Bone & Joint Expert Care

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Clavicle Fractures


Clavicle fractures are relatively common making up 5% of all fractures. Fractures are typically associated with a fall on the shoulder. It is a common sporting injury from contact sports such as rugby as well as other activities with an increased risk of falls such as cycling or horse riding.

Fractures of the Clavicle are common in children in whom they rarely require treatment beyond symptomatic relief with a broad arm sling or PolyslingTM.

Most Clavicle fractures occur in the middle third of the clavicle (Mid-shaft clavicle fractures) (70%). Fractures may also occur of the distal Clavicle (outer third) (25%) and the medial Clavicle inner third) (<5%).

Clavicle fractures are not a single entity and may have varying outcomes depending on the location and type of fracture . The management should be carefully chosen dependent both on the fracture and the individual who has the sustained the fracture.


Anatomy:

The Clavicle lies anteriorly (at the front) at the base of the neck. It acts to strut the shoulder out to the side away from the midline. It also provides a degree of protection to the important nerves and blood vessels which lie just behind it. Laterally (at the outer end) it articulates (or forms a joint) with the Acromion (or tip of the shoulder blade). Medially (or at the inner end) the Clavicle articulates (or forms a joint) with the Sternum (or breastbone) and the first rib.


Symptoms:

Pain
There is typically pain felt over the Clavicle with associated tenderness at the fracture site.

Deformity
There may be a degree of deformity associated with the Clavicle itself. The Clavicle is largely subcutaneous and the fracture may be clearly visible or a bend or bump may be seen.

There may be an appreciable deformity of the shoulder. The shoulder itself may appear to be lying lower and nearer to the midline than the other side.

Skin tenting
The skin may be puckered or tented as a consequence of the fracture end lying close to surface and becoming caught on the undersurface tissues. There may be concern that the fracture end may penetrate the skin. Although this may occur it is rare.

Crepitus
The ends of the fracture may be felt to move or grind against each other.

Bruising and swelling
There may be marked bruising around the fracture site or the bruising may appear lower down the chest as the bruising tracks down under the effect of gravity.

Neurovascular damage
Rarely there may damage to the nerves and blood vessels which lie below the clavicle.


Diagnosis:

The diagnosis is often apparent from the history and examination. If the fracture is not displaced the diagnosis may be more difficult. Additional injuries may need to be excluded.

Plain radiographs (X-Rays)
Investigations in the form of plain radiographs are typically requested. It may be image both the clavicle and the shoulder. The Clavicle should be imaged obliquely as the degree of displacement may be underestimated on a single projection.

Computerised tomography (CT)
Computerised tomography is sometimes arranged for acute fractures but is more commonly used in the assessment of possible nonunions or malunions.


Midshaft clavicle fractures:

This is the most common type of Clavicle fracture. It is may take 8 to 12 weeks for the fracture to unite but it may take up to 6 months. There is a small but definite risk that the fracture will not unite or go on to a non-union (approximately 15%).


Treatment of mid-shaft clavicle fractures.

Non operative treatment:

Support
The majority of clavicle fractures can be treated with a supportive PolyslingTM type sling. Alternative immobilisation with a brace or figure of eight support can be used. There is little evidence to support improved outcome with any particular method of support. The support is typically used for 4 to 6 weeks.

Analgesia and anti-inflammatories (painkillers)
Anti-inflammatories eg: Diclofenac, Ibuprofen or VolatrolTM may be helpful in addition to simple painkillers (analgesia) eg: Paracetamol.


Physiotherapy and Rehabilitation
Rehabilitation guidance is often helpful to maintain range of movement while the fracture is healing and then to improve strength and function once the fracture has healed.


Operative treatment:

Midshaft Clavicle fractures may be stabilised surgically using open reduction and internal fixation (using a plate and screws) or intramedullary fixation (using a rod passed down the centre of the bone). There are advantages and disadvantages to each technique.

Midshaft clavicle fracture surgical fixation.


Clavicle fractures are not a single entity and may have varying outcomes depending on the location and type of fracture . The management should be carefully chosen dependent both on the fracture and the individual who has the sustained the fracture.

