Condition
Clavicle fracture
A clavicle fracture is a break in the collarbone, typically after a fall onto the shoulder or a direct sports impact. Most fractures heal well in a sling. Selected displaced or distal-third patterns benefit from plate fixation to restore length, alignment, and an early return to function.
Anatomy
The collarbone
The clavicle is the S-shaped bone running across the front of the chest from the breastbone (sternum) to the shoulder blade (scapula). It is the only bony connection between the arm and the rest of the skeleton, with the sternoclavicular joint at the inner end and the acromioclavicular joint at the outer end.
Below the bone runs the brachial plexus, the subclavian artery, and the subclavian vein. The lung lies just deep to the medial clavicle. These structures are normally well protected, but a heavily displaced fracture or a missed open fracture can put them at risk, which is part of why the bone gets the attention it does in trauma assessment.
Fracture patterns are described by the part of the bone involved. Around 80 percent of clavicle fractures occur in the middle third (midshaft), 15 percent in the distal third (the lateral end nearest the AC joint), and 5 percent in the medial third. Each region has its own treatment considerations.
Mechanism
How clavicle fractures happen
The most common mechanism is a fall directly onto the point of the shoulder: coming off a bike, being tackled in rugby or AFL, a fall from a horse, a motorbike crash, or a fall onto the shoulder during sport. A direct blow to the front of the clavicle is also possible. A fall onto an outstretched hand transmits force through the arm to the clavicle and is a common mechanism in older patients and children.
Clavicle fractures span all age groups. They are common in young, active patients (cyclists, contact-sport athletes) and in older patients after a low-energy fall.
Symptoms
How a clavicle fracture presents
Pain at the front of the shoulder over the bone, with immediate difficulty using the arm. The shoulder often droops and slumps forward as the strut function of the clavicle is lost. Patients typically support the affected arm with the other hand to take weight off the fracture.
A visible deformity is common with displaced fractures. The skin over the fracture can be tented by the bone ends. Bruising develops over hours to a day or two. Numbness or tingling in the hand, or a cool or pulseless arm, are red flags for neurovascular injury and require urgent assessment.
Diagnosis
How clavicle fracture is diagnosed
- Examination. Tenderness over the bone, deformity, and assessment of the skin for tenting or threatened breakthrough. Distal neurovascular status is checked carefully.
- X-rays. An AP and a 30-degree cephalad view of the clavicle are usually diagnostic. They show the location, displacement, comminution, and shortening of the fracture and guide the treatment decision.
- CT scan. Used in selected cases, particularly for medial-third fractures (where x-rays are difficult to interpret), comminuted fractures, or to plan a complex fixation.
- Chest x-ray. Considered when the mechanism of injury is significant, to exclude associated pneumothorax or rib fractures.
Treatment
Treatment options
The decision between non-operative and surgical management depends on the fracture pattern, the degree of displacement, the patient's age and functional demand, and any associated injuries.
- Sling immobilisation. The standard treatment for the majority of clavicle fractures. A simple broad arm sling is worn for four to six weeks, with gentle pendulum exercises early and progressive return of range of motion as comfort allows. Most undisplaced or minimally displaced fractures heal well with this approach.
- Open reduction and plate fixation (ORIF). Considered for significantly displaced midshaft fractures (more than two centimetres of shortening or 100 percent translation), comminuted fractures, displaced distal-third fractures (Type II and III), open fractures, fractures with skin tenting at risk of breakthrough, fractures with neurovascular injury, and patients with multiple injuries needing both arms working early. A pre-contoured plate is fixed across the bone with screws either superior or anteroinferior on the clavicle, depending on the pattern. The procedure is typically performed with one overnight stay.
- Distal clavicle fixation. Distal-third fractures with disruption of the coracoclavicular ligaments are at high risk of non-union if managed in a sling and benefit from surgical stabilisation. Several techniques are available, including hook plates, anatomic distal clavicle plates, and suture-button or graft reconstructions of the coracoclavicular ligaments. The choice is tailored to the fracture pattern.
- Non-union surgery. For fractures that fail to heal, revision surgery with bone grafting and plate fixation is usually successful in restoring bony union and function.
Recovery
What recovery looks like
Non-operative. Sling for four to six weeks. Pendulum and gentle range of motion exercises start early. Most patients are out of the sling and using the arm for light activities by four to six weeks. Heavy lifting and return to contact sport are usually cleared at twelve weeks once x-ray shows fracture consolidation.
