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Clavicle (Collar Bone) Fractures
The collar bone or clavicle is a bone which is located between the shoulder and the sternum (or breast bone). In my practice as a “shoulder and elbow” specialist it is the most commonly fractured bone seen in the clinic. The most common way to fracture the clavicle is through a fall or direct blow to the area. Most commonly the clavicle is fractured after a fall from a bike, a football injury or soccer injury. Occasionally it can be fractured in a car accident. It is generally an isolated fracture although sometimes it occurs with other shoulder fractures or more commonly with rib fractures.
How Do Patients Present?
Most patients hear or feel a crack when the clavicle breaks or fractures. They then notice specific pain over the clavicle and often feel a lump under the skin. The shoulder tends to sit forward and the patient can often feel the 2 ends of bone moving apart. The shoulder is very painful for the first week when any form of movement occurs in the arm. The shoulder is best rested in a sling until appropriate medical treatment can be sought and the diagnosis made. X-rays are usually performed in an “Accident and Emergency” department.
How are These Clavicle Fractures Treated?
In the past most patients have been treated in a sling and sent to their general practitioner for ongoing treatment. They have been told that it will take 6 to 8 weeks for the fracture to heal and that you will be left with a lump however it probably won’t bother you in the future. This is true for the majority of fractures in patients less than twelve to fourteen years of age however for those older it is slowly becoming more evident that a lot of these fractures don’t do as well as thought in the past.
It is generally accepted that clavicle fractures in adults that are in good alignment or near anatomical position can be left to heal well in a sling or in a figure of 8 bandage. In a child this will take about 4 weeks to heal and in an adult about 6 to 8 weeks.
Which Fractures Require Surgery?
In my practice and what is generally becoming more accepted in the literature is that most fractures of the clavicle that are displaced, angulated or overlapped are best treated with an operation. This operation can either be performed by realigning the bones in their original shape using a “plate and screws” on top of the bone or by using a “pin” that goes down the centre of the bone. Both of these techniques are successful and the decision generally comes down to the fracture pattern and the preference of the surgeon. The idea of the operation is to make the patient as comfortable as possible by making the fracture stable, and therefore allowing the patient to return to normal activities as soon as possible.
What do these Clavicle Fractures Look Like on XRay?
Below are examples of typical fractures that benefit from surgery.
Angulated fractures – as the clavicle is a flat bone if it heals in a bent position there is an increased chance of refracture when left alone.
Displaced fractures – A fracture where the 2 bone ends are widely separated. These fractures have a higher incidence of not healing and if they do heal the bone is often deformed causing the shoulder to “not feel right”.
Fracture in numerous pieces (comminuted) – the clavicle often has 2 main fracture fragments and then 2 or 3 other pieces which make healing difficult. These fractures are best to realign and prevent further complications of shortening and overlap.
Fractures that heal in a mal-united or wrong position – often patients have fractures that have been treated in a sling and heal in the wrong position. We have found that if you present even 2 to 3 years after the break has occurred, the bone can be re-broken and realigned into its previous normal position:
How is the operation performed?
To watch an actual operation click here
The operation involves coming into hospital for either one day or overnight. The fracture can be fixed with one of two methods using either a plate with screws or using a long pin that goes down the centre of the bone. My preferred method of treatment now in the majority of fractures is with a plate and screws. The surgery is performed under general anaesthesia in hospital. A small incision is made below the clavicle and the fractured bone ends are then exposed. The bone ends are then prepared to be realigned in their normal position. Often the fracture is in a few pieces and requires numerous screws in different directions to put it back in alignment. Once the bones are aligned a plate is placed on top of the bone and screws placed through the plate to hold the fracture together. The fracture when fixed is imaged in the operating theatre under X-Ray to check it is in perfect position. Generally at the time of surgery bone graft taken from around the fracture can be used to also stimulate healing. Once the fracture is secure the wound is then closed securely and a dissolving stitch is used to close the skin. The patient is placed in a sling for comfort.
Further X-Rays are taken a week after surgery and again 6 to 8 weeks later to make sure the fracture has healed.
Below are examples of fractures before and after surgery.
Case 1: 15 year old female who fell from her pushbike causing displaced left mid-shaft clavicular fracture. Seen 5 days later, plate & screws inserted 2 days later.
To see more case studies click here
How long am I in a sling for?
1 to 2 weeks so long as you are careful.
Is it painful after surgery?
Generally patients feel pain relief quite quickly after surgery as the bones are in the right position.
How long am I in hospital for?
Usually only one night although some patients are only admitted for the day. It depends on your pain levels.
When can I drive?
Usually between 2 to 3 weeks after surgery.
When can I play sport again?
This depends on the fracture. A general rule is between 6-8 weeks as long as the bones have healed adequately. Every fracture however is different and some athletes return earlier or later depending on the circumstances.
When can I return to work?
Usually within a week if you perform desk work only. Physical work could take 6- 8 weeks to return to.
Does the plate need to be removed?
Only if it bothers you which would only occur in 10% of cases.