Clavicle fracture (Fracture of the collarbone)

A clavicle fracture is a break in the collarbone, one of the main bones in the shoulder. This fracture is relatively common, accounting for about 5% of all adult fractures.

Most clavicle fractures occur when a fall onto the shoulder or an outstretched arm puts enough pressure on the bone that it snaps or breaks. A broken collarbone can be very painful and make it hard to move your arm.

 

Clavicle fractures can be treated by wearing a sling to keep the arm and shoulder from moving while the bone heals. With some clavicle fractures, however, the pieces of bone move far out of place when the injury occurs. Surgery may be needed to realign the collarbone for these more complicated fractures.

Anatomy

The clavicle is between the ribcage (sternum) and the shoulder blade (scapula). It is the bone that connects the arm to the body.

The clavicle lies above several important nerves and blood vessels. However, these vital structures are rarely injured when a fracture occurs.

The clavicle is part of your shoulder and connects your arm to the rest of your body.

Description

Clavicle fractures are relatively common and occur in people of all ages. Most fractures occur in the bone’s middle portion or shaft. Occasionally, the bone will break where it attaches to the ribcage or shoulder blade.

Clavicle fractures vary. The bone can crack slightly or break into many pieces (comminuted fracture). The broken pieces of bone may line up straight or may be far out of place (displaced fracture).

Cause

A direct blow to the shoulder most often causes clavicle fractures. This can happen during a fall on the shoulder or an accident like a car collision. A fall onto an outstretched arm can also cause a clavicle fracture. In a baby, a clavicle fracture can occur during the passage through the birth canal.

Symptoms

A clavicle fracture can be very painful and may make it hard to move your arm. Other signs and symptoms of a fracture may include:

• Sagging of the shoulder downward and forward
• Inability to lift the arm because of pain
• A grinding sensation when you try to raise the arm
• A deformity or bump over the break
• Bruising, swelling, and tenderness over the collarbone

Examination

Prof Imam will want to know how the injury occurred and ask about your symptoms. They will then carefully examine your shoulder.

In a clavicle fracture, there is usually an obvious deformity or bump at the fracture site. Gentle pressure over the break will bring about pain. Although it is rare for a bone fragment to break through the skin, it may push the skin into a tent formation.

In a clavicle fracture, the broken ends of the bone may cause tenting of the skin over the fracture site.

Prof Imam or a team member will also perform tests to ensure that no nerves or blood vessels were damaged when the fracture occurred.

Imaging Studies

X-rays. X-rays provide images of dense structures, such as bone. Prof Imam will order an X-ray:

• To help pinpoint the location of the fracture
• To learn more about the severity of the break

The doctor may also order X-rays of your entire shoulder to check for additional injuries.

If other bones are broken, Prof Imam may order a computerised tomography (CT) scan to see the fractures in better detail.

Treatment

Nonsurgical Treatment

If the broken ends of the bones have not significantly shifted out of place, you may not need surgery. Many broken collarbones can heal without surgery.

Nonsurgical treatment may include:

• Arm support. A simple arm sling is usually used for comfort immediately after the break and to keep your arm and shoulder in position while the injury heals.
• Medication. Pain medication, including acetaminophen, can help relieve pain as the fracture heals.
• Physiotherapy. Although there will be some pain, it is essential to maintain arm motion to prevent shoulder and elbow stiffness. Often, patients will begin doing exercises for elbow motion immediately after the injury.

  After a clavicle fracture, it is common to lose some shoulder and arm strength. Once the bone begins to heal, your pain will decrease, and you may start gentle shoulder exercises. These exercises will help prevent stiffness and weakness. You will gradually start more strenuous activities once the fracture is completely healed.

Follow-up care. You will need to see Prof Imam regularly until your fracture heals. During these visits, he might take X-rays to ensure the bone is recovering well. After the bone has healed, you can gradually return to your normal activities.

Complications. 

