Q: I broke my collarbone mountain biking. Will I need surgery?
A: Broken collarbones or fractured clavicles are common injuries, accounting for about 3% of all fractures seen in adults. 80% of these fractures take place in the middle part of the clavicle and are called mid-shaft fractures. In ski or bike injuries, these fractures are typically comminuted or have multiple fractured fragments.
Traditionally, clavicle fractures were treated without surgery. Patients were placed in a sling for comfort and orthopedic surgeons advised patients that the bone should heal uneventfully and the patient should do well. However, as orthopedists looked more critically at outcomes, a number of studies showed that in high energy fractures where the bone ends are separated or where the bone ends overlap significantly, the results are not always excellent.
The clavicle has an important function. It serves as a strut that connects your arm to your chest wall. The motion of your shoulder blade or scapula is dependent on normal alignment, length, and function of your clavicle. As you lift your arm overhead, the clavicle elevates, rotates and retracts. Thus, If your clavicle fractures and then heals shortened this can have cause abnormal scapula motion and possibly pain and weakness around the shoulder. The clavicle also protects your lung tissue that underlies it as well as the nerves that cross underneath it as they go on to supply the muscles to your arm and hand. The clavicle is the last bone in our body to stop growing with its growth plate fusing at age 23 or so.
90% of the time people break their clavicle as a result of a fall onto their shoulder or a direct blow to it. Rarely do we fracture our clavicle by landing on an outstretched hand. Fractured ends of the clavicle rarely break through the skin. Patients experience immediate pain of course and then swelling and bruising. Clavicle fractures are very painful for weeks as it is difficult to immobilize them. Thus, little movements such as coughing cause severe pain. Unlike some fractures, there is no way to “set” or reduce a clavicle fracture. Thus, I do not manipulate the arm or shoulder as the bones will not stay aligned. Xrays tell me how displaced the fracture is. There is no reason to get additional studies such as a CT or MRI unless other associated injuries are suspected. For instance, last week I was called to see a gentlemen in the ER who presented with a clavicle fracture but was also somewhat short of breath. His Xrays and a subsequent CT showed that he also had multiple rib fractures and an associated punctured lung.
How do I currently treat clavicle fractures in adults? I obtain different xray views and with these I assess several things. First of all, I measure how separated or displaced the broken ends are. Secondly, I measure whether the fractured ends are overlapped or shortened. If a clavicle fracture is displaced or shortened more than 15 mm or 6/10 of an inch (in kids more displacement can be accepted as they are still growing), then I recommend that the fracture be treated surgically as the clinical results are better than allowing the fracture to heal in a displaced position. In surgery, the clavicle fragments are put back together like a puzzle and the bone fragments are held in this position with newer hardware that is designed to fit the normal S shape curvature of the clavicle. After surgery, the patient is placed in a sling for 4-6 weeks at which time the bone has enough healing such that the sling can then be discontinued and physical therapy started to restore normal shoulder range of motion and strength. If the fracture is minimally displaced and shortened, then no surgery is required and the fracture should heal uneventfully in a sling. I do not put patients in a figure of 8 bandage as there is no difference in overall healing with these and most patients report more discomfort with them.
If a patient chooses not to have surgery for a significantly displaced or shortened fracture, I counsel them that there is an increased risk of a nonunion (the bone does not heal and is then harder to correct down the road) or malunion (the bone heals crooked and shortened which can lead to pain and weakness). The main benefit of fixing a clavicle fraction with surgery is that the patient has a shorter healing time and can get back to their sport or work sooner than without surgery. In a recent study of more than 100 patients with displaced midshaft clavicle fractures, the nonsurgical group healed at an average of 28 weeks, while the surgical group healed at an average of 16 weeks.
Dr. Rick Cunningham is a Knee and Shoulder Sports Medicine Specialist with Vail-Summit Orthopaedics. He is a Physician for the US Ski Team and Chief of Surgery at Vail Valley Medical Center. Do you have a sports medicine question you’d like him to answer in this column? Visit his website at www.vailknee.com to submit your topic idea. For more information about Vail-Summit Orthopaedics, visit www.vsortho.com.