Clavicle (Collar Bone) Fractures 

What are the symptoms?

These fractures generally occur due to a fall directly onto the shoulder or a fall onto an outstretched hand. One generally feels a crack or acute pain through the outer end of the collarbone. There’s generally swelling and bruising and in a lot of cases an obvious deformity or lump on top of the shoulder. This is usually due to the bone displacing upwards and often backwards. The shoulder is often painful and a clicking sensation is often felt.

How is a diagnosis made?

Diagnosis of a clavicle fracture is made using the history described by the patient, a plain x-ray of the clavicle and in some instances a CT scan.

How are these problems 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 clavicle fractures look like on X-ray?

Below are examples of typical fractures that benefit from surgery.

What are the symptoms?

These fractures generally occur due to a fall directly onto the shoulder or a fall onto an outstretched hand. One generally feels a crack or acute pain through the outer end of the collarbone. There’s generally swelling and bruising and in a lot of cases an obvious deformity or lump on top of the shoulder. This is usually due to the bone displacing upwards and often backwards. The shoulder is often painful and a clicking sensation is often felt.

How is a diagnosis made?

Diagnosis of a distal clavicle fracture is made with history, then a plain xray of the clavicle and in a lot of cases a CT scan. With new 3D CT scan imaging, separation of bony fragments can be well visualised which helps for possible surgical planning.

What do Distal Clavicle Fractures Look Like on X-ray and CT?

How are these problems treated?

The management of the distal clavicle fracture really depends on whether it is displaced or undisplaced. If it is undisplaced and there is no obvious lump, the fracture can be treated without surgery and resting the arm in a sling for 4-5 weeks. These fractures can then take up to three months to completely heal.

If there is any evidence clinically and radiologically of displacement, then surgery is generally recommended due to the high incidence of the fracture not healing (non-union).

Which fractures require surgery?

Generally all displaced fractures of the distal clavicle require surgery to increase the incidence of union. In my practice, the operation is performed by realigning the bones back to their original position using a plate and screws on top of the bone. The advantage of fixing them with a plate and screws generally means that you can start to move the arm a lot quicker and to also decrease the incidence of non-union.

How is the Operation Done?

The operation is performed with the patient under a general anaesthetic, in other words, completely asleep, and a small 3-4 cm incision is made under the collarbone, at the end of the shoulder. The fractured bone ends are exposed and put back into position using a plate and screws as shown below.

This fixation also needs reinforcement using special sutures around the plate and around the bone next to the clavicle called the coracoid process. The sutures are used to decrease the deforming forces from your shoulder muscles. In the majority of cases, in my hands, the operation is extremely successful resulting in the bone healing and the return of near normal function. In a small number of cases, the plate needs to be removed if it irritates the patient under the skin.

In certain circumstances, when the fractured piece of bone is only small, special figure-of-eight sutures are used and no plate is necessary as shown in the images below.

1. 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.

2. 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".

3. 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 treated by realigning the clavicle through surgery in order to prevent further complications of shortening and overlap.