There’s new thinking on how to treat one of summer’s most common injuries.
By Dr. Nathan Endres
It happens quickly. You lose your balance, you tumble over the handlebars and as you reach for the ground to break the fall, something snaps.
One of the most commonly broken bones in the body, the clavicle (or collarbone) usually fractures after a fall onto an outstretched arm or directly on the shoulder. Here in Vermont, most of the clavicle fractures I see are from skiing or snowboarding, cycling, hockey, football, lacrosse and horseback riding. This time of year, though, it’s mostly cyclists going over the handlebars.
Until the last decade or so, nearly all middle clavicle fractures (the most common type), were treated without surgery. There is an old saying that as long as the clavicle pieces are in the same room together, they will heal. This is true … to an extent.
We all probably know someone who broke their clavicle, let it heal and is doing just fine with a big bump to show for it. However, some recent studies have shown that the clavicle doesn’t always heal and even when it does, some patients report ongoing discomfort and weakness. How you treat the injury is often determined by the demands of the patient and the amount of separation of the bony pieces. To put it simply, the more active you are and the more displaced the fracture is, the more likely you are to have issues down the road. Problems may include low-grade soreness, strength deficits and functional limitations, especially when raising your arms overhead. The good news, a broken collarbone rarely means any serious disability.
And that’s good because we need our collarbones. A flat bone that looks like an “s” from the top down, the clavicle serves as a strut to hold your shoulder away from your body. It connects to the shoulder at the acromioclavicular joint (AC joint) and to the chest at the sternoclavicular joint (SC joint). The clavicle also protects important nerves and blood vessels travelling from the neck and chest out to the arms.
Often, clavicle fractures are associated with other shoulder, head, neck, lung, or rib injuries. It is important to rule out these other injuries (especially head and neck) before focusing on the clavicle.
Clavicle fractures are classified by where the break happens in the bone (outside third, middle third, inside third). By far, most breaks occur in the middle and we will only talk about those in this article. When the clavicle breaks in the middle, the weight of the bone and the muscles that attach to it pull the broken pieces apart. The amount of separation that occurs is called displacement. Sometimes the bones shatter into multiple pieces and this is called comminution. All of this can be seen on a regular x-ray. Very rarely is a CAT scan or MRI helpful when dealing with a clavicle fracture.
Clavicle fractures usually are not considered an emergency, unless the bone comes through the skin or there is an injury to a major artery. Most patients head to the emergency room, get an x-ray to confirm the diagnosis and are sent home in a sling, unless other major injuries are identified. If you have a fractured clavicle and the pieces are separated, it is a good idea to have follow-up with an orthopaedic doctor within a week.
Most clavicle fractures are treated without surgery. Healing takes on average 8 to 12 weeks, depending on factors like age, displacement and whether you are a smoker. If the bone doesn’t heal (called a non-union), it is possible to still fix it later on. Once it is fully healed, it is hard to undo but this can be done if someone is having major problems with their shoulder. Fortunately, this scenario is quite unusual.
However, some patients may benefit from surgery right from the start. These are often athletes, who place high demands of their shoulder and who have displaced and/or comminuted breaks. There are a fair number of people who meet that description, so it is now more common than ever to surgically fix clavicle fractures.
This is usually done with stainless steel plates and screws, or sometimes a pin placed down the middle of the bone. Once the bone is fixed, patients stay in a sling for two to four weeks but can move their fingers, wrists, elbows and are allowed limited shoulder motion. Keep in mind, the recovery may vary based on the patient, the break itself and the surgeon’s preferences.
Benefits of surgery are that it can be done at a very low non-union rate and in some cases, results in a quicker return to work and sports. By anatomically fixing the clavicle to its normal shape, overall shoulder function may be more normal than leaving it alone to heal.
But surgery has risks, too. The most common complications of clavicle surgery are numbness on the skin around the incision and prominent hardware. The numbness is often permanent, but rarely an issue for patients. If the hardware is bothersome, it can be removed after the bone is healed (usually 6 to 12 months after surgery). Other serious complications like infection or wound problems can occur, but are rare.
The bottom line is it really comes down to an individual discussion about the pros and cons of each option, with your doctor.
Dr. Nathan Endres is an orthopaedic surgeon at the University of Vermont Medical Center. He specializes in sports medicine and fracture treatment. He is a team physician for the University of Vermont, St. Michael’s College and the U.S. Ski Team