Clavicle Fractures

Patient information — Dr Christopher Spelman, Orthopaedic Surgeon

Overview

The clavicle (collarbone) connects the arm to the trunk and is one of the most commonly fractured bones. Most clavicle fractures occur in the middle third of the bone and result from a fall onto the shoulder or an outstretched arm, or from a direct blow, often during sport or a cycling accident. They cause pain, swelling and sometimes an obvious deformity or bump over the collarbone.

Assessment

The diagnosis is confirmed with x-rays, which show the location of the fracture, the number of fragments and the degree of displacement and shortening. These features, along with your activity level, help determine whether the fracture is best treated in a sling or with surgery.

Non-operative treatment

The majority of clavicle fractures heal well without surgery. Treatment involves a sling for comfort, pain relief and a graduated return to movement. This is generally recommended for fractures that are not significantly displaced or shortened.

Surgical treatment

Surgery, usually fixation with a plate and screws, is considered for fractures that are completely displaced and shortened, that are in several pieces, that have broken the skin (open fractures), or that involve associated injuries. Fixation restores the normal length and alignment of the bone and allows earlier, more predictable recovery in selected patients.

Outcomes and what the evidence shows

A landmark multicentre randomised trial found that, for completely displaced mid-shaft clavicle fractures in active adults, plate fixation resulted in better function, faster union (16 versus 28 weeks) and markedly lower rates of nonunion (about 2% versus 15%) and symptomatic malunion compared with non-operative treatment at one year. The trade-off is that surgery introduces hardware-related problems. The evidence supports offering surgery for significantly displaced fractures in active patients, while most non-displaced fractures do well without it.

Complications

The risks differ between treatment paths, and Dr Spelman will weigh them for your particular fracture:

Non-operative treatment

●      Nonunion – failure to heal, occurring in around 15% of completely displaced mid-shaft fractures (and far less often in undisplaced fractures).

●      Malunion – healing with shortening or a bump, which can occasionally cause weakness, fatigue or altered shoulder mechanics.

Surgical treatment

●      Hardware prominence and irritation – the plate lies just under the skin and is frequently noticeable; hardware removal is the most common reason for a second operation.

●      Infection – wound or deep infection in a small percentage of cases.

●      Nonunion or hardware failure – uncommon after fixation but possible.

●      Numbness below the incision – from small skin nerves crossing the collarbone, often improving with time.

●      Rare neurovascular injury – the major nerves and vessels lie beneath the clavicle and are very rarely injured.

●      Refracture – can occur after the plate is removed.

Summary

Most clavicle fractures heal well in a sling. For completely displaced, shortened or multi-fragment fractures in active patients, plate fixation lowers the risk of nonunion and malunion and speeds recovery, at the cost of hardware