Question: I broke my collarbone mountain biking. Will I need surgery?
Answer: Broken collarbones or fractured clavicles are common injuries, accounting for about 3 percent of all fractures seen in adults. Eighty percent of these fractures take place in the middle part of the clavicle and are called mid-shaft fractures. In ski or bike injuries, these fractures are typically have multiple fractured fragments.
Traditionally, clavicle fractures were treated without surgery. Patients were placed in a sling for comfort, and orthopedic surgeons advised patients that the bone should heal. However, as orthopedists looked more critically at outcomes, a number of studies showed that in high energy fractures where the bone ends are separated or overlap significantly, the results are not always excellent.
The clavicle has an important function. It serves as a strut connecting your arm to your chest wall. The motion of your shoulder blade is dependent on normal alignment. As you lift your arm, the clavicle elevates, rotates and retracts. Thus, if your clavicle fractures and heals shortened, it can cause abnormal scapula motion and possibly shoulder pain and weakness. The clavicle also protects lung tissue and nerves. The clavicle is the last bone in our body to stop growing, with its growth plate fusing around age 23.
Ninety percent of the time, people break their clavicle as a result of a fall onto their shoulder or a direct blow to it. Rarely do we fracture our clavicle by landing on an outstretched hand. Fractured ends of the clavicle rarely break through the skin. Patients experience immediate pain, swelling and bruising. Clavicle fractures are very painful, as it is difficult to immobilize them. Thus, little movements such as coughing cause severe pain. Unlike some fractures, there is no way to “set” or reduce the fracture. Thus, I don’t manipulate the arm or shoulder, as the bones will not stay aligned. X-rays tell me how displaced the fracture is. There is no reason to get additional studies such as a CT scan or MRI unless other injuries are suspected.
For instance, last week I was called to see a man in the ER who had a clavicle fracture, but was also short of breath. His x-rays and a subsequent CT showed that he also had multiple rib fractures and a punctured lung.
How do I currently treat clavicle fractures in adults? I obtain different x-ray views and assess several things. First, I measure how displaced the broken ends are. Secondly, I measure whether the fractured ends are overlapped or shortened. If a clavicle fracture is displaced more than 15 mm (in kids more displacement can be accepted as they are still growing), then I recommend the fracture be treated surgically, as the clinical results are better than allowing the fracture to heal in a displaced position. In surgery, the clavicle fragments are put back together like a puzzle, and the bone fragments are held in this position with hardware designed to fit the normal curvature of the clavicle. After surgery, the patient is placed in a sling for 4 to 6 weeks, at which time the bone is healed enough that the sling can then be discontinued and physical therapy started. If the fracture is minimally displaced, then no surgery is required and the fracture should heal in a sling. I don’t put patients in a figure eight bandage as there is no difference in overall healing with these and most patients report more discomfort.
If a patient chooses not to have surgery for a significantly displaced fracture, I counsel them that there is an increased risk of a nonunion (the bone does not heal and is then harder to correct down the road) or malunion (the bone heals crooked, which can lead to pain and weakness). The main benefit of fixing a clavicle fraction with surgery is that the patient has shorter healing time. In a recent study of more than 100 patients with displaced midshaft clavicle fractures, the nonsurgical group healed at an average of 28 weeks, while the surgical group healed at an average of 16 weeks.
Dr. Rick Cunningham is a knee and shoulder sports medicine specialist with Vail-Summit Orthopaedics. He is a physician for the U.S. Ski Team and chief of surgery at Vail Valley Medical Center. Visit www.vailknee.com to submit topic ideas. For more information about Vail-Summit Orthopaedics, visit www.vsortho.com.