A clavicle fracture (or broken collar bone) is a common injury usually caused a fall, a direct blow or a car accident. Broken collarbones are most common in children in young adults. The collar bone is the most commonly fractured bone in the body. Whilst they may be very painful, clavicle injuries are rarely serious and in most cases are managed conservatively with a sling rather than requiring surgery. Clavicle fractures are the most common cause of collar bone pain.
Here we will look at the common causes and symptoms of clavicle fractures, how they are diagnosed and treated, how to make the best recovery and common problem associated with a broken collarbone.
The clavicle, aka collarbone, sits at the front of the shoulder joint. It is a long, thin bone that sits in-front of the top of the ribcage. It connects the sternum (breastbone) to the acromion (front part of the scapula) forming two joints, the sternoclavicular and acromioclavicular joints.
It is slightly curved in shape, like a stretched-out “S” and is help in place by various ligaments and muscles. It helps to hold the shoulder blade in place, like a strut, so that the arm can hang freely, as well as protecting underlying nerves and blood vessels.
Interestingly, the clavicle is the first bone to start growing during embryonic development (5-6 weeks gestation) and one of the last bones to finish growing, around the age of 21-25 years.
Clavicle fractures are most commonly caused by an injury or trauma such as a fall, sports injuries, or car accidents. They may be caused by:
1) A sideways fall: where you land on the outer side of the shoulder. This is the most common cause
2) A fall onto an outstretched arm
3) A direct blow to the clavicle
4) During birth: particularly with breech babies
Broken collarbones are often caused by contact sports such as football, wrestling, ice hockey and rugby, winter sports such as skiing and snowboarding and cycling (particularly mountain biking). Children may fracture their collarbone when playing or falling out of bed. Weakness in the collar bone from conditions such as osteoporosis or cancer can also lead to a clavicle fracture.
A broken collarbone is one of the most common acute (sudden) shoulder injuries and the most common fracture seen in children. It is less common over the age of 20, but still accounts for 2-5% of adult fractures.
The most common symptoms of a clavicle fracture include:
1) Noise: Clavicle fractures are often accompanied by a “snapping” or “grinding” noise
2) Pain: there may be immediate sharp pain at the time of injury which should settle to a dull ache. The pain usually increases with any movement of the arm or upper chest or with any pressure over the fracture site
3) Deformity: swelling and bruising may develop around the fracture site. The arm will often hang forwards and down compared to normal. There may be a small bulge/bump over the fracture site. In severe cases the bone may be so displaced that it punctures the skin and there may be associated bleeding but this is rare.
4) Numbness and/or pins and needles: if there is damage to the surrounding nerves , but this is uncommon
5) Decreased Movement: it may be difficult and/or painful to lift the arm. The first sign of a broken collarbone in children may be them not using their arm normally if at all
Anyone with a suspected clavicle fracture should see their doctor immediately. The doctor will ask questions about how you injured yourself. He will then examine your arm looking at the position and your arm movements as well as gently palpating along the length of the bone. You will usually be sent for an x-ray to determine the type of fracture and to check for any associated damage. Diagnosis in children may be done with an ultrasound rather than x-ray.
Clavicle fractures can be classified into three groups, known as the Allman Classification, depending on the location and severity of the fracture:
Location of Fracture: middle third of the clavicle
Incidence: The most common type, accounting for 80-85% of clavicle fractures in both children and adults as this is the weakest part of the bone
Presentation: If the fracture is displaced the outer (lateral) side of the clavicle is usually pulled down due to the weight of the arm and the inner (medial) side is usually pulled up by one of the surrounding muscles (sternocleidomastoid).
Location of Fracture: Outer (lateral) third of the collarbone – the side nearest the arm
Incidence: Accounts for 10-15% of clavicle fractures
Presentation: These fall in to three sub categories
Type 1: non-displaced or with minimal displacement (i.e. the broken parts of the collarbone are lined up normally) as the ligaments remain intact
Type 2: displaced - the inner (medial) part of the clavicle raises upwards due to damage to the surrounding ligaments
Type 3: articular surface fractures - associated damage to the acromioclavicular joint where the collarbone meets the acromion (part of the scapula)
Location of Fracture: Inner (medial) third of the collarbone – the side nearest the breastbone
Incidence: Rare – accounts for approximately 5% of clavicle fractures
Presentation: If displaced there may be associated injuries to the surrounding tissues
In most cases, broken collar bones are treated conservatively i.e. non-operatively. With more severe, unstable fractures, surgery may be indicated, but this is only needed in around 5-10% of clavicle fractures.
The arm will be immobilised in a sling to hold the arm in place, giving the bone time to heal by laying down new bone (ossification) to re-join the broken sections. Either a simple triangle sling or a figure of eight sling (that wraps around both shoulders and the neck to hold the shoulders back) will be used. There is little evidence that one is better than the other.
You should keep using the sling until there is no pain when you move your arm. Initially you will need to wear it all the time (including at night), except when you are doing your exercises, but as it heals you will be able to wear it less – be guided by pain. Children can usually stop using their sling after around 2-4 weeks, adults will need it for longer, usually around 3-8 weeks, depending on the level of displacement of the fracture.
