Clavicle (Collar Bone) Fractures

The collar bone or clavicle is a bone which is located between the shoulder and the sternum (or breast bone) and is the most commonly fractured bone seen in the clinic.

Anatomy

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, often 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.

The clavicle bone is divided into 3 main parts:

1. Medial end (part closest to the sternum)

2. Midshaft (is in the middle of the clavicle and the most commonly fractured part)

3. Distal end (The part on the outside part of the clavicle)

Mid-shaft Clavicle 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.

There are various types or classifications of clavicle fractures and below are some examples of each type and how they look once they have been fixed:

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.

This young man was 16 years old at when he landed heavily while playing rugby. He had surgery three days after seeing me and healed within 5 weeks:

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".

This 14 year old male fell from his skateboard and within 5 weeks of having the plate inserted had healed, had full range of motion and absolutely no pain.

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.

This 34 year old man came off his pushbike and landed on his right shoulder causing a fracture of his clavicle. He had surgery one day after seeing me and while his x-rays showed he hadn't quite healed, he was doing everything and had a full range of motion. He had one more visit two months later which showed he had completely healed therefore was discharged from my care.

This 38 year old man came off his motorbike at high speed on the race track and presented with a comminuted fracture of his clavicle. His 3D CT scan highlighted the extent of the damage and I operated on him two days later. The plate used is much larger than I would normally use as is the scar, however this was necessary in order to secure all of the fracture fragments. He told me he felt better as soon as he woke up in the recovery room. When I saw him six and a half weeks following his surgery his fracture has already healed in perfect position, he had a full range of motion and volunteered to prove he was already able to do push ups (watch the following videos to see for yourself!)

This 17 year old male came of his bike and had surgery the same day he saw me. He did very well with a good range of motion and no pain within five weeks of his operation

The following xrays belong to a 21 year old lady who was visiting from overseas and who fell while staying at a farm. She suffered a 4-part fracture of her clavicle which required fixation before she returned to Germany two weeks after her surgery.

This 41 year old man came off his motorbike at Eastern Creek raceway and had surgery two days after seeing me. Five weeks later he had almost a full range of motion and strength and the last time I saw him, three months after his surgery, he was extremely happy with his progress and doing everything normally.

This 23 year old fell when playing soccer and managed to shatter his clavicle into 5 pieces. Five weeks following his surgery his fracture had almost completely healed and he had a good range of motion. Three months after his operation he had a normal shoulder again, the clavicle fracture was solidly healed and he was a happy man.

4. 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. See below for further information about this and x-ray images.

How is the operation done?

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. Generally at the time of surgery bone graft taken from around the fracture can be used to also stimulate healing. The fracture when fixed, is imaged in the operating theatre under X-Ray to check it is in perfect position. Once the fracture is secured the wound is then closed 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. The length of time in a sling depends on the age of the patient, how many pieces the fracture was in and the stability of the fracture fixation at the end of the surgery. Some patients are really only in a sling for a week and some patients need to be cautious for up to 6 weeks.

The clavicle can take a minimum of 6 weeks to heal and others can take 6 months to fully heal. Healing is determined by successive XRays and clinical examination.

What happens after surgery?

We usually see our patients a week or two after surgery to check on progress. At this visit, you have an x-ray to check the position of the plate and screws. Your dressing will be removed and the wound checked. The sutures are buried beneath the skin and they will dissolve.

Further follow up is required approximately 5 weeks and then 12 weeks after your operation. At each visit an x-ray will be requested. I am able to assess the amount of callus (new bone) on your x-ray. The other important aspect to check on post-surgery x-rays is the position of plate. I also like to assess your movement to ensure that it is returning to normal. At each of these visits I will discuss with you the activities I am happy for you to resume.

Once your collarbone has healed, and your movement is back to normal and you have returned to your normal work and sports, there is no need to keep coming back to see me though about a year after your surgery you will most likely be contacted so that we can ask you to complete a questionnaire to see how you are getting on.

Mal-united or Non United Fractures of the Clavicle

There are still a percentage of clavicle fractures that don't heal after treatment in a sling (Non-union) and there are ones that heal in the wrong position with the bones overlapped leaving a lump and the shoulder sitting forward. (Mal-union)

These can cause ongoing problems for patients and the reason why they seek further specialist opinion. In these circumstances patients complain of pain, a palpable lump, or the fact that their shoulder just doesn't feel right.

