Clavicle Fractures

Description

The clavicle, or collarbone, is a long bone in the shoulder and upper chest region.  It serves as a strut or connection between the central skeleton, via the sternum (breastbone) of the chest, and the shoulder and arm. Breaks in the bone, also called, ‘fractures’ of the clavicle are common in children and adolescents, with most fractures typically occurring in the middle third of the bone (what orthopedic doctors call the “midshaft” of the bone). 

Types of Fractures

• Sternoclavicular fracture or fracture-dislocation: This is a break in the part of the clavicle that connects to the sternum (breastbone). The break may connect to the sternoclavicular joint and frequently runs through the growth plate.
• Clavicle Shaft Fracture: This is a break in the middle part of the clavicle bone. This information sheet refers to this type of fracture, which is where this bone breaks 80-90% of the time.
• Distal or Lateral Clavicle Fracture: This is a break in the end of the clavicle bone that is adjacent to the shoulder and the acromioclavicular joint (AC joint), where the collarbone connects to the acromion). The break may extend into the growth plate next to the end of the bone or into the AC joint.

Symptoms

If there has been a significant fall or collision involving the shoulder and there is pain, swelling, or a crack was felt or heard, an x-ray should be obtained to check for a clavicle fracture. Children with this injury are usually unable to raise their arm.  Fractures usually occur from a fall or collision, in which the top or front of the shoulder hit the ground, an object (like a wall) or another player’s shoulder (such as in football or lacrosse).  

Examination

Doctors will check the skin to see if any bruising or swelling is present.  If there is a fracture in the clavicle, the doctor will make sure the bone ends haven’t pushed through the skin (an open or compound fracture) or the skin isn’t “tented.”  If there is skin ‘tenting’, the skin may look tight or whitish, and there can be a risk that the bone pushes through the skin over time. The doctor will also make sure that the muscles and nerves work and the arm has good circulation. Open fractures, tenting of the skin and nerve injuries are quite rare with clavicle fractures

X-Rays

In almost all cases, x-rays will be performed to confirm the diagnosis of a clavicle fracture. In rare circumstances, a doctor may order a CT scan to help guide treatment if the break is at either end of the bone. 

Non-Operative Treatment

Clavicle fractures are treated based on whether there is a complete break in the bone, how many fragments (broken pieces ) there, how the fragments are aligned, as well as the age of the child.  The vast majority of clavicle fractures in children can be treated with a simple shoulder sling and a period of rest to allow the bone to heal.  

In older adolescents, there is still some controversy regarding whether there may be some benefit to doing surgery for complete breaks in which the fractured pieces have slid past each other significantly, which is referred to as ‘shortening’. This controversy stems from the fact that some studies in the past 10-15 years have suggested that surgery may be beneficial to adults, in terms of overall shoulder function, when there are multiple fragments to the fracture or severe shortening of the broken fragments of the clavicle. As older adolescents may be similar to young adults in the way their bones heal and their shoulder functions, they too may benefit from surgery. Newer studies that have focused specifically on these fractures in adolescents, however, have suggested that the presumed benefit from surgery may not be same for this younger age group, and, in fact, that surgery has more risks to an adolescent than letting the bone heal on its own. While more research is ongoing on this subject, it is reasonable to have an informed discussion with your orthopedic surgeon to see what he/she feels may be best option for the long term health of the shoulder. 

The first 2 weeks following a clavicle fracture can be painful, so use of a shoulder sling most of the time is helpful. Sometimes, doctors will get a new x-ray 2-4 weeks following the injury. From weeks 2 to 6 after the injury, the pain tends to improve, and movement and use of the arm will improve. While the sling may no longer be needed at home, some doctors will recommend sending kids to school with the sling to help remind the patient, their friends, and their teachers/coaches that there are still restrictions that should be followed to avoid re-injury. Your doctor will decide when your child may safely return to sports and normal activities, usually sometime between 2-3 months after the injury. 

Operative Treatment

Surgery may be needed early for a clavicle fracture if there is significant stretch of the skin by one of the broken bone edges, or if the bone does not show signs of healing over time, which is extremely rare. If surgery is needed, it is usually performed through a single incision (cut in the skin) just below the clavicle, with placement of a metal plate and screws to hold the broken pieces in place while the bone heals (as seen below). 

Sometimes, the plate and screws end up being painful or uncomfortable over time, even after the bone heals completely. Studies have suggested this occurs in 5-20% of adolescents who undergo the surgery. In these scenarios, a small procedure to remove the plate and screws can be performed, which generally eliminates the pain. However, enough time should be planned after the procedure to remain out of contact sports, such as football or lacrosse, to avoid the bone from breaking again, which can occur through one of the holes where the screws had previously been. Within several months, the holes fill in with new bone, and the risk of this re-injury goes down. 

Outcomes

Most children recover completely from their clavicle fractures within a few months. A sling is generally used for 2-8 weeks, after which time arm function can return to normal, with strength exercises slowly being resumed, though formal physical therapy appointments are usually not required. 

In most cases, the bone needs around 3 full months to undergo more advanced, or complete, healing. Therefore, activities in which there is significant risk of falls, as well as contact sports, such as football, hockey, or lacrosse, should be delayed or modified until an additional radiograph has shown that the bone is ready for such activities without a significant risk of re-fracture.  

Children are not little adults, but like adults, they need expert care.  A pediatric orthopedic surgeon will have experience in managing these injuries in children and adolescents in order to make the sure the fracture is adequately aligned, to decrease the risk of complications, and increase the likelihood of a good outcome.