Pain relieving analgesia and anti-inflammatories can help following a clavicle fracture. Always talk to your doctor before taking any medication.
Ice should be applied to the area as soon as possible after injury and used regularly for the first couple of weeks to help reduce pain and swelling. An ice pack wrapped in a towel can be placed over the area for 10-15 minutes. You should wait at least 2 hours before reapplying the ice. For more information on using ice packs safely and effectively visit the Ice Therapy section on our sister site
You will be encouraged to start gentle range of movement exercises almost immediately in order to minimise stiffness. These will start with gentle pendulum exercises for the shoulder and exercises for the elbow and hand, progressing on to range of movement exercises as the pain allows. As the bone heals you will gradually progress on to strengthening exercises to regain full strength in the arm. You will need to continue with exercises until you have regained full range of movement and strength – this usually takes up to three months. Visit the rotator cuff exercise section for some great exercises for improving strength and flexibility.
If a baby has suffered a broken collarbone during delivery, treatment will usually consist of pain relief and careful handling of the baby.
Surgical treatment of broken collarbones is only necessary in 5-10% of cases. Surgery is indicated if there is:
a) Skin Penetration: the broken collarbone has broken through the skin, known as an open fracture
b) Severe Displacement: the two parts don’t line up
c) Multiple Fractures: when the collarbone is broken in more than one place
d) Clavicle Shortening: more than 2cm, caused by either overlapping of the bone fragments, or if the bone has shattered
e) Associated Damage: to surrounding nerves and/or blood vessels
f) Non-Union: the fracture has failed to heal after around 3 months
If surgery is required, the surgeon will realign the bone fragments and fix them together with either:
A nail or rod may be used to fix the bone together. This goes through the middle of the bone (known as the canal) to hold the pieces together.
A specially shaped metal plate, made of titanium or steel is placed over the top of the collarbone or occasionally around the front to hold the bones in the correct alignment. It is fastened in place with screws.
Whichever method is used, you will normally be discharged home later
that day or the following day. In most cases, the metal work will be
left in place indefinitely, but if it starts to causes a problem, such
as pain, stiffness or it shifts out of position, it can be removed once
the bone has fully healed.
Following surgery, the treatment will be similar to the non-surgical treatment above. You will need to wear a sling for at least 3-4 weeks and you will be given an exercise programme to follow by a physical therapist to ensure you regain full movement and strength - visit the rotator cuff exercises section to find out more.
It usually takes 3-6 weeks in children and 6-12 weeks in adults for the
bone to fully heal. It takes about twice as long to regain full
function. Most people make a full recovery within three months, at
which point it is safe to return to contact sports. Healing may take
longer if you smoke or suffer from diabetes.
Here is some advice on how to make the best recovery:
1) Keep your arm well supported in the sling the first few weeks except for when you are doing your exercises. Gradually wean yourself off the sling as the pain reduces, starting with short periods, but as soon as your arm feels sore, pop it back in the sling
2) Use medication as directed by your doctor: this helps keeps pain and swelling under control and will enable you to get going with your exercises
3) Follow the exercise plan given to you by your physical therapist and keep going with it until you have regained full strength and movement – don’t be tempted to stop too soon
4) Start moving your fingers, hand and elbow as soon as possible to prevent them from stiffening up in the sling. Remove your arm from the sling to do this a few times a day
5) At night prop yourself up with pillows to get yourself into a comfortable position. You will need to wear your sling in bed initially
6) Avoid lifting your arm above should height for the first few weeks, until your doctor or physical therapist gives you the go-ahead
7) Avoid any heavy lifting: anything over 5lbs for at least 6 weeks
8) Avoid contact sports at least 10-12 weeks: check with your doctor before returning to them
9) Think about your posture: avoid the temptation to let your shoulders drop forwards and your upper back to round
Long-term problems following a clavicle fracture are rare with most people making a full recovery.
1) Non-union: in 1-5% of cases the bone does not reunite. If there are no symptoms associated with this, no further treatment is indicated but if there are ongoing symptoms such as pain or reduced movement, surgery may be required
2) Bony Prominence: you may be left with a small lump over the fracture site. This may settle down after a few months but may remain in some cases
3) Mal-union: the bone may heal in a displaced position which may lead to ongoing shoulder problems
4) Decreased Shoulder Strength and/or Movement: The risk of this can be reduced by following your exercise programme. It most commonly affects people where there was shortening of the collarbone
Any surgery is associated with risks such as infection, bleeding, blood clots and damage to the surrounding nerves and/or blood vessels. Specific risks associated with surgery for a broken clavicle include:
1) Implant problems: in around 30% of cases the metal work may need to be removed due to discomfort or if it has loosened and shifted position. Occasionally, the hardware fails (breaks)
2) Injury to the Surrounding Tissues: in around 3% of cases there may be some damage to the surrounding blood vessels or nerves during surgery
3) Non-union: similar frequency to those treated non-surgically
4) Frozen Shoulder: approximately 4% of surgical patients develop a frozen shoulder aka adhesive capsulitis after surgery for a clavicle fracture
Clavicle fractures are the most common cause of collar bone pain but there are a number of other things that can cause pain in this area. Visit the Collar Bone Pain section to find out more.
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