Clavicle fracture
What is a clavicle fracture?
The clavicle is also known as the collar bone. It is a strut between the sternum and the shoulder blade. It is the pivot which the shoulder blade moves around, keeping the shoulder out to the side of the body.
What is the non operative treatment?
Because the clavicle has a complex movement and is surrounded by muscle, it cannot be immobilized in a plaster cast in the usual way. The normal treatment for a broken clavicle is simply to keep the arm in a sling. 90% of all fractures heal well with this treatment.
How long does it take to heal?
The time a clavicle fracture takes to heal is variable; affected by age, health, type and location of the break. Adult fractures typically take a minimum of 3-4 weeks of sling immobilization to allow the bone and soft tissue to heal. It will be 6 weeks before returning to manual work or sports. Children take less time and can often achieve the same healing in only two weeks.
During this period, patients should remove the sling to perform pendulum exercises to minimize stiffness and keep the shoulder muscles active. Activities can be increased as pain allows; if you are doing something which is making it hurt- you should stop, on the other hand if all is well- activities can be increased.
In some cases the fracture does not heal. In most cases you surgeon will be able to predict which fractures are likely not to heal (see below). However rarely some simple fractures do not heal. This is called a non-union and when painful will require surgery.
What is the operative treatment?
The surgery may be necessary when there is;
- Multiple fragments of bone with gaps between them.
- Shortening of the clavicle when the fractured ends overlap by more than 2cm.
- If the broken bone has, or is at risk of coming out through the skin.
- Non Union (hasn't healed) after 3-6 months
- Fractures at the distal end of the bone (near to the shoulder) which can interfere with Acriomio Clavicular Joint of the shoulder.
The operation is through an 8 -12cm 'bra strap' incision which goes from front to back of the shoulder. This incision gives the best scar. The fracture is reduced by putting the bone ends back together. They are held in place by an 8 cm plate and some screws. The skin is then closed over the top with absorbable sutures.
If the surgery is to treat a non union, bone graft may be taken from the hip. The bone in the Iliac crest (which is the bone you can feel at your side below the waist) has lots of bone healing cells in it, when placed in the fracture site it helps the non-union to heal. Only a 1cm chunk of bone is removed from the hip, however the operation site is reported as being very painful for a few weeks. The wound and dressings should be treated in the same way as the shoulder wound (see below).
What should I expect after the operation?
The anaesthetist will have used an anaesthetic block to make the arm numb during surgery and the immediate post operative period. Once the numbness has worn off (4-8 hours) the shoulder will become painful and you will be given regular pain killers as soon as you get back to the ward. Even though you may be pain free at rest you must take the tablets for when you move the shoulder as part of your rehabilitation program. A combination of regular painkillers such as paracetamol or codeine should be taken with NSAIDs (unless contra-indicated) such as ibuprofen- which is also an anti inflammatory drug. If the pain killers you have been given are not sufficient please contact your consultant's secretary or your GP.
The procedure is an open operation through a 8-12 cm incision and is closed with a dissolving stitch. This heals well, usually leaving a faint scar. The dressing should remain on for 10- 14 days, kept clean and dry until it is removed at your follow up appointment. If you have any concerns about the wound you should contact your surgeon's secretary or your GP practice nurse.
You will be given a sling which will protect your shoulder and should be worn for a minimum of 3 weeks. You will need a dedicated physiotherapy program after your surgery. If you have been seeing a physiotherapist prior to your surgery (who may have referred you to Guildford Upper Limb), you should arrange to see them afterwards so you can start your rehabilitation straight away. If you do not have a physiotherapist we can arrange for you to be seen before you go home after the operation.
After surgery, full union is seen on x-rays typically at 12 weeks for adult patients, and shorter times are achieved by children. In patients who work at the physiotherapy, 85-100% mobility returns in 6-9 months, with full strength returning in 9-12 months. Return to driving and office work at 3 weeks, manual work will take 12 weeks.
Is there anything that can go wrong?
Operations to fix the clavicle are very successful and most people who have them are delighted with the operation and are glad they had it done. Like any operation a very small number of people can have a problem. The main problem is non union and failure of the plate and screws. If the bone does not heal the screws will always pull out of the bone because they fatigue with repetitive movement. Some patients experience a patch of numb skin below the operation site which is unpleasant. Nerves can be bruised and the shoulder can become stiff. In thin patients the plate can be visible under the skin and cause irritation when wearing a seat belt or rucksack, the plate can be removed at 1 year but is not routinely recommended. The risks of these problems only add up to 3-5% of all operations but need to be taken into account when deciding whether to have the operation. You should discuss the possibility of problems with your surgeon before your operation.
