The Broken Clavicle or Collar Bone - Four Myths You Need To Understand

The Broken Clavicle or Collar Bone - Four Myths You Need To Understand

The clavicle or collarbone is one of the most commonly broken bones in our body.  The clavicle will break or fracture if you fall onto the side of your shoulder.  Once struck you will notice pain, and you will usually notice a bump in the middle of your collarbone.  Moving your arm will be very painful.  A trip to a local Urgent Care center will reveal the diagnosis on a routine X-ray. Most clavicle fractures will heal well without surgery. Again, most collarbone fractures will heal well without surgery. Most athletes will return to sports after their clavicle has healed.

What should your next steps be to manage your clavicle fracture?

First, a bit of history. The recommended treatments of clavicle fractures has changed a lot over the last 20 years.  For a long time there was a significant degree of controversy about the best way to manage a clavicle fracture.  A while back many surgeons felt that all collar bone fractures should be treated surgically, yet other surgeons were firmly in the camp of treating most fractures without surgery.  What does the research show about clavicle fractures?  In this post, we are going to try to help teach more about clavicle fractures and what the current research says your options are.

The treatment trends for a broken clavicle have swung back and forth many times over my career.  There was a long stretch where we never operated on clavicle fractures.  Then we swung into a phase … pushed by colleagues in Philadelphia, where surgery was recommended on most clavicle fractures.  As the research into this area improved, the pendulum started to swing back towards a non-surgical approach.  Even though the majority of recent literature shows that most clavicle or collar bone fractures can be managed without surgery, this still remains a very controversial area. Hopefully, this post will help you in your decision making on how to manage your clavicle fracture or broken collarbone.

For the vast majority of clavicle fractures this is simply not true. Many collarbone fractures heal at a very reasonable pace when treated without surgery.  The younger you are, the faster your fracture typically heals.  For a fracture to heal, it requires a blood supply, which typically comes from the muscles attached to the clavicle.  During the surgery, we must strip off a lot of the muscle so that we can see the fracture.  In addition, when we place a plate and screws on the bone — the bone will not heal in the same manner as a fracture left alone to heal on its own.  That process can take longer to heal than a fracture that was not operated on.  In a small number of collarbone fractures which are significantly “displaced” — eg. the distance between the fragments is large (2cm), then surgery might result in faster healing.  A clavicle that has been operated on might feel better faster than a clavicle fracture treated without surgery.  That difference might be a few weeks.  That doesn’t mean the clavicle is healing faster, that means that the screws are not allowing the pieces to move as much.  Given that the surgery has a relatively high risk of potential complications, it is hard to recommend surgery to feel better 10-14 days sooner.

Given the current evidence, you have a great chance of returning to sports after your clavicle fracture heals — with or without surgery.  There are certain fractures where surgery to put the fractured clavicle back into place might lead to a better chance of healing.   This is usually the case if the fracture has resulted in significant shortening (2cm) — meaning that the two ends of the collar bone overlap by a significant distance (2cm).  This is actually a rare finding and most fractures do not shorten that much– and thus, when they heal it should not affect the function of your arm.  Many athletes will return to their chosen sport with or without surgery for a collarbone fracture.

Basically, the answer is no.  But. This is a controversial area.  We need to be sure that we are comparing apples to apples.  If you want to compare one clavicle fracture to another, then they need to look the same.  That means that the separation between the two pieces is not significant in both, or the separation between the pieces is significant in both.  In some studies, the return to sports and overall function was quite good with non-surgical management of a clavicle shaft fracture. Other papers show that the return to sports after surgery on a clavicle fracture was also successful in returning most athletes to sports.  BUT … the later paper had no controls… in other words, they were just presenting the results of the fractures they operated on. They are not comparing them to a group of patients who did not have surgery.  Thus the results of this paper lead to limited conclusions at best.  A few papers do show that patients who have a clavicle fracture addressed surgically will be happier at 6 weeks after the injury .. but in the long term — up to 5 years later, there is little or no difference between the surgically managed group and the non-surgically managed group.   Given the current scientific literature on the treatment of clavicle shaft fractures it appears that the only potential upside is that there will be fewer cases of clavicle non-unions after surgery.  A non-union is a fracture that doesn’t heal.  However, surgery brought along a very high risk of needing further surgery to remove the plates and screws, and other  complications that the group treated without surgery did not have.

Complications can occur with the surgical or non-surgical treatment of any broken clavicle.  Complications in the non-surgical group include the potential for pain and decreased function associated with a fracture that healed “short” — where the two broken pieces were overlapping more than 2 cm.  This is a common teaching in Orthopedics, but recent studies show that function might actually be unaffected by shortening.  The group of patients most at risk for functional issues after a clavicle fracture are high-level elite overhead athletes. Most recent papers do not show an improvement in function when surgery is performed routinely for clavicle fractures.

Most people with non-surgically managed broken collar bones will have a bump for life. That is not a complication, but it is a fact of life.  Many prefer a bump to a scar.  After surgery for a clavicle fracture, many of you will have numbness along the clavicle and upper chest wall.  This will be permanent.  A few of you might develop painful neuromas … or nerve scars after surgery too. In an effort to minimize the scar from clavicle surgery a screw that goes inside the bone was invented. They were popular for a while, but have fallen out of favor. If your clavicle doesn’t heal and the screw breaks it can be quite a challenge to get the broken piece out.

The risks of surgery on the clavicle include a risk of infection, and nerve injury which will make your upper chest area numb.  There is a risk of non-union where the fracture will not heal, and there is a risk that the hardware we place will bother you and require removal.  Bottom line: the risks of surgery outweigh the risks of non-surgical management for most all clavicle fractures.

Yes.. Whether your  fracture is treated with or without surgery there is a risk that the bone will break again.  Both methods to manage a clavicle shaft fracture have a risk of re-fracture … or breaking your clavicle again.  Think of Tony Romo who found this out the hard way.

Clavicle shaft fractures are a very common injury.  Most of these fractures can be managed without surgery.  Many research papers show that return to sports and normal use is similar with surgery or non-surgical treatment.  Surgery might decrease the risk that the clavicle will not heal.  Clavicle fractures heal 88-100% of the time in many trials published about clavicle fractures — without surgery.

Surgical management of a clavicle fracture is appropriate to consider with significant shortening… and perhaps in an elite overhead athletes shoulder.

The risks of surgery on a clavicle include infection, numbness over the front of your chest, the need for a removal of the hardware and the possibility that the fracture will not heal.

Do you have a story about your clavicle fracture journey?  Share it with our readers.

Images Powered by Shutterstock