The following section deals with the most common type of fracture that occurs in the mid portion of the Clavicle.


Anatomy:

The Clavicle (Collar bone) lies at the base of the neck between the Sternum (breast bone) and the Acromion of the Scapula (Shoulder blade).


The image below is an X-Ray of a displaced Clavicular fracture (inset) and post fixation with a locking plate. (Courtesy of AcumedTM).




Indication for surgery:

Given that mid-shaft Clavicle fractures with little displacement usually heal well these can typically be satisfactorily treated without surgery. However, in certain circumstances including the presence of significant displacement or shortening (overlap) of the clavicle there is increasing evidence to support early surgical fixation. This surgical stabilisation may reduce the associated deformity or mal-union and reduce the risk of a non-union with certain fracture patterns.

Midshaft Clavicle fractures may be stabilised surgically using open reduction and internal fixation (using a plate and screws) or intramedullary fixation (using a rod passed down the centre of the bone). There are advantages and disadvantages to each technique.


Alternative non-operative treatment:

The majority of clavicle fractures can be treated with a supportive PolyslingTM type sling. Alternative immobilisation with a brace or figure of eight support can be used. There is little evidence to support improved outcome with any particular method of support. The support is typically used for 4 to 6 weeks.


Anaesthetic:

The surgery is typically undertaken with the patient asleep.


Incisions:

The fracture can normally be reduced and stabilised with a plate through an incision approximately 5cm long. The length of the scar will depend on the length of the plate that in turn depends on the degree of fragmentation of the Clavicle. There are advantages to placing the incision a few centimetres below the Clavicle and orientated slightly obliquely to minimise scaring.

The wound is typically closed with MonocrylTM a dissolvable suture. This means there are no stitches to be removed but occasionally the ends of the suture may need to be trimmed. The wound is typically protected with Steri-StripsTM and an antiseptic gauze dressing covered by a splash-proof OpsiteTM dressing.

The dressing can usually be left in place for 10-14 days when it can be removed and the wounds inspected.


Procedure:

The fracture fragments are reduced (re-positioned) into their correct alignment and stabilised using a metal plate and screws.

Alternative procedures involve the placement of a rod or nail down the inside of the bone. There is typically a scar over the fracture (or break) and at the back of the shoulder to allow insertion of the pin.

The following video is provided by AcumedTM who are one of the manufacturers of anatomically designed plates specifically for the clavicle.


Rehabilitation:

Following the surgery the arm is usually placed in a PolyslingTM. Specific gentle exercises can be undertaken immediately following surgery under the guidance of a physiotherapist. The sling is typically worn for between 3 and 6 weeks.

Driving is usually possible by 6 to 8 weeks and a return to sport at 12-16 weeks depending on progress and follow up.



Risks associated with the operation:

All operations are associated with a degree of risk. The risk of complications is higher in those who smoke or use Tobacco products and consideration should be given to stopping use before surgery.

Scar.
Typically a 5cm scar over the front of the chest just below the Clavicle. Occasionally the scar may become hypertrophic or Keloid (raised and red). There is usually a patch of skin that feels numb or desensitised just below the scar. This numbness often improves with time but may be permanent.

Prominence and removal of metalwork.
The skin over the Clavicle is normally relatively thin and the Clavicle can be felt under the skin. If a fracture of the Clavicle is treated non-operatively the site of the fracture and any mal-union (deformity) is often seen and palpable through the skin. If the Clavicle fracture is stabilised with a plate and screws then these may be felt under the skin, particularly in slim individuals. Occasionally this prominence causes discomfort if, for example, heavy packs or rucksacks are carried over the shoulder (eg: military personnel, hod carriers etc.). It is not necessary to remove the plate and screws routinely. The metalwork is unlikely to be detected at airport security etc..

Infection (<1%).
An infection in the wound is uncommon and would typically be expected to settle with oral antibiotics. If there is any concern the surgeon or hospital should be contacted. Rarely there is a deep infection which may require re-admission to hospital for antibiotics and occasionally removal of the plate and screws. Further surgery may then be necessary to re-fix the Clavicle once the infection has settled.

