The clavicle or collar bone 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 collar bone. What should your next steps be to manage your clavicle fracture?
For a long time there was a ton of controversy about the best way to manage clavicle fractures. Many surgeons felt that all fractures should be treated surgically, yet other surgeons were firmly in the camp of treating most without surgery. What does the research show about clavicle fractures? In this post we are going to try to help learn more about clavicle fractures and what the research says your better options are.
The treatment trends for a broken clavicle has swung back and forth many times over my career. We went through 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 emerged, the pendulum started to swing back towards a non-surgical approach. This remains a very controversial area. Hopefully this post will help you in your decision making on how to manage your clavicle fracture or broken collar bone.
Myth #1: My broken clavicle will heal faster after surgery
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. Comfort is important…. a cold therapy compression/ice sleeve can help that. 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 collar bone fractures which are significantly “displaced” — eg. the distance between the fragments is large (2cm), then surgery could result in faster healing.
Myth #2: I will play better if I have surgery on my broken clavicle.
Given the current evidence, you have a great chance of returning to sports after your clavicle 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.
Myth #3: I will return to sports faster after surgery to fix my broken clavicle.
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 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 leads 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.
Myth #4: Complications are more common after non-surgical management of a broken collar bone.
Complications can occur with the surgical or non-surgical management 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 most 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.
The risks of surgery on the clavicle are greater than the risks of non-surgical management. There is a risk of infection, nerve injury which will make your upper chest are 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.
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.
Take Home Messages:
- Most clavicle shaft fractures or broken collar bones do not require surgery.
- Fractures with “significant” displacement or shortening (think 2cm) might benefit from surgery.
- Most clavicle fractures heal without surgery
- Most athletes with a clavicle shaft fracture or a broken collar bone will return to sports within a few months – with or without surgery.
- The long-term outlook for most patients with a broken collar bone is excellent.
- Research shows that a simple sling, as opposed to a figure of eight bandage is more comfortable and equally as effective.
- The risks of surgery for a clavicle shaft fracture might outweigh the potential benefits for you! Have a long discussion with your surgeon before signing a consent for surgery.