Sometimes, a clavicle fracture can move out of place before it heals. It is essential to follow up with Prof Imam as scheduled to ensure the bone stays in position.

If the fracture does not heal, it is called a non-union.

• In some cases of nonunion, the patient has very little pain and good motion, so no further treatment is required.
• In other cases, nonunion can result in significant pain and may require a repair operation. 

If the fracture fragments move out of place and the bones heal in that position, it is called a malunion. Surgical treatment for this is scarce, 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 spot often remains permanently.

Surgical Treatment

If the broken ends of the bones have significantly shifted out of place, Prof Imam may recommend surgery.

Surgery typically involves putting the broken pieces of bone back into position and preventing them from moving out of place until they are healed. This can improve shoulder strength when you have recovered.

Open reduction and internal fixation. This is the procedure most often used to treat clavicle fractures. The bone fragments are first repositioned (reduced) into their normal alignment during the process. The pieces of bone are then held in place with special metal hardware.

Standard methods of internal fixation include:

• Plates and screws. After being repositioned into their normal alignment, the bone fragments are held in place with special screws and metal plates attached to the outer surface of the bone.

  After surgery, you may notice a small patch of numb skin below the incision. This numbness will become less noticeable with time. Because the clavicle lies directly under the skin, you may be able to feel the plate through your skin.

  Plates and screws are not routinely removed after the bone has healed unless they are causing discomfort. Problems with the hardware are not common, but some patients find that seatbelts and backpacks can irritate the collarbone area. If this happens, the hardware can be removed after the fracture has healed.

• Pins or screws. Nails or screws can also hold the fracture in a good position after the bone ends have been put back. The incisions for pin or screw placement are usually smaller than those used for plates.

  Pins or screws often irritate the skin where they have been inserted and are usually removed once the fracture has healed.

Pain management. After surgery, you will feel some pain. This is a natural part of the healing process. Many patients find that ice and non-prescription pain medications are sufficient to relieve pain.

If your pain is severe, Prof Imam may suggest a prescription-strength medication, such as an opioid, for a few days.

Rehabilitation. Specific exercises will help restore movement and strengthen your shoulder. Prof Imam may provide you with a home therapy plan or suggest you work with a physical therapist.

Therapy programs typically start with gentle motion exercises. As your fracture heals, Prof Imam will gradually add strengthening exercises to your schedule.

Although it is a slow process, following your physical therapy plan is essential in returning to all the activities you enjoy.

Complications. There are risks associated with any surgery. These include:

• Infection
• Bleeding
• Problems with wound healing
• Pain
• Blood clots
• Damage to blood vessels or nerves
• Reaction to anaesthesia

Risks that are specific to surgery for clavicle fractures include:

• Difficulty with bone healing
• Lung injury
• Numbness below the clavicle
• Hardware irritation

Patients who smoke or use tobacco products, have diabetes, or are elderly are at a higher risk for complications during and after surgery. They are also more likely to have problems with wound and bone healing.

Before your surgery, Prof Imam will discuss the risks with you and take specific measures to avoid complications. Check our Before surgery section. 

Outcome

Whether or not your treatment involves surgery, it can take several months for your collarbone to heal. Healing may take longer in people with diabetes or who smoke or use tobacco products.

Most people return to their regular activities within three months of their injury. Prof Imam or a member of the physiotherapy team will tell you when your injury is stable enough to do so. Returning to regular activities or lifting with your arm before Prof Imam advises may cause the fracture fragments to move or the hardware to break. This may require you to start your treatment from the beginning.

Once your fracture has completely healed, you can safely return to sports activities.

Questions to Ask Our team

If you experience a clavicle fracture, here are some questions you may wish to ask Prof Imam or a team member:

• When can I start using my arm?
• When can I return to work?
• Do I have any specific risks for not doing well?
• If I have surgery, what are the risks and benefits, and will I need to stay in the hospital?
• What are the risks and benefits of nonsurgical treatment?