly (weight of arm + pectoralis pull)

Palpation (Feel)

• Point of maximal tenderness (localize to medial, middle, or lateral third)
• Crepitus at fracture site (handle gently - not necessary to elicit)
• Step deformity or bony prominence on palpation
• SC joint tenderness (medial fracture vs. SC dislocation)
• AC joint tenderness (lateral fracture vs. AC injury)
• Coracoclavicular interspace tenderness

• Mark the midline of the suprasternal notch
• Mark the palpable AC joint ridge
• Measure this distance bilaterally
• A difference >1.5-2 cm is clinically significant and associated with worse prognosis

Range of Motion

• Shoulder active ROM: abduction, forward flexion, internal/external rotation
  • Document as "limited by pain" or give degrees
  • Patients typically hold the arm adducted against the body in a guarded position
• Cervical spine ROM: rule out referred cervical injury
• Elbow, wrist, hand ROM: check for ipsilateral upper limb injuries

Neurovascular Examination (MANDATORY)

• Radial pulse (bilateral - compare)
• Capillary refill (<2 sec)
• Skin color and temperature of hand
• Document any signs of subclavian artery injury (expanding hematoma, pallor, pulselessness)

Respiratory Assessment

• Tracheal deviation
• Breath sounds bilaterally (rule out pneumothorax - especially with posterior SC displacement or medial fractures)

3. ASSESSMENT

Diagnosis

Classification

• Type I: Minimally displaced; CC ligaments intact
• Type II: Displaced; medial fragment detached from CC ligaments (highest nonunion risk)
• Type III: Fracture extends into AC joint

Imaging Review

• Fracture location (thirds)
• Displacement (in mm or cm)
• Shortening (measured)
• Comminution
• Associated injuries (pneumothorax, rib fractures, scapular fractures - "floating shoulder")

4. PLAN

Indications for Orthopedic Consultation (document urgency):

• Open fracture
• Neurovascular compromise
• Significant skin tenting threatening open wound
• Floating shoulder (associated ipsilateral scapular fracture)
• Posterior SC dislocation (mediastinal risk - call CT surgery backup)

• Comminuted fractures

• 2 cm shortening or >100% displacement

• High-level athletes
• Adolescents >12 years with significant displacement

Non-operative Management (document)

• Arm sling (simple sling - standard of care)
• Duration: typically 4-6 weeks (children/adults)
• Figure-of-eight bandage: not recommended due to risk of brachial plexus palsy
• Analgesia plan (NSAIDs, acetaminophen; opioids if needed short-term)
• Ice application
• Activity restrictions
• Follow-up imaging at 4-6 weeks

Follow-up

• Return precautions documented (increasing pain, numbness, skin breakdown, dyspnea)
• Orthopedic follow-up timing
• Physical therapy referral (once healed, for ROM and strengthening)

Sample Documentation (SOAP Note Format)

SUBJECTIVE:
30-year-old right-hand dominant male presents with right shoulder and 
clavicle pain following a fall directly onto the right shoulder during 
a bicycle accident 2 hours ago. Reports immediate pain, inability to 
raise the arm, and visible deformity. Denies neck pain, numbness, 
tingling, shortness of breath, or chest pain. No prior right shoulder 
injuries. Works as a construction worker (overhead tasks). Non-smoker.

OBJECTIVE:
Vitals: [document]
General: Alert, holding right arm adducted against body.

Inspection: Visible swelling and ecchymosis over right mid-clavicle. 
  Mild shoulder ptosis with right shoulder appearing lower and shorter 
  than left. No skin tenting. No open wounds.

Palpation: Point tenderness at junction of middle and lateral thirds of 
  right clavicle. Palpable step deformity at this site. Crepitus present. 
  SC joint non-tender. AC joint non-tender.

ROM: Right shoulder active abduction limited to ~30 degrees by pain. 
  Cervical spine full ROM.

Neurovascular: Radial pulse 2+ bilaterally. Capillary refill <2 sec. 
  Sensation intact C5-T1 distribution. Motor strength 5/5 all groups 
  distal to injury. No brachial plexus signs.

Respiratory: Breath sounds clear bilaterally. No tracheal deviation.

Clavicle shortening: Right - 14.5 cm, Left - 16 cm (1.5 cm shortening).

Imaging: AP and cephalic tilt view right clavicle - Comminuted fracture 
  at middle-lateral third junction. ~1.5 cm shortening. No pneumothorax 
  on PA chest X-ray.

ASSESSMENT:
1. Right middle-third clavicle fracture (Allman Group I), displaced, 
   comminuted, 1.5 cm shortening. No neurovascular deficit.

PLAN:
- Right arm sling applied; advised against figure-of-eight bandage
- Ibuprofen 400 mg TID with meals + acetaminophen 1g QID PRN
- Ice to right shoulder 20 min every 2-3 hours for first 48 hours
- Orthopedic referral arranged (routine; comminuted with borderline 
  shortening, physically demanding occupation)
- PA chest X-ray reviewed - no pneumothorax
- Return precautions: increasing pain, numbness/weakness in arm, 
  skin breakdown, shortness of breath
- Follow-up 1 week (earlier if new symptoms)

Key Documentation Pearls

1. Laterality every time - document right/left in history, examination, imaging, and plan sections
2. Neurovascular status is non-negotiable - must be documented in every clavicle fracture, especially displaced ones
3. Measure shortening clinically - tape measure from suprasternal notch to AC joint; >1.5-2 cm is significant
4. Skin tenting requires urgent surgical consult - note it explicitly
5. Occupation and activity level must be in the history - they directly drive surgical vs. non-operative decision making
6. Respiratory exam is mandatory with medial fractures or high-energy trauma
7. Associated injuries - floating shoulder, pneumothorax, scapular fractures, rib fractures, brachial plexus injury
8. Classification - at minimum document which third is involved; use Craig/Allman for lateral fractures