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Arturo Villarreal M.D., Board Certified Orthopaedic Surgeon, Georgetown, Cedar Park, Round Rock, TX / Services / Shoulder / Conditions / Shoulder Fracture / Clavicle Fracture

What is the clavicle?

The clavicle is commonly referred to as the collar bone. The clavicle attaches the upper extremity to the sternum. Through this connection, the clavicle aids in arm elevation, movement and shoulder strength.

the bones of the upper extremity with the clavicle labeled

Figure 1 Image showing the bones of the upper extremity with the clavicle labeled. (licensed from Adobe stock)

the bones of the upper extremity with the clavicle labeled

Figure 2 Image demonstrating a clavicle fracture. (licensed from Adobe stock)

How is the clavicle injured?

Fractures of the clavicle occur through both direct and indirect trauma. Clavicle fractures are common in sports such as football, rugby, and soccer. They are also common with motor vehicle accidents or cycling after falls.

What are the symptoms of clavicle fractures?

Fractures of the clavicle will result in pain, swelling and bruising. Displacement of the fracture can result in being able to feel and see the fractured ends of the bone. This is due to the pull of muscles attached to the clavicle.

How is a clavicle fracture diagnosed?

During the clinic visit x-rays will be obtained. This is typically sufficient for diagnosis. In some cases advanced imaging such as MRI or CT scan may be needed for determining more subtle injuries, ruling out related injuries or for surgical planning purposes.

the bones of the upper extremity with the clavicle labeled

Figure 3 X-ray showing a fractured clavicle.

What are the types of clavicle fractures?

Types of clavicle fracture can largely be grouped based on which area of the clavicle is fractured i.e. medial, middle, or lateral; displacement, and whether or not the clavicle fracture broke through the skin. There are multiple classification systems utilized.

the bones of the upper extremity with the clavicle labeled

Figure 4 General classification of clavicle fractures

the bones of the upper extremity with the clavicle labeled

Figure 5 Classification of lateral clavicle fractures

What are the treatment options for clavicle fractures?

Treatment options are always individually tailored. Considerations include age, activity level, type of activity, how recent the injury occurred, location and displacement of the fracture and associated injuries.

The x-rays will be used to evaluate several measurements. Evaluation will include location of the fracture. The most common location of clavicle fractures is the middle third, followed by the lateral aspect of the clavicle. Fractures of the lateral region of the clavicle often have a higher rate of not healing in comparison to fractures of the mid portion of the clavicle.

Other important factors measured on x-rays include the amount of displacement and the amount of shortening of the fractured ends. More displacement and shortening can result in high rates of the bone not healing or lower outcome scores.

Age is an important factor as well. Children and adolescents will often do well without surgery despite displacement and shortening. Some fractures of the lateral end of the clavicle will often do well in older patients even if they do not completely heal.

For non-surgical treatment of the clavicle a sling will be used initially to allow rest of the arm. Patients can typically wean from the sling between 2-6 weeks out from injury. Full healing will still take 3 or more months.

Surgical treatment typically involves placement of one or more plates and screws on the clavicle. For fractures of the mid portion of the clavicle patients are placed in a sling for comfort but are often able to move their shoulder as tolerated after surgery. For fractures of the distal end of the clavicle a sling will be continued for up to 6 weeks to improve healing prior to advancing range of motion.

How is clavicle fracture fixation performed?

The surgery is performed under a general anesthetic typically with the use of a regional nerve block.

the bones of the upper extremity with the clavicle labeled

Figure 6 After an incision is made, the fracture is exposed and reduced using clamps. A metal plate is then placed and then secured with screws. (credit: Arthrex.com)

the bones of the upper extremity with the clavicle labeled

Figure 7 If injury to the ligaments connecting to clavicle to the coracoid has occured, a device such as the one noted above may be used the secure the clavicle and the plate to the coracoid. This can be done through the same incision. (credit: Arthrex.com)

the bones of the upper extremity with the clavicle labeled

Figure 8 Example of a clavicle after surgical fixation.