Anaesthetic Risks (Anaesthetic complications).
Problems following or during anaesthetics are very rare but include Heart Attack (Myocardial Infarction, MI), Stroke (Cerbero-Vascular Accident, CVA) and a clot in the leg (Deep Vein Thrombosis, DVT) or lungs (Pulmonary Embolus, PE).

Neuro-Vascular damage (Damage to nerve or blood vessels).
There are major blood vessels behind the Clavicle and as such care is needed when undertaking the operation. Damage to these vessels is very rare but could be very serious. A small area of altered sensation over the front of the chest below the scar is relatively common but is rarely troublesome.

Stiffness.
There is a small risk of developing a stiff or frozen shoulder after the surgery. This should get better but does occasionally require treatment.

Change in symptoms.
While the probability of symptom improvement is high it remains possible that symptoms may remain unchanged or deteriorate).

Re-operation (further surgery).
While the plate and screws can be left undisturbed it is occasionally felt necessarily to remove them after the fracture has healed.

Non-union.
The probability of a displaced fracture not uniting is considered to be reduced with surgical stabilisation but there remains a small probability of a non-union developing despite surgery.

Mal-union.
The probability of the fracture healing in an unsatisfactory position is reduced with surgical stabilisation but a degree of mal-union remains a possibility.


Decision making – operative vs nonoperative management:

Given that mid-shaft Clavicle fractures with little displacement usually heal well these can typically be satisfactorily treated without surgery. However, in certain circumstances including the presence of significant displacement or shortening (overlap) of the clavicle there is increasing evidence to support early surgical fixation. This surgical stabilisation may reduce the associated deformity or malunion and reduce the risk of a non-union with certain fracture patterns. It must be remembered that no surgical intervention is without the risk of complications.


Potential considerations:

Open fractures (a wound over the fracture) require surgery.
Displacement (complete displacement makes the fracture less likely to unite)
Age (older less likely to unite)
Gender (female less likely to unite)
Tenting of the skin or risk of penetration of the skin
Comminution (fragmentation less likely to unite)
Fractures of the Scapula (shoulder blade) or proximal Humerus (arm)
Fractures elsewhere.
Associated nerve and blood vessel injury.
High velocity or energy injury
Sporting participation type and level.
Risk of re-fracture or re-injury.
Smoking (increases risks of surgery and reduces the probability of the fracture healing).


Possible benefits of surgery include:

Earlier return to activities.
Less discomfort once the fracture is stabilised.
Improved probability of fracture healing and reduced risk of non-union in certain fracture patterns.
Less deformity.
More normal biomechanics and power.
Better overall appearance.


Possible risks of surgery include:

A scar that may be tender and visible.
Numbness beyond the scar, affecting the upper chest but not the breast.
Metalwork that may be prominent and require later removal.
Infection and problems with wound healing.
Failure of the fixation.
Re-fracture.
Non-union (failure of the fracture to unite despite surgery).
Anaesthetic risks these include clots in the legs (Deep Vein Thrombosis, DVT) or lungs (Pulmonary Embolus, PE), heart attack (MI, Myocardial Infarction) and stroke (CVA, Cerebro-Vascular Accident)


Malunion:

The mid-shaft Clavicle fractures typically unite with a degree of malunion, that is with a degree of deformity of the bone. This may not be noticeable without a radiograph (or X-Ray) or may be apparent with the presence of a prominent bony lump over the fracture and narrowing of the midline to shoulder distance. If the fracture heals with significant overlap or shortening of the clavicle there may be functional impairment and loss of power on high demand activities particularly overhead or at reach.

If the fracture goes on to heal but with a malunion which causes problems the Clavicle may need surgery to divide and re-fix it in a more normal position, typically with a plate and screws and sometimes using bone graft from the pelvis (hip bone).


Nonunion:

There will be a proportion of midshaft Clavicle fractures that do no unite (heal) after non-operative treatment by 3-6 months. Some of these will not cause significant symptoms and can be left alone. Others will continue to give problems including pain and a sensation of movement at the fracture site. In this situation surgery in the form of fixation of the fracture, typically with a plate screws, may be required. It may be necessary to use a bone graft typically from the pelvis (hip bone) to encourage the fracture to heal.