Collar Bone Fracture

(Originally published in the March 4-10, 2012 issue of the Baguio Chronicle ---

a weekly newspaper based in Baguio City, Philippines ---

by Sly L. Quintos, Associate Editor.)

THE clavicle is the most commonly broken bone in cycling crashes or accidents. It is often caused by a fall onto an outstretched upper extremity, a fall onto a shoulder, or a direct blow to the clavicle.

The immediate signs or symptoms of a collar bone fracture are: pain (particularly with upper extremity movement), swelling (often, after the swelling has subsided, the fracture can be felt through the skin), sharp pain (when any movement is made), referred pain (dull to extreme ache in and around clavicle area, including surrounding muscles) nausea, dizziness, and/or spotty vision due to extreme pain.

X-Rays are the standard method of diagnosis; however, ultrasound imaging performed in the emergency room may be equally accurate.

The standard treatment for a collar bone fracture includes: (non-operative) resting the affected extremity and supporting the arm with the use of a sling.

In older practice, a Figure-8 brace is used to immobilize and retract the shoulder, maintaining symmetric positioning to facilitate healing. More recent clinical studies have shown that the outcomes of this method were not measurably different from simple sling support, and due to the movement difficulties caused to the patient, this method has mostly lapsed.

Current practice is generally to provide a sling, and pain relief, and to allow the bone to heal itself, monitoring progress with X-rays every week or few weeks. Surgery is employed in 5 to 10 percent of cases. However, a recent study supports primary plate fixation of completely displaced mid-shaft clavicular fractures in active adult patients.

More than 90 percent of clavicle fractures are successfully healed by non-operative treatment. If the fracture is at the lateral end, the risk of non-union is greater than if the fracture was of the shaft.

Surgical treatment is also resorted to when some of the following conditions are present: comminution with separation (multiple-piece), significant foreshortening of the clavicle (indicated by shoulder forward), skin penetration (open fracture), clearly associated nervous and vascular trauma (Brachial Plexus or Supra Clavicular Nerves), non-union after several months (3 to 6 months, typically), Distal Third Fractures which interfere with normal function of the ACJ (Acriomio Clavicular Joint).

A discontinuity in the bone shape often results from a clavicular fracture, visible through the skin, if not treated with surgery. Surgical procedure will often call for an Open Reduction Internal Fixation or ORIF where an anatomically-shaped titanium or steel plate is affixed along the superior aspect of the bone via several screws.

In some cases, the plate may be removed after healing, but this is very rarely required (based on nerve interaction or tissue aggravation) and typically considered an elective procedure. Alternatively, intramedullary fixation devices (within the medullary canal) can be implanted to support the fracture during healing. These devices are implanted within the clavicle's canal to support the bone from the inside. Typical surgical complications are infection, neurological symptoms distal the incision (sometimes to the extremity), and non-union.

Healing time varies based on age, health, complexity and location of the break as well as the bone displacement. For adults, a minimum of 3 to 4 weeks of sling immobilization is normally employed to allow initial bone and soft tissue healing, teenagers require slightly less, children can often achieve the same level in two weeks.

During this period, patients may remove the sling to practice passive pendulum Range of Motion (ROM) exercises to reduce atrophy in the elbow and shoulder, but they are minimized to 15 to 20 degrees off. The immobilization is followed by a therapeutic regimen of passive exercises and later of active exercises. Full radiological union is typically achieved in 16 weeks for adult surgical patients, and shorter times are achieved by teenagers and young children. In patients who participated in prescribed physical therapy, 85 to 100 percent mobility returned in 6 to 9 months, with full strength returning in 9 to 12 months.*