Timing of clavicle surgery

Surgery is ideally performed within 2-3 weeks from the time of injury. Although surgery can be performed after this time period it may require additional procedures such as osteotomy (re-breaking the bone) in order to properly reduce the fracture.

Outcomes of clavicle fracture surgery

Outcomes after clavicle surgery are generally good to excellent. The majority of patients are able to return to their pre injury activity level. Bony healing is typically achieved by 3-4 months after surgery.

the bones of the upper extremity with the clavicle labeled

Figure 9 Outcome table from 2024 Mannan et al. Cureus 16(10): e72048. DOI 10.7759/cureus.72048

Return to sport after clavicle fracture surgery

The majority of patients are able to return to sport after clavicle fracture surgery with many studies reporting rates from 80-100% return to sport. Timing of return to sport will largely depending on patient age, type and level of sport. In general, timing for return to sport is often expected at 6-16 weeks after surgery.

What are the possible complications after clavicle fracture surgery?

Complication rates after surgical fixation have been reported around 5-30%.

Infection

Infection is an uncommon complication after this type of surgery. Rates are typically below 3% for any type of infection with rates of deep infection being less than 1%. Smoking can increase infection risk. Prevention at the time of surgery includes the surgical sterilization of the skin and using the use of antibiotics at the time of surgery. Presentation of infections could include fever, chills, increased pain and swelling at the surgical site, redness, warmth and drainage. Management often includes antibiotics and possibly surgical irrigation and debridement and possible removal of the hardware.

Nerve Injury

Major nerve injury is uncommon. Delayed time to surgery can increase the chance of nerve injury secondary to adhesions formed between the fracture and brachial plexus. More common nerve injury involves the suprascapular nerves. These nerves provide sensation to the upper chest. It is more common to have an injury these nerves at the time of surgery. This may result in a numb area at the chest.

Vascular Injury

Major vascular injury is rare. Injuries could include vessel injury, arterio-venous fistula, deep venous thrombosis, or pseudoaneurysm. Reports of these injuries are typically < 1%. Treatment of these injuries would be on a case by case basis.

Malunion and nonunion

Malunion is when the bone heals in the incorrect position. Nonunion is when the bone does not heal at all. Both appear to occur at rates < 4%. Treatment of malunions may not always be required beyond normal recovery as some patients remain asymptomatic. If symptoms persist, treatment may include revision surgery to correct bony alignment. In the case of nonunion, treatment may include treatment of underlying causes for the nonunion, including smoking cessation, correction of vitamin D levels, use of a bone stimulator or possible revision surgery.

Hardware irritation

Hardware irritation is the most common reason for reoperation after clavicle fracture surgery. Due to the hardware location there can be irritation in the region. If this pain persists after bone healing a second surgery may be required to remove the hardware.

Other reported complications

Other complications reported include, shoulder stiffness, hardware breakage, delayed union, shoulder weakness and continued pain.

This is not an exhaustive list of all complications. Other complications, although uncommon, can still occur.

Complication tables from JBJS REVIEWS

Figure 10 Complication tables from JBJS REVIEWS 2023;11(1):e22.00171 · http://dx.doi.org/10.2106/JBJS.RVW.22.00171

Pain management after surgery

Narcotic pain medications and anti inflammatories may be prescribed after surgery to help reduce pain. Nerve blocks at the time of surgery have been shown to be affective at reducing pain with low risk of long term deficits.

Do I need to use a sling after my clavicle fracture surgery?

Patients will be placed in a sling post operatively. You will use this sling for comfort but are able to come out of the sling as symptoms allow.

When can I return to work after surgery?

Return to work will largely depend on your specific occupational requirements. Many patients are no longer requiring the use of pain medications during the day by the third to fifth day after surgery. If your work is sedentary, you may be able to return as soon as this time. Work that involves heavy lifting will require longer periods away from work if light duty is not available.

When can I drive after surgery?

