Clavicle fracture

What is clavicle fracture?

The clavicle or collar bone is a pair of long bones that are located in the top of your chest between the shoulder joint and the breast bone (sternum). Clavicle connects the arm (upper limb) to the body and has strong ligamentous attachments to the scapula (shoulder blade) and breast bone. Clavicle fracture also called Broken collar bone, accounts for around 5% of all adult fractures, 10% of sports-related fractures and occurs due to falling on an outstretched hand or due to the direct impact on the shoulder. It commonly occurs in cyclists, people who are involved in contact sports like martial arts, rugby, foot ball, motor racing and horse riding. Any direct blow to collar bone or an accidental fall on an outstretched hand can cause Broken collar bone. Most fractures are located on the middle third (81%) followed by lateral (17%-near shoulder) and medial (2%-near breastbone).

 

What are the symptoms of clavicle fracture?

Fracture of the collar bone can cause bruising, swelling and pain over the bone that increases with the movement of the shoulder. You may experience difficulty in raising the arm and feel deformity or prominence at the fractured bone. Sagging of the shoulder downward and forward is common and with the movement, you can feel a grinding sensation in the shoulder. The sharp ends of Broken collar bone can occasionally tent the skin, pierce the skin or could cause injury to lungs, nerve and blood vessels causing breathlessness, numbness and coldness in the arm. Immediate medical attention is needed in these scenarios.

 

How is it diagnosed?

Diagnosis is made on the basis of detailed medical history, physical examination and an X-ray. X-ray helps to find the exact location of the fracture. CT scan can be used rarely to detect the extent of fracture and involvement of neighbouring structures.

 

What happens if nothing is done?

The fractured bone could heal in the wrong place causing pain, clicking and stiffness of the shoulder. Besides, in some cases, the fracture could take more time to heal or do not heal at all leading to a significant reduction in shoulder function.

 

How is it treated?

Clavicle fracture can be treated conservatively or by surgery. Conservative treatment involves the use of a polysling, painkillers and physiotherapy.

Surgery is indicated

Absolute indications

  1. Open fractures
  2. Associated injuries to nerves/blood vessels/lung
  3. Floating shoulder – fracture of the arm bone (humerus) or shoulder blade
  4. Skin tenting with the possibility of skin necrosis

 Relative indications

  1. Gap at the fracture site (100% displacement)
  2. Shortening >2cm
  3. Fractures at the lateral end (near shoulder joint)
  4. Bilateral fractures
  5. Polytrauma (esp. associated rib fractures)
  6. Severe communition

 

What are the non-operative treatments?

Most clavicle fractures can heal with non-operative methods within 6 to 12 weeks in adults and 3-6weeks in children.

  1. A simple arm sling is used to give support and comfort to the arm soon after the fracture. The most commonly used sling is polysling that minimises the movement of the affected area of bone for a few weeks and also helps to keep the arm and the shoulder in its position during healing. Studies have shown that there is no difference in the outcome with either a poly sling or figure of 8 –bandage and the author’s preferred method is to treat these injuries with polysling.
  2. Painkillers such as paracetamol and codeine are prescribed to relieve pain.
  3. Anti-inflammatory drugs, ice packs might be needed to control swelling and pain in the early stages. However, using anti-inflammatory medications longer could lead to delayed bone healing.
  4. Physical therapy, especially pendulum exercises are started early to prevent stiffness and weakness. It is important that the elbow, wrist and hand are kept mobile during this period of immobilisation. Gentle shoulder range of motion exercises is started around 3 weeks and gradually progressed to more strenuous exercises after the fracture has healed.

 

What are the risks of non-operative treatments?

  1. The fracture may not heal in 1-15% of the cases
  2. Symptomatic malunion in 15-20% of the cases
  3. Weakness of the arm with easy fatiguability
  4. Scapular winging
  5. Neurologic (thoracic outlet syndrome)
  6. Droopy, asymmetric shoulder, difficulty with backpacks shoulder straps etc.
  7. Strength deficits ranging from 10% to 35%

 

What does the operation involve?

To reduce the risks of non-operative treatment, surgery is performed in 5 to 10 % of cases of clavicle fractures. The main purpose of the operation is to facilitate the realignment and stabilization of the fractured ends during the process of healing.

