Clavicle (Collarbone) Fracture

The clavicle is the S-shaped strut that runs from the top of the breastbone to the point of the shoulder. It is the only bony connection between the arm and the trunk, and it holds the shoulder blade out and back so the arm can work away from the body. Beneath it run the major blood vessels and nerves to the arm, and the top of the lung sits just behind its middle third.

Fractures are grouped by location. About four out of five happen in the middle third, where the bone is thinnest and least protected. Roughly one in six involve the outer (distal) third, near the acromioclavicular joint, where the ligaments that suspend the shoulder attach. Fractures of the inner (medial) third near the breastbone are uncommon.

Almost every collarbone fracture comes from a direct blow to the point of the shoulder, or from landing on it. The usual culprits in this practice are:

• Cycling and mountain biking: going over the handlebars is the single most common story.
• Lacrosse, football, hockey, and rugby: body checks and tackles that drive the shoulder into the ground.
• Skiing and snowboarding: a fall onto the shoulder at speed.
• Falls onto the shoulder or onto an outstretched arm, where the force travels up the arm into the clavicle.

Newborns can fracture the clavicle during delivery, and children break it often, but those heal reliably on their own. Dr. Petre's practice treats teenagers and adults, where the bone is mature and the healing question is more nuanced.

A broken collarbone is rarely subtle. Most patients know immediately that something is wrong.

• Sharp pain between the base of the neck and the point of the shoulder, worse with any arm movement.
• A visible bump or deformity along the bone, from the displaced fragments or the swelling over them.
• Swelling and, within a day or two, bruising that can track down the chest and arm.
• A grinding sensation when the arm moves.
• The shoulder sags forward and down, and the arm is held against the body for support.

Seek care the same day if the skin over the bone is tented or broken, if the hand or fingers are numb, tingling, pale, or cold, or if breathing is painful or short. These signs point to injury of the skin, nerves, vessels, or lung, and they change the plan.

Plain X-rays make the diagnosis. Dr. Petre uses two views, a straight-on view and an angled view, to see how far apart the fragments sit and whether the bone has shortened. Those two measurements, displacement and shortening, drive most of the decision-making that follows. A CT scan is occasionally added for fractures near the breastbone or when the pattern is complex.

The examination also checks the skin, the pulses and sensation in the arm, the acromioclavicular joint, and the shoulder blade, because a clavicle fracture can travel with other injuries from the same impact.

Fractures with the bone ends still touching, and without much shortening, heal well in a sling. The sling is for comfort, usually for the first two to four weeks, and is not a cast; the fingers, wrist, and elbow should move from day one to avoid stiffness. Pendulum exercises for the shoulder start as soon as pain allows, usually within the first couple of weeks.

Bone healing takes six to twelve weeks in adults. X-rays at follow-up visits track it. Non-contact activity resumes as comfort returns, and contact and collision sports wait until the bone has healed on X-ray and strength is back, typically three to four months.

Most patients heal with a permanent bump where the fragments knit. It is cosmetic and does not affect function. The real risk of sling treatment is nonunion, when the bone fails to heal at all, and that risk climbs with wide displacement, shortening, a shattered (comminuted) fracture, smoking, and age.

Some fractures need surgery, and some benefit from it. Dr. Petre recommends fixation when:

• The fragments are fully displaced with no bony contact.
• The clavicle has shortened by about 2 cm or more. Shortening changes how the shoulder blade sits and is the finding most associated with lasting weakness and fatigue if the bone heals in that position.
• The fracture is in several pieces or there is a separate floating segment.
• The skin is tented or broken, or there is injury to the nerves or vessels.
• A distal-third fracture has torn the ligaments that suspend the shoulder, which makes that pattern prone to not healing.
• There are other injuries to the same shoulder or arm, or the opposite arm, that make early use of the arm important.

Then there is the athlete with a displaced midshaft fracture who could heal in a sling but wants a faster and more predictable return. Randomized trials comparing plating to sling treatment for displaced midshaft fractures have shown lower nonunion rates, earlier healing, and better early function with surgery, traded against the risks of an operation. For an in-season athlete or a patient whose work demands both arms, that trade is often worth making. Dr. Petre walks through it candidly, and plenty of patients still choose the sling.

Clavicle fixation is usually scheduled within one to two weeks of the injury, once swelling has settled and the skin looks healthy; it is not an emergency unless the skin or vessels are threatened. The pre-operative visit covers your medical history, any blood thinners or supplements to pause, and the plan for anesthesia, which is typically a general anesthetic combined with a nerve block that numbs the shoulder for the first day.

Arrange a ride home and someone to help for the first evening. Shirts that button or zip in the front are far easier than pullovers for the first couple of weeks. Our Preparing for Shoulder Surgery checklist lists everything else worth having at home before surgery day.

The operation is called open reduction and internal fixation, or ORIF. It is outpatient surgery, and you go home the same day.

1. Anesthesia. A nerve block is placed in the neck, then a general anesthetic is given.
2. Incision. An incision is made along or just below the collarbone over the fracture. The small sensory nerves that cross the clavicle are identified and protected where possible.
3. Reduction. The fragments are cleaned of clot and brought back to their proper length and alignment. For a fracture in several pieces, individual fragments are secured with small screws first.
4. Fixation. A pre-contoured plate shaped to the clavicle's curve is placed along the top or front of the bone and fixed with screws on either side of the fracture. For a simple two-part fracture, a rod inside the bone is sometimes used instead of a plate. Distal-third fractures may need a specialized plate or ligament repair in addition.
5. Closure. The wound is closed in layers with dissolving sutures under the skin, and a dressing and sling are applied.

The procedure takes about an hour. X-rays in the recovery room confirm the alignment before you leave.

The advantage of a fixed clavicle is that it is stable immediately, so motion starts right away. The sling is for comfort for the first one to two weeks and then comes off. Elbow, wrist, and hand motion begins the day of surgery; pendulums and gentle passive shoulder motion start within the first week; active motion follows as the incision heals.

Lifting is limited to a few pounds until the bone shows healing on X-ray, usually at about six weeks. Strengthening builds from there. Running and cycling on a trainer are often possible within a few weeks. Non-contact sport returns around six to eight weeks when motion and strength allow, and contact and collision sports wait for solid radiographic healing, usually ten to twelve weeks.

Dr. Petre's written protocol, Clavicle ORIF Rehabilitation, lays out each phase for you and your physical therapist. His general After Fracture Surgery instructions cover wound care, pain control, and when to call.

Clavicle surgery is reliable, and serious complications are uncommon, but they are real and worth knowing.

• Numbness below the incision. The sensory nerves that cross the collarbone are often stretched or cut, leaving a patch of numb skin on the upper chest. It is the most common issue after this operation, is usually harmless, and often shrinks over the following year.
• Hardware irritation. The clavicle has little padding, so a plate can be felt under the skin and can rub on backpack or seatbelt straps. A minority of patients have the plate removed once the bone has healed, generally after a year.
• Infection. Uncommon, but it can require antibiotics or further surgery.
• Nonunion or malunion. Rare after fixation, but the bone can still fail to heal, particularly in smokers.
• Refracture. The bone is briefly weaker after a plate is removed, and a fracture through an old screw hole is possible in the months that follow.
• Injury to the structures beneath the bone. The vessels, nerves, and lung lie just under the clavicle. Injury to them is very rare with careful technique but is the reason this operation deserves an experienced surgeon.