There is no definitive test we can do to determine when a patient is safe to return to driving. You should not be taking narcotic or sedating medications prior to driving. You should also not need the use of a sling. In general, a patient should possess the strength and range of motion to utilize the vehicles steering wheel in all situations prior to driving.

Post operative Instructions

  • Following your stay in the recovery room and when your vital signs are stable you will be discharged to your escort.
  • Remember, it is normal to feel a little dizzy or drowsy for several hours after surgery. This is due to the action the medicine used during surgery.
  • If you do not have a post operative appointment scheduled, please call the office as soon as possible to schedule this appointment.
  • Take your pain medicine as directed. Begin the pain medicine before you start getting uncomfortable, as the nerve block will wear off. If you wait to take your pain medication until the pain is severe, you will have more difficulty in controlling the pain.
  • If you are taking narcotic pain medication you may need a stool softener to prevent constipation. Over-the-counter medication such as Docusate or Milk of Magnesia is recommended.
  • Notify the office of any fever, chills, or temperature > 100.5.
  • Notify the office of any wound drainage.

Post-Surgery Diet

  • Resume your diet as tolerated and include vegetables, fruits, and proteins (such as meats, fish, chicken, nuts, and eggs) to promote healing. Also, remember to have adequate fluid intake. It is common after surgery to lack an appetite. This may be the result of anesthesia and the medications. Proper nutrition is needed for healing. During the healing process, the body needs increased amounts of calories and protein. Eat a variety of foods to get all the calories, proteins, vitamins, and minerals you need. If you have been told to follow a specific diet, please follow it.

How should I manage my surgical site and bandages?

Your incision is typically closed with buried dissolvable sutures covered by a skin glue. This will be covered with a bandage after surgery. This bandage can be removed on the second day after surgery. You are able to shower after removing the bandage.

What is my activity level after surgery?

You will use a sling for comfort. It is okay to remove the sling as tolerated and move the elbow. You should not be lifting with the shoulder. You are also encouraged to move your fingers as tolerated. Elevation of the hand will aid with swelling.

Can I smoke following surgery?

You should not smoke after surgery as it interferes with healing.

Questions or Concerns

If at anytime you have questions or concerns you can either contact your surgeon’s medical assistant via email or you can call the main office numbers at: (855) 624-3306. You can also use the electronic medical record’s online portal to send questions.

Example rehabilitation protocol:

Sling for 4-10 days (FOR COMFORT ONLY)

  • Post-OP Week 0-1:
  • Begin:
  • Goals:
  • 1. Minimize pain and inflammation
    2. Full elbow and wrist ROM
    3. Scapular stabilization
    4. No active shoulder ROM, lifting, supporting body weight or lifting of body weight with hands
  • Exercises Days 1-10:
  • 1. Pendulum SWINGS
    2. Squeeze ball
  • Post-OP Weeks 2-4:
  • Begin:
  • Exercises:
  • 1. Pendulums to warm up
    2. Active ROM with passive stretching
    3. Gentle pulley for shoulder
    4. Isometric scapular PNF
  • Post-OP Weeks 4-8:
  • Begin:
  • Goals:
  • 1. Pendulums to warm up and con't with phase 2
    2. Begin resistance exercises
    3. May begin lifting 5 lbs (ONLY AFTER 6 WEEKS)
    4. May begin elliptical without active arm movement
    5. Continue NWB UE
  • Exercises:
  • 1. Mid-range motion of rotator cuff (ER and IR rotations)
    2. Active and light resistance exercises (through 75% of ROM as patient's symptoms permit) without shoulder elevation and extreme end ROM
    3. Strive for progressive gains to active 90° of shoulder flexion and abduction
    4. Shrugs, seated rows, etc
  • Post-OP Weeks 8-12:
  • Begin:
  • Goals:
  • 1. Maintain full pain-free ROM
    2. Increase manual mobilizations of soft tissue as well as GHJ and scapulothoracic jts for ROM
    3. No repeated heavy resisted exercises or lifting until 3 months

Golf: 8 weeks, chip/putt only Tennis: 3 months Contact Sports: 4 months (per MD clearance)

References:

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