The Broken Clavicle or Collar Bone – Four Myths You Need To Understand

The clavicle or collarbone is one of the most commonly broken bones in our body. It represents 4-5% of all fractures.  Fractures of the clavicle are more common in children, cyclists, rugby players and football players. Many of you will be reading this because you were told that surgery was necessary to fix your clavicle.  The research might not agree with early surgical intervention.  You do have a choice. We are going to dive into what the research says about how we should manage a midshaft fracture of the clavicle.

The clavicle connects the arm to the rest of the skeleton. That means that all the pressure put on the arm from lifting or motion will go through the clavicle and around the ribs, into the spine and disburse through the ground.  The clavicle will break or fracture if you fall onto the side of your shoulder. Another common cause of collarbone injuries is a direct hit from a helmet. Once struck you will notice pain, and you will usually notice a bump in the middle of your collarbone.  Moving your arm will be very painful.  A trip to a local Urgent Care center will reveal the diagnosis on a routine X-ray. Cat scans or an MRI of the clavicle is not necessary to make this diagnosis.  We know from many publications that most clavicle fractures will heal well without surgery. Again, most collarbone fractures will heal well without surgery. Most athletes can return to sports after their clavicle has healed.  Surgery might improve the time to return to sports.

[Updated with more recent scientific evidence October 2018. ]

You break your clavicle.. what’s your next step?

You or your child break their clavicle… you were seen in an urgent care center, then you met with an Orthopedic surgeon.  Your surgeon recommends a sling or they recommend surgery.  Perhaps you are a professional rock climber, or a fireman. Perhaps you are a desk worker, or a runner.  We need a lot of information about you, your occupation and hobbies to give you the appropriate treatment recommendation.

You would think that there would be a simple consensus on how to manage a broken clavicle by now – but there isn’t.  Competing interest exist. There is evidence, there is the fee for service model in medicine, and there is physician personal preference.  Evidence should guide decision making about whether or not your injury or your child’s injury should be managed with surgery or with a sling. That’s why I am writing this.  If there is a need for surgery, it should be based on science and sound judgement.

The recommended treatments for clavicle fractures have changed a lot over the last 20 years. For a long time, there was a significant amount of controversy about the best way to manage a clavicle fracture. 20 years ago many surgeons felt that all broken collarbones should be treated surgically.  Yet prior to that we were taught that all clavicle fractures were treated without surgery. The research into this area has improved our understanding dramatically over the last decade.  The most recent scientific paper was just published in prestigious journal in October, 2018.

Management of Clavicle Fractures: follow the evidence

What is our current thinking? What does the research show about the treatment of clavicle shaft fractures?  In this post, we are going to try to teach you more about clavicle fractures and what the current research says your best options are.

As the research into this area has improved, the pendulum has clearly started to swing back towards a non-surgical approach. Even though the majority of recent literature shows that most clavicle or collarbone fractures can be managed without surgery, this still remains a very controversial area. Many of you might learn that your  surgeon wants to operate on your clavicle.  Hopefully, this post will help you in your decision making on how to manage your clavicle fracture or broken collarbone. It should also help you with questions that you should be asking when you are meeting with your surgeon.

1. Will my broken clavicle heal faster after surgery?

For the vast majority of clavicle fractures, this is simply not true. The clavicle does not always heal faster with surgery.  Many collarbone fractures heal quickly when treated without surgery. The younger you are, the faster your fracture typically heals. For a fracture to heal, it requires a blood supply. That blood supply comes from the arteries and  muscles attached to the clavicle. During the surgery, we must strip off a lot of the muscle so that we can see the bone. 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 could take longer to heal than a fracture that was not operated on.  In a small number of collarbone fractures which are significantly “displaced” – eg. the distance between the fragments is large (2cm), then surgery might result in faster healing. A clavicle that has been operated on might feel better faster than a clavicle fracture treated without surgery. That is because the bones are no longer moving. But that feeling that the bones are moving goes away in a week or two when managed without surgery.  That difference might be a few weeks. That doesn’t mean the clavicle is healing faster, that means that the screws are not allowing the pieces to move as much. Given that the surgery has a relatively high risk of potential complications, 10-15%, it is hard to recommend surgery to feel better 10-14 days sooner.

 2. Will I 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 fracture heals – with or without surgery. There are certain fractures where surgery to put the fractured clavicle back into its normal position 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 collarbone overlap by a significant distance (2cm). This is actually a rare finding and most fractures do not shorten that much.  Thus when they heal it should not affect the function of your arm. Many athletes will return to their chosen sport with or without surgery for a collarbone fracture.

