Clavicle Fracture (Broken Collarbone) - Patient education

A broken collar bone is a common injury, that is seen in patients of all ages. It is very common in motorcycle riding, horse back riding and any other sport or activity that is associated with direct blow to the shoulder. Often times it is seen in car accidents or falls as well.

The collarbone (clavicle) is located between the ribcage (sternum) and the shoulder blade (scapula), and it connects the arm to the body.

The clavicle lies above several important nerves and blood vessels. However, these vital structures are rarely injured when the clavicle breaks, even though the bone ends can shift when they are fractured.

The collar bone connects to the chest cage and to the scapula (shoulder blade)

Description

The clavicle is a long bone and most of the time it breaks in the middle. Sometimes the fracture is closer to the heart and sometimes closer to the shoulder.

Mechanism of injury in a motorcycle rider

In babies, these fractures can occur during the passage through the birth canal. For more information about those injuries please refer to your pediatrician.

Symptoms

Pain is the predominant symptoms associated with deformity if the bone fragments are displaced. In addition:

• Sagging shoulder (down and forward)
• Inability to lift the arm because of pain
• A grinding sensation if an attempt is made to raise the arm
• A deformity or "bump" over the break
• Bruising, swelling, and/or tenderness over the collarbone

Fractured collarbone on the left. Notice the deformity and loss of width of the shoulder.

Fractured collarbone on the left. Notice that the deformity and loss of width of the shoulder has been corrected after the surgery.

Office or hospital visit

Examination begins with the history. The medical professional will ask you questions about the mechanism of injury and examine your arm to evaluate the function of the muscles tendons and nerves. In addition, examination of your arm pulses may take place.  Gentle pressure over the collarbone will bring pain. True emergencies are situations when the bone has penetrated the skin and there is bleeding or when the bone fragment is under the skin and causes skin color changes of pressure to the skin (white appearance).

IX-rays of the collar bone will be taken to assess the location of the fracture and the number of fragments. Xrays of the entire shoulder will often be done to check for additional injuries. If other bones are broken, your doctor may order a computed tomography (CT or CAT) scan to see the fractures in better detail.

Xray show a clavicle fracture below the letter L.

This x-ray shows a fracture in the end of the clavicle. Note how far out of place the broken ends are.

Treatment without surgery

If the broken ends of the bones have not shifted out of place and line up correctly, you may not need surgery. Broken collarbones can heal without surgery. Currently theres is a trend towards more operative treatment of these fractures in young active patients like athletes or when there is displacement of more than 100% (the fragment ends do not touch each other) or they are is overlapping of the fragments and shortening of more than 2 cm.

Arm Support

A simple arm sling or figure-of-eight wrap is usually used for comfort immediately after the break. These are worn to support your arm and help keep it in position while it heals. This treatment does not accelerate the healing time and does not immobilize the fragments. It provides comfort only.

Medication

Pain medication will be provided by your doctor to reduce the pain as the fracture heals.

Physical Therapy

While you are wearing the sling, you will likely lose muscle strength in your shoulder. Once your bone begins to heal, the pain will decrease and your doctor may start gentle shoulder and elbow exercises. These exercises will help prevent stiffness and weakness. More strenuous exercises can gradually be started once the fracture is completely healed.

Healing time

You will need to see your doctor regularly until your fracture heals. The healing time depends on the age of the patient, the other medical problems, the location of the fracture and the compliance with restrictions. On average it takes 6 weeks to 12 weeks for healing and 6 months for return to normal activities. Maximum improvement is usually observed one year after the injury.

Why do I need to see my doctor often after the injury?

The doctor will evaluate if the bone fragment shift and move creating a gap that increases the chances of no healing. If the fracture does not heal in 6 months or does not change appearance on the x-rays and shows no signs of union within 3 months then it is called a non- union and further operative treatment may be necessary. 

If the fracture fragments do move out of place and the bones heal in that position, it is called a "malunion." Treatment for this is determined by how far out of place the bones are and how much this affects your arm movement.
A large bump over the fracture site may develop as the fracture heals. This usually gets smaller over time, but a small bump may remain permanently.

When do I need to have surgery and how is it done?

Your doctor may suggest surgery if:
1. The bones are out of place (displaced)
2. The skin is pushed by the bone fragments and it is white or whitish in color
3. The fracture fragments penetrated the skin (bone spike) and the bone was exposed
4. If you have other fractures around the shoulder that need surgery as well.

Fixation of clavicle fractures can improve shoulder strength when you have recovered.

Plates and Screws

A skin incision will be made over the collar bone and plates and screws will be used for stabilization of the fragments. These plates have screw holes and the bone is drilled for insertion of the screws. The number of the screws and the length of the plate is decided at the time of surgery.

Picture from www.aofoundation.org

After surgery, you may notice a small patch of numb skin below the incision. This numbness will become less noticeable with time. Because there is not a lot of fat over the collarbone, you may be able to feel the plate through your skin.

FOR CASE examples please refer to previous posts:

"Clavicle fractures. Reducing the cost of the implant. The use of reconstruction 3.5 mm plates"

"Distal clavicle fracture fixation using locking plates"

Will I have to have my plate removed? 

Plates and screws are not removed unless they are causing pain or discomfort. Problems with the plate are unusual, but sometimes, seatbelts and backpacks can irritate the collarbone area. If this happens, the hardware can be removed after the fracture has healed. Usually one year after the surgery. We strongly recommend not to have the plate removed because the collarbone and break again through the screw holes of the bone. If it is removed it takes 6 months for these screw holes to fill in and the bone to become strong again.

A

(A) The clavicle is broken in one place and the fragments are severely out of alignment.

B

B) The fractured pieces are held in place by a combination of plates and screws.

Pins

Pins are also used to hold the fracture in good position after the bone ends have been put back in place. The incisions for pin placement are usually smaller than those used for plates. Pins often irritate the skin where they have been inserted and are usually removed once the fracture has healed. It is a less commonly used method of fixation of the fracture.

What do I need to do after the surgery?

After it is safe to move your arm and lift weight your doctor may ask you to do exercises to strengthen your shoulder. It can be a home therapy plan or referral to a physical therapist

Start with gentle motion exercises and then gradually add strengthening exercises to your program as your fracture heals. Your doctor will guide you when to start which exercise in collaboration with the therapist if you are prescribed physical therapy.

What are the risks of surgery?

If you have history of tobacco use, diabetes, obesity or advanced age you are at a higher risk for complications during and after surgery. Please refer to blog post here.
or look for the post entitled

"Calculating major surgical risks of complications and the surgical consent"

 Some conditions are associated  with wound and bone healing problems. Your doctor can discuss those with you. Be sure to ask your doctor.

There are risks associated with any surgery, including:

• Infection
• Bleeding
• Pain
• Blood clots in your leg
• Damage to blood vessels or nerves
• Nausea

The risks specific to surgery for collarbone fractures include:

• Difficulty with bone healing
• Lung injury
• Hardware irritation

What to I need to discuss with my Surgeon?

1. When will I be able to start using my arm?
2. When can I return to work?
3. Do I have any specific risks for not doing well?
4. If I have surgery, what are the risks and benefits and how long will I be in the hospital?
5. If I do not have surgery what are the risks and benefits?
6. Is my bone weak?
7. Should I be taking calcium and Vitamin D?