  • Surgery is usually performed as a day case under general anaesthetic, a cut is made in the skin over the fracture site and the fragments of the clavicle are first repositioned to their normal position.
  • Then, internal fixation of the fragments is done with the help of plates, pins and screws to keep the bone in proper position during healing. In some cases with multiple fracture fragments, bone substitutes are used to accelerate healing and to bridge the gap.
  • The skin is stitched using absorbable sutures and a polysling is applied. The surgical time is usually 1-2hrs and the majority of the patients go home the same day

 

What happens after surgery?

  • The local anaesthetic wears off 4-10 hrs after surgery, patients are encouraged to start taking painkillers before the pain starts i.e. on return home and for at least 48 hours from there. This way most of our patients report little or any pain.
  • Initially, the aims are the comfort and rest the arm in a sling for a couple of days.
  • Before discharge, you may see a physiotherapist, who will teach you gentle exercises of your fingers, wrist, elbow and pendulum exercises of the shoulder. You may be able to start these gentle exercises on the day of your operation and they are essential to reduce stiffness, pain and to strengthen the muscles around your shoulder.
  • You can use your arm to do light activities (writing, using keyboard etc) that don’t cause excessive pain or discomfort.
  • The patient is reviewed in clinic around 2 weeks following the operation for wound check and physiotherapy.
  • The wound should be massaged (typically after 2 weeks) using moisturising cream by the patient 3 times a day for 3 months once the wound is well healed. This reduces the scar sensitivity and scar-related complications (tenderness, helps scar to mature).
  • You could start a gentle range of movement (ROM) exercises at 3 weeks and progress to more strenuous activities (swimming, driving, lightweights in gym etc) around six weeks. This will be guided by your surgeon and is based on radiographic (X-ray) and clinical union of the fracture. It is advisable to avoid contact sports or any injury to the affected area for 3 months. The duration may increase or decrease based on the personality of fracture, quality of bone and method of fixation.
  • Physical therapy plays an important role in returning back to the normal activities and its vital to work with the physiotherapists to get full function back in your shoulder.
  • Plates and screws are usually not removed from the bone even if the healing process is complete until they cause discomfort in the skin of the affected area.

 

Are there any risks?

The risks related to surgery of Broken collar bone can be-

Early

  • There is a risk of injury to the lungs, nerves and major blood vessels (3%) during the surgery.
  • Pneumothorax
  • Infection (4%) – risks are diabetes, drug abuse, previous surgery
  • Numbness around/below the scar (10-29%) –usually improves, could persist for up to 2 years and may be permanent. Very well tolerated, rarely symptomatic.
  • Failure of fixation (1%)

Late

  • Non-union/delayed union (1-5% )
  • Pins or plates can irritate the skin over the affected area of the clavicle and around 30% of patients need implant removal.
  • Adhesive capsulitis or frozen shoulder (4%)
  • Refracture after plate removal (1-5%)

 

What are the results of the operation?

The outcome of the operation is excellent with minimal chances of complications like non-union, delayed union, weakness, stiffness, pain etc. The outcome is more predictable in the author’s experience

 

When can I return to driving and work?

You can return to work between a week and 3 months of the injury. You can start driving from six weeks. Both depend on the nature of your job, severity of the injury and the treatment involved in the Broken collarbone, your surgeon will be able to advise.

Clavicle fracture_1

  1. 41year old gentleman with comminuted minimally displaced clavicle fracture with no shortening and was not tenting the skin. B. 3 months after conservative treatment, the fracture healed completely and patient returned back to pre-injury level of activities.

Clavicle fracture_2

  1. 25 year old gentleman had a fall during snowboarding and broke his collar bone with one of the fragments tenting the skin (Red arrow) and fracture gap. B. 6 months radiograph with fully healed clavicle after open reduction and internal fixation with plates and screws. Patient returned back to pre-injury level of activities, three months after surgery.

Clavicle fracture_3

  1. 55 year old polytrauma patient following road traffic accident was admitted with comminuted lateral end clavicle fracture. B. 5 months radiograph with fully healed clavicle after open reduction and internal fixation with plates and screws augmented with anchor in coracoid (shoulder blade). Patient returned back to pre-injury level of activities, six months after surgery.

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