Broken collar bone (clavicle fracture)The SportsMD Editors
A broken collar bone (clavicle fracture) comprises up to 5% of all fractures. The clavicle is a bone in the upper part of the torso popularly referred to as the “collarbone.” The clavicle is the most commonly broken bone in the body, probably due to its location just beneath the skin and the forces it is subjected to in connecting the arm to the body. Generally, a fall onto the shoulder causes 85% of these fractures. Direct impact and fall onto an outstretched hand comprise the other 15%. Occasionally, the clavicle can break during violent seizures, from chronic stress resulting in “micro-fractures,” or due to tumors or other lesions that weaken the bone.
The clavicle is an S-shaped bony strut that connects the arm to the trunk. Interestingly, the clavicle is the first bone to start to ossify in the fifth week of the fetal life and last to conclude the growth through its growth center as late as the age 25. It is a very prominent structure with only skin and “supraclavicular” skin sensory nerves crossing its surface.
Conceptually, the clavicle can be divided longitudinally along its length into thirds. The “medial” or inner third is closest to the center of the body and connects to the chest bone (sternum) at the sterno-clavicular (SC) joint. The outer (distal) third is furthest away from the center of the body and makes the connection with the shoulder blade (acromion portion) through the acromio-clavicular (AC) joint. Both joints are minimally mobile and occasionally can be dislocated, but this rarely occurs in conjunction with the clavicle fractures. Clavicle motion mostly occurs with elevation of the arm to the side and in front of the body. This becomes important if the clavicle fracture is treated non-operatively, as the fracture fragments can move independently and displace relative to each other.
The cross-sectional profile of the clavicle changes from one side to the other. The inner third of the clavicle shaft is tubular in cross section and protects the network of nerves (brachial plexus) and the blood vessels on their way to the arm and the hand. It also protects the tip of the lungs, which is just below this section of the clavicle. The outer third of the clavicle is flat and provides origin to the trapezius and deltoid muscles along with the suspensory ligaments that connect the clavicle to the shoulder blade (scapula). These ligaments can be injured and result in what is commonly referred to as the “shoulder separation” or AC joint dislocation.
The middle third is a transition zone between the tubular inner third and relatively flat outer third. It lacks any muscular reinforcements and is structurally the weakest point along the shaft of the clavicle. For this reason, a broken collar bone most commonly occurs in the middle-third. This shape of the clavicle along with its ligamentous and muscular attachments are responsible for the pattern of displacement following fractures in this location.
Diagnosis of broken collar bone
After a traumatic fall or collision, athletes with a broken collar bone tend to present with the affected arm supported by their other arm in an attempt to offload the fracture. Frequently, there is bruising in the area and/or an abrasion directly over the broken bone. Physicians should carefully examine any skin cuts to make sure that the broken clavicle ends did not poke out through the skin (“open fracture”), as these injuries are a surgical emergency. Careful evaluation of sensation and motor function in the extremity is necessary to ensure no injury to the nerves and blood vessels behind the clavicle. Athletes that report any tingling, loss of sensation in their hand/fingers, or inability to move their fingers should be evaluated very carefully for occult injury to these structures.
An asymmetric appearance of the shoulders with deformity in the broken collar bone is often apparent. Palpation along the clavicle can elicit pain and frank motion between the ends of the bones. Because these fractures can often occur in the setting of associated injuries, a detailed examination of the head, neck, and chest wall should also be performed. Associated rib fractures are not uncommon with high-energy trauma. It is also important to listen to the patient’s chest and breath sounds to confirm no lung injury or perforation (“pneuomothorax”) has occurred.
In cases of a high-energy mechanism of injury such as in the fall from significant height or direct blow at high velocity, physicians should examine the shoulder blades for symmetry to confirm no dissociation between the shoulder blades (scapula) and the chest wall (scapulothoracic dissociation). In addition, the joints at both clavicle ends (SC and AC joints) should be evaluated for evidence of dislocation by checking for asymmetry from the opposite side and pain that reproduced with palpation. In patients younger than 25 yrs of age, the last growth center may still be open and susceptible to injury (“physeal injury”). This would mimic dislocation of the joint between the chest bone and the clavicle (SC joint).
Plain radiographs are used to confirm the diagnosis and determine the fracture pattern, location, and degree of displacement. Views should include standard “front-to-back” (AP) view and one or more of other specialty views. Careful scrutiny of the lung fields and the ribs should be performed to avoid missing associated rib or thoracic injuries. Physicians should use radiographs to carefully characterize the fracture pattern and the amount of shortening that has occurred between the fractured ends of the bones. Significant comminution, or “shattering” of the bone at the fracture site, is also an important finding that suggests a high-energy mechanism of injury and may warrant surgical intervention.
How does a broken collar bone occur in athletes?
The clavicle can break in any location along its length. Presently, the exact location of the fracture along the clavicle shaft and the type of trauma is not fully understood. Because of its unique anatomy, the middle-third of the clavicle is most commonly broken. As mentioned previously, 85% of these breaks occur as a result of a fall or a blow directly onto the “point” of the shoulder. Such injuries are common in contact sports such as football, hockey, or rugby, but also occur with falls in “extreme” sports such as biking, skateboarding, or motor-cross. Falls in virtually any sport onto an outstretched hand can also transmit significant indirect forces to the clavicle and account for the remaining 15% of broken collar bones. Other less common but documented mechanisms of a clavicle fracture include trauma from the seat belt strap during a motor vehicle accident, or from the direct blow of a hockey or lacrosse stick. Elite athletes who have suffered and been treated for a clavicle fracture include multiple time Tour De France winner Lance Armstrong, NHL star Oscar Moller of the Los Angeles Kings, and Arizona Cardinals quarterback Matt Leinart.
