Anatomy and Fun Facts  

 

The clavicle lies above several important structures important for arm function. The brachial plexus, subclavian artery and vein all run underneath and are somewhat protected by the clavicle.  In spite of their close proximity, these structures are rarely injured when the clavicle breaks. This is very surprising especially when you consider the bone ends can shift and the entire shoulder girdle drops when the clavicle is fractured.

 

The clavicle is part of your shoulder and connects your axial skeleton to your arm.  Reproduced from The Body Almanac. (c) American Academy of Orthopaedic Surgeons, 2003

At the lateral end the clavicle forms a joint with the part of the shoulder blade called the Acromion. This joint is called the Acromioclavicular (or AC) joint. When the joint is injured, and displaced, it is termed a "separated shoulder." At the medial end the clavicle forms the Sternoclavicular joint with the sternum, or breast bone. Many muscles important for shoulder and arm power and function attach to the clavicle. The deltoid, trapezius and pectoralis major muscles all have significant attachments to the clavicle. 

 

 

The Injury

 

The clavicle is a long bone and most breaks occur in the middle of it. Occasionally, the bone will break where it attaches at the ribcage or shoulder blade.

In this drawing, the fracture is closer to where the clavicle attaches to the shoulder blade. (Reproduced from Nuber GW, Bowen MK: Acromioclavicular joint injuries and distal clavicle fractures. J Am Acad Orthop Surg 1997;5: 11-18.)

Causes

 Clavicle fractures are often caused by a direct blow to the shoulder. This usually happens during a fall onto the shoulder. A fall onto an outstretched arm can also cause a clavicle fracture. In babies, these fractures can occur during the passage through the birth canal. Incidents that may lead to a clavicle fracture include automobile accidents, biking accidents, especially common in mountain biking, horizontal falls on the shoulder joint, or contact sports such as football, soccer, rugby or wrestling.

 

 Sustaining a clavicle fracture is typically not a subtle occurrence. Upon impact the sound and feel of cracking or popping is experienced. This is immediately followed by fairly severe pain and limited ability to lift the arm. Since the main connection to the axial skeleton is lost the entire shoulder and arm drops or sags due to gravity. This may appear as if the medial fracture fragment still attached to the sternum to "stick up", and result in a bump at the fracture site but it's actually the arm and shoulder dropping. Attempts to move the arm usually results in a grinding or popping sound and the bone ends rub against each other. Many patients feel the need to support the arm because of this.

Nonsurgical Treatment

Initial Immobilization:  If the fracture is nondisplaced, or minimally displaced as above, this means the broken ends of the bones have not shifted out of place and can line up correctly. In this case you may not need surgery. Broken collarbones usually can heal without surgery. A simple arm sling or figure-of-eight wrap is usually used for comfort immediately after the break. These are worn to support your arm and help keep it in position while it heals. Pain medication, including acetaminophen, can help relieve pain as the fracture heals.

Physical Therapy:  As a result of the injury and the time spent in the sling, you will likely lose muscle mass, tone and strength in your shoulder. Once your fracture begins the initial phases of healing, usually about 10-14 days after the injury the pain will decrease and arm movement can be started. As the healing continues and the fracture becomes more stable, formal physical therapy can be started. These exercises will help prevent stiffness and weakness. More strenuous exercises can gradually be started once the fracture is completely healed. Follow up x-rays are done to make sure the bone is healing in good position. After the bone has healed, you will be able to gradually return to your normal activities. A large bump over the fracture site may develop as the fracture heals. This usually gets smaller over time, but a small bump may remain permanently. In healthy adults clavicle fractures heal well and return to most activities occurs in 6-12 weeks after the injury.

Surgical Treatment

If your bones are significantly out of place (displaced), as above, surgery may be recommended. Surgery can align the bones exactly and hold them in good position while they heal. This can stabilize the fracture sooner, allowing earlier return of function and motion and improved shoulder strength when you have recovered.

There are primarily two ways to fix clavicle fractures. In both procedures, the bone fragments are first re-positioned into their normal alignment. They are then held in place with either a plate and screws on the bone or a large screw in the middle of the bone (intramedullary). Plates and screws are usually not removed after the bone has healed, unless they are causing discomfort. The intramedullary screw is often, but not always, removed. Problems with the hardware are not common, but sometimes, seat belts and backpacks can irritate the surgical area. If this happens, the hardware can be removed after the fracture has healed. The incisions for pin placement are usually smaller than those used for plates. 

(A) The clavicle is broken in more than one place and the fragments are severely out of alignment. (B) The fractured pieces are held in place by a combination of plates and screws.  Reproduced with permission from Bahk MS, Kuhn JE, Galatz LM, Connor PM, Williams GR: Acromioclavicular and sternoclavicular injuries and clavicular, glenoid, and scapular fractures. Instructional Course Lectures, Vol. 59. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010, p 215.

The intramedullary screw is also used to hold the fracture in good position after the bone ends have been put back in place.

Once the clavicle has been fixed, therapy can be started sooner. While total time to healing and return to activity is the same as long as the clavicle heals, often the sense of recovery is faster with surgery because the fracture feels stable immediately after surgery.

 If you suspect you have sustained a clavicle fracture you should go to a local ER or urgent care center for examination and x-rays. The entire shoulder should be evaluated for other injuries as well. You will likely get a sling and pain medications. Prompt follow up with an orthopedic surgeon should happen in the following few days. Your orthopedic surgeon will examine you, evaluate your x-rays and often repeat x-rays to recheck the alignment of the fracture fragments.

 

He will then learn about you, your activity level, job requirements, future plans and goals. Synthesizing all your personal information with the details of the fracture pattern you two will determine the treatment plan that is right for you.