After ORIF. Sling for two to four weeks for comfort. Range of motion exercises start within the first few days. Most patients return to office work within one to two weeks, driving by two to four weeks (once out of the sling and with safe two-handed control of the steering wheel), and full unrestricted activity by twelve weeks. Surgical fixation does not change the biological healing timeline but allows much earlier comfortable use of the arm.
Plate prominence under the skin is common and not a complication in itself. Most patients are bothered enough by the plate to ask for it to be removed once the fracture has healed, usually after six months. Plate removal is a smaller day-case procedure. There is a small risk of re-fracture after the plate and screws are removed, so heavy lifting and contact sports should be avoided for six weeks after the plate has been removed.
Risks
Risks of clavicle fracture and its treatment
- Non-union. A small percentage of fractures fail to heal. Higher risk in smokers, distal-third fractures, displaced fractures, and patients with diabetes. Treated with revision surgery and bone grafting.
- Malunion. The fracture heals in a shortened or angulated position. Some patients are bothered by the cosmetic deformity or the functional effect of significant shortening.
- Plate-related symptoms. Prominence and irritation under the skin, particularly when wearing a backpack or seatbelt strap. Most patients elect to have the plate removed once the fracture has healed.
- Infection. Uncommon. Antibiotics are given at induction.
- Numbness below the scar. Small branches of the supraclavicular nerves are often divided during the surgical approach. This produces numbness over the front of the chest below the scar in most patients, which usually settles partially over six months.
- Complex regional pain syndrome (CRPS). A rare condition that causes pain and stiffness in the hand.
- Anaesthetic and medical complications. Discussed in detail by the anaesthetist before surgery.
FAQ
Frequently asked questions
- Do all clavicle fractures need surgery?
- No. The majority of clavicle fractures heal well in a sling. Surgery is recommended for selected patterns: significantly displaced midshaft fractures (more than two centimetres of shortening or 100 percent translation), comminuted fractures with multiple fragments, displaced distal-third fractures, open fractures, fractures with skin tenting at risk of breaking through, fractures with neurovascular compromise, and fractures in patients with multiple injuries who need both arms working early. The decision is individualised at consultation.
- How long does a clavicle fracture take to heal?
- Most fractures heal radiographically over six to twelve weeks. Comfort improves much earlier. Most patients are out of the sling and using the arm for light activities by four to six weeks. Heavy lifting and contact sport are usually cleared at twelve weeks once the fracture has consolidated on x-ray. Surgical fixation does not change the biological healing timeline but allows earlier comfortable use of the arm.
- Will the bump from the fracture go away?
- A non-operatively treated displaced fracture often heals with a visible callus, a thickened area of new bone at the fracture site. The lump usually softens and remodels over six to twelve months but a small bump under the skin often remains long-term. Surgical fixation reduces the deformity but leaves a 6 to 8 centimetre scar over the collarbone. Cosmetic preference is one factor in the operative decision in younger patients.
- Can I drive with a clavicle fracture?
- Driving requires comfortable two-handed control of the steering wheel. It is illegal to drive a car with your arm in a sling. After surgical fixation, driving is usually possible at four weeks once out of the sling and pain-free with steering wheel use. Always check with your insurer. They may have specific requirements about post-surgical driving.
- What happens if a clavicle fracture does not heal?
- A small percentage of clavicle fractures fail to heal and form a non-union. The risk is higher for distal-third fractures, smokers, fractures with significant displacement, and patients with diabetes. Non-unions are diagnosed on x-ray and CT around four to six months after the injury and are usually treated with surgery: bone grafting and plate fixation. Outcomes after non-union surgery are generally good.
References
- Postacchini F, Gumina S, De Santis P, Albo F. Epidemiology of clavicle fractures. J Shoulder Elbow Surg. 2002;11(5):452-456.
- Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures: a multicenter, randomized clinical trial. J Bone Joint Surg Am. 2007;89(1):1-10.
- Robinson CM. Fractures of the clavicle in the adult: epidemiology and classification. J Bone Joint Surg Br. 1998;80(3):476-484.
Recent collarbone injury?
Book an appointment with Dr Piper
Consultations at Lakeview Private Hospital, Norwest. Trauma and public referrals seen at Westmead. Bring a referral and any imaging you have.