Clavicle fractures are one of the more common fractures of the upper extremity. Also known as the ‘collar bone’, the clavicle acts as a strut to hold out the shoulder from the chest wall. Clavicle fractures commonly occur because of falls onto a shoulder, although they may occur due to a direct blow to the collar bone or due to high-energy trauma (i.e. a car accident). They can occur in any age group.
Patients are often seen first in the Emergency Room, where the diagnosis is made. A sling is applied to help with pain control and to avoid movement around the shoulder. In contrast to many other fractures, it is not possible to ‘cast’ clavicle fractures, nor is it necessary in this instance to allow for healing.
Patients are then referred to a fracture clinic where they are seen by an Orthopaedic surgeon. The X-rays obtained and the cause of the injury will help the surgeon determine how severe the injury is. As treatment decisions depend on the size of the fracture and how far it has moved away from its normal (or ‘anatomic’) location. To aid in treatment decision making, a CT scan may be obtained if necessary.
Clavicle fractures with minimal movement from their anatomic location can be treated without surgery. The clavicle will often heal with a robust ‘callus’, resulting in a bump that often smooths out with time.
In the event the bone has moved, many factors will determine the best course of action, including fracture location, hand-dominance, age, occupation, activity level, and medical status. For example, fractures on the inner or outer third of the clavicle can be prone to delayed or non-healing, which needs to be considered in the context of a patient as a whole. If surgery is recommended, the main goal of the procedure is to recreate normal anatomy by fixing the clavicle with a plate and screws. The plate and screws will hold the bone in place while it heals together. However, it is important for patients to know that clavicle surgery comes with a few notable and unique surgical risks. Firstly, the surgical scar is permanent and can be noticeable given the location on the body. Additionally, two skin nerves cross the surgical site, and because of this the surgery may result in some numbness of the chest wall. Thirdly, major blood vessels, nerves and the lung are close to the clavicle, and very rarely may be injured during surgery. Finally, the plate used during clavicle surgery may become bothersome and cause irritation. Should this occur, hardware removal at a later date may be considered.
As each of the above considerations will differ from patient to patient, It is important that treatment options be discussed with your treating surgeon, including the risks and benefits of each. It is important to remember that clavicles have been treated without surgery for all but the last few decades. The orthopaedic goal of achieving the best possible function with the least risk is very well represented when considering treatment for a fractured clavicle.
Delayed or Non-Union
Approximately 5-10% of clavicle fractures take longer then 6 weeks to heal. Excessive time to heal is referred to as delayed union, while a bone that does not heal is referred to as a non-union. Factors involved in excessive healing time or non-union of the clavicle include smoking, fracture location (close to the end of the bone), severe fractures, and excessive movement through the fracture. Delayed or non-united clavicle fractures may benefit from more time, physical therapy, bone stimulation or surgery.
Expected Follow-up and Recovery
Expected recovery is not notably different between non-surgery and surgery groups, although is delayed in those whose clavicles take a while to heal:
- No Surgery: Sling for comfort for 4 weeks. During this time finger, wrist and elbow motion may occur, but no motion at the shoulder. Following this, physical therapy can be started in an active/assisted fashion, with fully active motion starting at 6 weeks and strengthening starting at 2 months.
- Surgery: Sling for comfort for 4 weeks. During this time finger, wrist and elbow motion may occur, but no motion at the shoulder. Following this, physical therapy can be started in an active/assisted fashion, with fully active motion starting at 6 weeks and strengthening starting at 2 months.
- Delayed Healing: Initial treatment as above. If the clavicle is taking an excessive amount of time to heal, contributing factors will be explored. Patients who smoke will be encouraged to quit. Those who are putting too much motion through their shoulder will be asked to modify their activity. The potential benefit of a bone stimulator will be discussed if felt relevant. Finally, surgery may be an option. Time to recovery will ultimately depend on the cause of the delayed healing.
- All slings should be kept clean and dry.
- Swelling is common following an injury or fracture. To decrease swelling consider icing it 15 minutes at a time every 1-2 hours. Ice should be wrapped in a tea-towel to avoid frost-bite.
- Bruising down the arm or across the chest is expected following any fracture around the shoulder
- Occasional numbness that resolves quickly is to be expected. Persistent numbness in the arm is not common and should be mentioned to your physician.
- Chest pain or shortness of breath is not normal and should prompt immediate return to the emergency room.
- You may find it more comfortable to sleep in a reclining chair for the first 2-5 weeks following the injury. Ensure the chair is placed close to washrooms and away from any tripping hazards.
General Therapy Instructions
Please note: this alone does not constitute as a formal referral to a physical therapy. As each injury is unique, the below may not apply to everyone.
- While in a sling: Work on active and active assisted range of motion of your fingers/thumb, wrist and elbow to prevent stiffness. As long as your elbow is close to your body, non-weight bearing exercises are safe to perform for the above joints.
- 4-5 weeks following injury: As pain subsides, you can begin to perform light pendular exercises. To do this, you let your arm hang and have gravity rotate your hand around. This allows for some motion through your shoulder without excessive stress on the fracture.
- 5-6 weeks following injury: Once your fracture is healed you will begin to wean the sling and start physical therapy. The goal is to regain 80% of your shoulder motion by 12 weeks post injury.
- 12 weeks post injury: Add in strengthening of the shoulder, with sport or job specific exercises as needed.
- At all times: Let pain be your guide. Excessive discomfort or therapist concern should prompt you to contact your Orthopaedic Surgeon or Family Physician.
Clavicle fractures can cause stiffness and weakness around the shoulder. Depending on the severity, your treating physician will comment on your expected recovery. In general, we aim to return people to 90-95% of their previous function and back to work before the 12-week mark. Office workers are often able to return to work 2-4 weeks following injury, and may use a keyboard and mouse in a sling with their elbow at their sides.
- Wrist/Finger Stiffness: May require formal physical therapy over 6 months to resolve. Chance of finger/wrist stiffness can be greatly decreased by keeping both joints moving.
- Shoulder Stiffness and Weakness: Stiffness around the shoulder is to be expected. It can take upwards of a year to maximize gains in shoulder range of motion and strength. Physical therapy and ongoing exercises are critical for recovery during this time.
- Complex Regional Pain Syndrome: a challenging adverse pain response associated with some fractures. Requires time, physical therapy and occasionally medications to treat.
- Non-Union or Delayed Union: See the above section.
Summary of Common Treatment/Rehabilitation Pathway