References from PubMed.gov:

1. Results of conservative treatment of displaced mid-clavicular fractures in adults
2. Mid-clavicle fractures in adults: end result study after conservative treatment.
3. Operative versus nonoperative treatment of midshaft clavicle fractures in adolescents.
4. Sports participation and radiographic findings of adolescents treated non-operatively for displaced clavicle fractures.
5. Surgical versus conservative interventions for treating fractures of the middle third of the clavicle.

3. Will I return to sports faster after surgery to fix my broken clavicle?

Basically, the answer is maybe. But, this is a controversial area. A recent 2018 article shows that the return to sports was faster in the surgery group.  High level athletes returned had a faster return of function after surgery on the clavicle.  BUT, when all athletes were assessed at 6 month and one year following their injury there was no functional difference.

For research to be useful, we need to be sure that we are comparing apples to apples. If you want to compare one clavicle fracture treatment to another, then they need to look the same. That means that the separation between the two pieces 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 the 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 (reference 1). However, 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 lead 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 after 6 months most all patients, whether they had surgery or not are doing the same with regards to function. 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 (reference 2). Given the current scientific literature (current to 2018) 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 and perhaps a faster return of function. A non-union is a fracture that doesn’t heal. If it occurs, a non-union can be be operated on if it proves to be painful.  So, do we operate on 100 out of 100 fractures if only 8 -10 will not heal completely?  Also, surgery is not without risk.  The incision is not pleasant looking. You have a high risk of nerve injury causing numbness of the upper chest. There is a risk of developing a painful nerve scar (neuroma).  Surgery brought along a high risk of needing further surgery (reference 3) to remove the plates and screws, and other  complications that the group treated without surgery did not have.  After the screws and plates are removed there is a risk that a fall will cause another fracture through one of the screw holes.

References

1. Return to sports after plate fixation of displaced midshaft clavicular fractures in athletes.
2. Plate fixation versus conservative treatment of displaced midshaft clavicle fractures: Functional outcome and patients’ satisfaction during a mean follow-up of 5 years.
3. Plate Fixation Compared with Nonoperative Treatment for Displaced Midshaft Clavicular Fractures: A Multicenter Randomized Controlled Trial.

4. Are complications more common after non-surgical management of a broken collarbone?

Complications are more common after surgery, as opposed to non-surgical treatment. Complications can occur with surgical or non-surgical treatment 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 more 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 clavicle surgery, that scar might be painful and fairly unsightly. After surgery for a clavicle fracture, many 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. In an effort to minimize the scar from clavicle surgery a screw that goes inside the bone was invented. They were popular for a while, but have fallen out of favor. If your clavicle doesn’t heal and the screw breaks it can be quite a challenge to get the broken piece out.

The risks of surgery on the clavicle include a risk of infection and nerve injury which will make your upper chest area numb. There is a also risk of non-union where the fracture will not heal, even after surgery.   There is a risk that the plates and screws we place will bother you and require removal. Bottom line: the risks of surgery often outweigh the risks of non-surgical management for most all clavicle fractures.

5. Can my clavicle fracture break again?

Yes. Whether your fracture is treated with or without surgery there is a risk that the bone will break again. 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. If you have surgery to repair your clavicle and then require removal of the plate. Your risk of developing a another broken clavicle goes up significantly for a few months until the old screw holes heal.

Take Home Messages About Clavicle Fractures and Surgery:

• Most clavicle shaft fractures or broken collarbones 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 collarbone will return to sports within a few months – with or without surgery.
• Surgery will improve the early return of function… but within a few months there is no longer a difference compared to fractures managed without surgery.
• The long-term outlook for most patients with a broken collarbone 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.

Clavicle shaft fractures are a very common injury. Most of these fractures can be managed without surgery. Many research papers show that return to sports and normal use is similar with surgery or non-surgical treatment. Surgery might decrease the risk that the clavicle will not heal. Clavicle fractures heal 88-100% of the time in many trials published about clavicle fractures – without surgery.

Surgical management of a clavicle fracture is appropriate to consider with significant shortening, and perhaps in an elite overhead athletes shoulder.

The risks of surgery on a clavicle include infection, numbness over the front of your chest, the need for a removal of the hardware and the possibility that the fracture will not heal.

Do you have a story about your clavicle fracture journey? Share it with our readers in the comments below.