Treatment for broken collar bone
The primary goal of the treatment of a broken collar bone is to restore the anatomy and thereby full, pain-free range-of-motion and function of the shoulder. These goals remain the same for all athletes whether non-operative or operative treatment is pursued. The decision for surgical versus conservative management is complex and based on a number of factors, including patient expectations, demands, the severity of injury, fracture pattern, and associated injuries. This decision must be individualized after an extensive discussion between the athlete and physician, with a full understanding of the risks and benefits of each treatment plan.
If the broken collar bone is minimally displaced with good apposition of the ends of the bones, non-operative treatment may be needed. Previous studies have reported relatively good results with minimally displaced fractures of the middle-third of the clavicle without significant shortening. If the broken collar bone is treated non-operatively, it usually involves using a simple sling for shoulder comfort and immobilization. In the past, a “figure-of-8” brace that would wrap around the front of the shoulders and upper back was used. Recently, its use has dramatically decreased because of the discomfort associated with its prolonged use and its inability to demonstrate an improved rate or speed of healing. Most physicians will restrict lifting with the arm on the involved side to avoid displacement of the fracture ends until some healing has occurred. Distal range-of-motion of the elbow and wrist, however, is encouraged. If the healing is progressing well, the sling can be gradually weaned and discontinued. Healing is assessed clinically to be a resolution of pain with motion and tenderness at the fracture site. It is radiographically confirmed by the new appearance of “fracture callus” (new bone) between the fractured ends. Frequently, intermittent and mild discomfort at the site of the break can persist for up to 3 months.
A broken collar bone that has significant shortening, overlap, poor alignment, distraction or multiple fragments should undergo surgical fixation. In addition, fractures that could poke out through the skin or ones that have already broken the skin should also be fixed urgently. Any fractures with associated nerve and blood vessel injury should be treated surgically. Finally, a broken clavicle that occurs in the setting of multiple other injuries (“polytrauma”) including fractures of the legs, opposite arm, and/or multiple rib fractures should undergo surgical fixation in order to enable the athlete to immediately use the arm in their mobilization and rehabilitation process.
Surgical fixation of a broken collar bone has evolved over time. In the past, surgeons used wires or pins inserted through the center of the clavicle (“intramedullary”) to maintain their alignment. However, because of a well-established risk of spontaneous “migration” of these devices, most surgeons today use “plate and screw” fixation for the surgical treatment of a broken collar bone. Breaks of the central third usually require standard plates and those at the outer third may require the use of specially designed plates for their fixation.
Traditionally, the skin incision is made over the clavicle and centered over the fracture. Careful dissection will ensure better cosmesis and fewer wound complications. If the skin “supraclavicular” nerve branches are recognized during the dissection, they should be preserved but when necessary they can be sacrificed with the caveat that the athlete may experience some numbness just below their collar bone. The fracture is identified, cleared of interposing debris, aligned anatomically, and rigidly fixed with the plate and screws. The plate can be placed along the top or front of the bone based on the fracture pattern. Care must be taken during fracture manipulation and fixation for protecting the critical underlying blood vessels and nerves. With an anatomically aligned fracture and stable fixation construct, the patient can begin immediate unrestricted motion with the exception of the overhead lifting for 6 weeks.
Complications of broken collar bone
Complications from the broken collar bone can occur in athletes that pursue either nonoperative or operative treatment. Nonoperative management can result in the bone healing in an imperfect position (“malunion”) with resultant cosmetic deformity and shortening. In addition, the bone can partially heal or fail to heal (“nonunion”) leading to instability, persistent pain or limitation in the shoulder motion that prevents a successful return to sports. Generally, failure of healing in the nonoperatively treated athletes occurs if the fracture pattern is highly unstable, inappropriately immobilized, or soft tissue interposition has occurred during traumatic displacement.
Complications of surgical treatment of broken clavicle also include a small risk of delayed or incomplete healing (0-5%). They are frequently associated with smoking, inadequate alignment or fixation of the fracture (i.e. poor technique), failure of fixation due to premature return to strenuous activity, indolent infection, or poor nutrition. Other complications of surgery can include skin numbness below the incision, a painful plate that would require removal (as high as 50%), or recurrent fracture following the plate removal at the empty screw holes (“stress risers”) (5%).
A broken collar bone that does not heal in athletes (“nonunions”) should be fixed surgically regardless of the prior treatment method. Generally, they do tend to go on to full healing after effective surgical treatment. The addition of bone graft may be necessary to stimulate healing of these chronic injuries.
Return to sport after a broken collar bone
Multiple factors determine an athlete’s return to unrestricted sport participation after a broken collar bone. Return to sports depends on complete bone healing and full, pain-free recovery of shoulder strength and motion. Physicians counseling an athlete on return to sports must take into consideration different levels of physical demand associated with each sport. Athletes returning to contact or overhead sports such as football will need more time before they can return to unrestricted play than the athletes returning to non-contact sports. Most physicians recommend that an athlete with a broken clavicle use a sling for 2 to 6 weeks with both nonoperative or operative treatment based on the athlete’s individual comfort level. During this time, the athlete is not recommended to lift using the affected arm is encouraged to move the elbow and the wrist. Athletes can commence assisted, gentle range of motion when they become pain-free and stop using the sling, usually by 4 to 6 weeks. Overhead activities can begin after clinical and radiographic findings confirm bone healing. Return to unrestricted sport activities is generally recommended 4 to 6 weeks after the complete healing, typically by 3 months after the injury or surgical fixation. Most athletes can ultimately expect a full return to sport participation without any consequences after their fracture has healed with satisfactory alignment.
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