In specific patients an operation can be done to re-break the clavicle and realign the bones. This is called an "osteotomy" and the bone is broken and re-aligned back to its original position. This operation can be done many years after the original break.

Over the last years in my practice we have had some remarkable results from re-breaking the clavicle and realigning the bones. In some cases the malunion had been present for up to 20 years. Patients often wake up immediately after surgery and say their shoulder feels like it is back in the right spot.

Recovery and bone healing from these operations does take a little longer than a standard fracture and one has to be a little more cautious during the healing period.

Below are some examples of clavicle fractures which healed badly and had to be re-broken:

This man is 38 years old and originally fractured his clavicle in 2003. It was left to heal naturally but unfortunately healed in a poor position. This year, he fell while playing soccer and fractured through the previous mal-union and callus. He had surgery and within just six weeks was almost healed and had a good range of motion, function and strength.

This lady is 65 years old and fractured her clavicle 28 years ago in a motor vehicle accident. At that time she was told that nothing could be done for her. It never really healed and as a result she had ongoing pain in her scapula, shoulder and clavicle. I managed to fix her fracture with a plate and screws and kept her in a sling longer than I normally would and reviewed her for a longer period of time than normal but at her final visit eleven months after her surgery she was delighted with the result as she had no pain, a full range of motion, the fracture was solidly healed and she was doing everything she wanted to do.

The following x-rays belong to a lady who had fractured her clavicle 18 years prior and it was left to heal without surgery. She always had a prominent lump over the clavicle but came to see me due to increasing pain. I had to re fracture her clavicle and put on a plate and screws and six weeks later she already had good function and range of motion and the fracture was almost completely healed. At her final visit she had normal strength, range of motion, absolutely no pain and back doing everything she wanted to do.

This lady is 45 years old and fractured her clavicle while skiing overseas and had it fixed there 6 months earlier. Unfortunately it didn't heal and the pin had to be removed. Her fracture was then replated and 3 months later her fracture healed.

This young man first fractured his clavicle when he was 9 years old and it was treated conservatively and healed. Then three years later he fell from his skateboard and broke it again and was again treated conservatively but this time did not heal and continued to be painful so he had a plate put on and he had healed eight weeks later.

How big will the scar be?

Dr Duckworth takes great pride in making the scar as small as possible. The scar on average will be between 3 and 6 cm long and the size will depend on the size of the plate needed to fix your clavicle properly. Below are some pictures of some scars:

Distal Clavicle 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 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 Xray and CT?

Xray

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.

What happens after surgery?

We usually see our patients a week or two after surgery to check on progress. At this visit, you have an x-ray to check the position of the plate and screws. Your dressing will be removed and the wound checked. The sutures are buried beneath the skin and they will dissolve.

Further follow up is required approximately 5 weeks and then 12 weeks after your operation. At each visit an x-ray will be requested. I am able to assess the amount of callus (new bone) on your x-ray. The other important aspect to check on post-surgery x-rays is the position of plate. I also like to assess your movement to ensure that it is returning to normal. At each of these visits I will discuss with you the activities I am happy for you to resume.

Once your collarbone has healed, and your movement is back to normal and you have returned to your normal work and sports, there is no need to keep coming back to see me though about a year after your surgery you will most likely be contacted so that we can ask you to complete a questionnaire to see how you are getting on.

Frequently Asked Questions

Q: How long am I in a sling for?
A: 1 to 2 weeks so long as you are careful when you are out of it. We ask that you wear the sling if you are going out anywhere where there is a crowd and thus a risk of being bumped or pushed.

Q: Is it painful after surgery?
A: Generally patients feel pain relief quite quickly after surgery as the bones are in the right position.

Q: How long am I in hospital for?
A: Usually only one night although some patients are only admitted for the day. It depends on your pain levels.

Q: When can I drive?
A: Usually between 2 to 3 weeks after surgery.

Q: When can I play sport again?
A: 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.

Q: When can I return to work?
A: Usually within a week if you perform desk work only. Physical work could take 6- 8 weeks to return to.

Q: Does the plate need to be removed?
A: Only if it bothers you which would only occur in 10% of cases

Q: Will I need physiotherapy after my surgery?
A: It is very unusual to require physiotherapy after this surgery. The patient is the best physio. Following your surgery you can gradually start to use your arm more or less straight away, but avoiding using your arm above shoulder height, lifting anything heavy or putting your arm behind your back. Due to this early movement it is highly unlikely that any formal physiotherapy programme would be required.