The clavicle or collar bone 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 I see. 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. 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:
- Medial end (part closest to the sternum)
- Midshaft (is in the middle of the clavicle and the most commonly fractured part)
- Distal end (The part on the outside part of the clavicle)
What are the symptoms?
Most patients hear or feel a crack when their 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 two ends of bone moving apart. The shoulder is very painful for the first week with movement. 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 Emergency Department.
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 is a clavicle fracture best treated?
In the past, most patients have been treated in a sling and sent to their general practitioner for treatment and told that it will take six to eight weeks for the fracture to heal. While this is true for many simple clavicle fractures, it is slowly becoming clear that a lot of these fractures don’t do as well as we 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 in a sling. 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, most fractures of the clavicle that are displaced, angulated or overlapped are best treated with surgery. We have seen that active patients are much happier and more functional when we are able to restore the normal anatomic alignment of the shoulder. 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 center 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 stabilizing the fracture, 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.
- 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 is a 16 year old rugby player who landed directly onto his shoulder. He had surgery within one week from his injury and healed within five weeks.
- 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 lacrosse player was injured during a game and within six weeks of having the plate inserted had healed, had full range of motion and absolutely no pain.
- Comminuted Fracture (in numerous pieces) – 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 17 year old male came of his bike and had surgery two days after his injury. He did very well with a good range of motion and no pain within 5 weeks of his operation.
- Malunited Fractures (healed in wrong position) – often patients have fractures that have been treated in a sling and heal in the wrong position. We have found that even if you present 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.
This 65 years old woman fractured her clavicle over 20 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. Her fracture was fixed with a plate and screws and a bone grafting technique to stimulate healing. Her post-operative course was more conservative, keeping her in a sling longer than normal but she eventually healed completely, had no pain, a full range of motion, and she was doing everything she wanted to do.
How is the operation done?
The operation is typically done as a same day surgery, meaning that you do not need to spend the night in the hospital. 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 center of the bone. My preferred method of treatment is a plate and screws.
The surgery is performed under general anaesthesia in the hospital. A small incision is made below the clavicle and the fractured bone ends are then exposed. The bone ends are 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. We are currently using a specially designed low-profile titanium plate that contours to the anatomy of the clavicle perfectly. Generally at the time of surgery bone graft taken from around the fracture can be used to also stimulate healing. 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.
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 only in a sling for a week while others need to be cautious for up to 6 weeks.
The clavicle can take a minimum of six weeks to heal and up to six months to fully heal. Healing is determined by successive X-Rays and clinical examination.
What happens after surgery?
We usually see our patients within a week or two of surgery to check on their progress. At the visit, you have an x-ray to check the position of the plate and screws. Your dressing will be removed and the suture or stitch threads are painlessly clipped.
Further follow up is required approximately five weeks and then 12 weeks after your operation. At each visit an x-ray will be requested. We will 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. We also like to assess your movement to ensure that it is returning to normal. At each of these visits we will discuss with you the activities that you are able to resume.
Malunited or Non United Fractures of the Clavicle
There are 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 (Mal-union) with the bones overlapped leaving a lump and the shoulder sitting forward. These can cause ongoing problems for patients. 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. This operation can be done many years after the original break.
Recovery and bone healing from these operations take a little longer than a standard fracture and patients have to be a little more cautious during the healing period. But despite the increased difficulty, we have had excellent results from re-breaking the clavicle and realigning the bones, even in cases where the malunion has been present for up to 20 years.
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 quickly after surgery as the bones are in the right position.
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: Plate removal from the clavicle is not routinely required or recommended. Symptomatic prominence and impingement of the plate can occur. After the fracture has completely healed, removal of the implant can be considered. This occurs in less than 5% of cases.
Q: Will I need physical therapy after my surgery?
A: It is very unusual to require physiotherapy after this surgery. 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. A more aggressive strengthening/sports program is gradually introduced as healing progresses.