Shoulder

Clavicle Fractures

What is a clavicle fracture?

A clavicle fracture is a break of the collarbone (clavicle).

The clavicle, also known as the collarbone, is a subcutaneous bone that is visible along its length from the sternum (breastbone) to the scapula (shoulderblade), where it connects to the shoulder. The clavicle is an S-shaped bone that protects the nerves (brachial plexus) and blood vessels as they exit the neck and enter the arm. It has two relatively stiff joints at each end: the AC joint (acromioclavicular joint) laterally near the shoulder, and the SC (sternoclavicular) joint at the sternum, or breastbone.

Clavicle fractures are relatively common, and represent approximately 2-5% of all fractures. Clavicle fractures can be divided by their location on the clavicle into thirds. These fractures are called medial near the sternum (about 3-5% of all clavicle fractures), midshaft (about 66% of all clavicle fractures), and lateral (about 25-30% of all clavicle fractures). These statistics are for adult clavicle fractures, as most children (>90%) sustain midshaft clavicle fractures. Certain fracture patterns have been recognized to have an increased incidence of nonunion (failure to heal) and for that reason, surgery is recommended. Distal clavicle fractures can have different fracture patterns based on the fracture relationship to the coracoclavicular (CC) ligaments. Fractures just medial to the CC ligaments tend to be vertically unstable with substantial displacement and often require surgery.

What is the treatment for clavicle fractures?

If you sustain a clavicle fracture, it is typical for a fracture to require 3-4 months for healing. Most patients will be given a sling for support. A figure of eight brace is no longer typically used for clavicle fractures; these are often more painful to get on and off, and do not have increased rates of healing. Immobilization and rest for 1-2 weeks followed by gentle progressive range of motion and physical therapy as needed are routine treatments. Ice, pain medication, anti-inflammatories, and elevation including sleeping propped up on pillows or in a recliner can be helpful.

In the past, the vast majority of midshaft clavicle fractures were treated non-operatively and thought to do well. Even now, most clavicle fractures are treated nonoperatively. However, several recent studies have shed light on the fact that not all clavicle fractures will do well without surgery, and that some fractures are at increased risk for not healing (nonunion), healing in an altered position with deformity (malunion), or causing functional problems due to substantial shortening of the clavicle, which acts as a strut for the shoulder.

What happens if surgery is necessary?

Absolute indications (reasons) for surgery include open fracture, tenting of the skin, the presence of neurological injury, multiple trauma, or floating shoulder (other fractures about the shoulder, particularly of the scapular neck.) In cases other than those just mentioned, treatment is individualized for each patient. In younger, more active individuals with shortening greater than 1.5 to 2 cm, displacement greater than 100%, or significant comminution (multiple bony fragments), it may be reasonable to consider surgery. This can be with intramedullary pins or rods, versus plates and screws. In nonunions (cases where the bone has failed to heal), plates and screws are typically used along with bone grafting. The medical terminology you will usually see on your consent form for surgery is “open reduction and internal fixation of clavicle fracture.” Depending on the technique, it may also be “arthroscopically assisted open reduction internal fixation of clavicle fracture.” Certain types of fractures can now be stabilized with an arthroscopically assisted technique, using a few small buttonhole sized incisions around the shoulder and clavicle (see below).

If for any of the reasons outlined above you and your surgeon decide that surgical fixation is right for you, most clavicle fractures are fixed on an outpatient basis or at most an overnight stay. The surgery itself will usually take 1-2 hours, although additional time will be needed before and after the surgery. Most patients will follow a similar postoperative course, with a sling for comfort, with immediate gentle range of motion and progressive physical therapy. Ice, pain medication and anti-inflammatories, as well as elevation including sleeping propped up on pillows or a recliner can be helpful after fixation of a clavicle fracture.

What are the risks of clavicle surgery?

There are risks with any surgery. The risks include but are not limited to bleeding, infection, nerve, blood vessel or other injury, malunion (deformity of the clavicle), nonunion (the clavicle may not heal). Skin numbness is common with incisions in this area. There may be need for further surgery. Especially in the case of plate fixation, the hardware may be quite prominent under the skin and may need to be removed in up to 30-40% of patients.

When can I return to sports after a clavicle fracture?

Return to sports is a decision based on individual patient demand, healing of the fracture, type of sports including level of contact, and whether the patient has regained full range of motion and strength in the affected arm. Patients will typically need 3 to 4 months from the injury to heal a clavicle fracture.

 

Figure 1: Distal clavicle fracture.  Figure 2: Aligned clavicle fracture after arthroscopic fixation.