Displaced collarbone fracture

The collarbone fracture is a relatively common injury, especially in children and young adults. The collarbone connects the upper part of the sternum to the shoulder blade.
The most common causes of a fracture include falls, sports injuries and traffic accidents.
Newborns can sometimes break their collarbone at birth.

Simple collarbone fractures heal under ice, painkillers, physiotherapy and immobilization.
A complex fracture, on the other hand, may require surgery to reposition the broken bone and fix it with plates, screws or rods. The collarbone is a long bone that connects the shoulder girdle to the trunk.
It gives the upper limb support and mobility.
Collarbone fractures account for 5% of all fractures and about 50% of shoulder girdle accidents.
In addition, they are the most common fractures in adolescence. Incomplete or greenwood fractures are common in children.
Most of these fractures are not displaced and heal without problems.
In the case of falls with the motorcycle or bicycle, a fracture with bone stumps pushed over each other is likely.
Anatomically, the acromioclavicular ligament and the coracoakromial ligament fix the collarbone laterally on the shoulder blade.
The sternoclavicular ligament and the costoclavicular ligament anchor the collarbone in the middle.
The sternocleidomastoid muscle (head nod) and the subclavius muscle (lower collarbone muscle) have their attachment points on the collarbone. The collarbone also protects the brachial plexus, lungs and blood vessels.
Only rarely do patients have a collarbone fracture and a shoulder blade fracture or a broken arm at the same time.


Who is affected?

The annual incidence of collarbone fractures amounts to 30 to 60 cases per 100,000 inhabitants. The majority of collarbone fractures are benign, but they can also be accompanied by intrathoracic injuries. Complications may vary depending on the location of the fracture.
The ratio of men to women for collarbone fractures is 2:1.

How old are those affected?

Collarbone fractures are the most common pediatric fractures.
They can occur in neonatal age, especially after a difficult birth. Almost half of all collarbone fractures occur in children under the age of 7.
There is a large incidence of collarbone fractures in men under 30 years of age, especially due to sports injuries.
Older people can also suffer a collarbone fracture as a result of a fall and due to osteoporosis.

Classification of collarbone fracture

Collarbone fractures can be mechanically and anatomically classified into 3 types.
About 80% of collarbone fractures occur in the middle third, 15% affect the distal or lateral third, and less than 5% occur in the proximal or medial third.
Most fractures of the first type occur centrally on the coracoclavicular ligament, namely at the intersection between the middle and outer third of the collarbone.
The proximal fragment shifts upwards due to the pull through the sternocleidomastoid muscle (head nod).
Fractures of the lateral third are usually the result of a direct blow to the top of the shoulder. These fractures occur distally on the coracoclavicular ligament and are classified into 3 subtypes:

  • undisplaced fracture without violation of the koracoclavicular ligament;
  • undisplaced fracture with rupture of the koracoclavicular ligament;
    usually the proximal segment of the collarbone is pulled upwards by the sternocleidomastoid muscle;
  • Fractures affecting the joint surface of the acromioclavicular joint (shoulder joint).

Fractures of the middle third occur as a result of a direct blow from the front to the chest.
A meticulous search for related injuries should accompany all these fractures, because for a collarbone fracture to occur in this area, a significant force must act.

Causes of a collarbone fracture

The main causes are:

  • falls on the shoulder or on the outstretched arm;
  • direct trauma to the shoulder during sports competitions;
  • trauma caused by traffic accidents;
  • Neonatal trauma at birth.

Symptoms of collarbone fracture

Collarbone fractures can be very painful and make it much more difficult to move the arm.
A patient with a collarbone fracture may present with the following signs and symptoms:

  • The affected limb is held close to the body.
  • Dislocation of the shoulder occurs as a result of loss of stability.
  • Stiffness.
  • Crunching of the fracture site (crepitation).
  • Swelling.
  • Deformation at the level of injury and possibly acromioclavicular diastase.
  • Pain-related inability to raise the arm.
  • Shoulder pain in the front area.
  • Hematoma, especially if it is a displaced or multiple fracture.
  • Bleeding in case of an open fracture (rare).
  • Decreased breathing sound during listening (auscultation). Indicates a possible pneumothorax.
  • Reduction in pulse rate or signs of reduced blood flow. Indicates a vascular problem.
  • Loss of sensation or distal weakness. Suggests an impairment of the nervous system.
  • Non-use of the arm of the affected side in newborns.

Diagnosis of a collarbone fracture

Physical examination
The doctor examines the shoulder and looks for touch-sensitive areas.
After that, he tries to move the arm to understand if the ability to move is restricted.
If the doctor suspects a fracture, he prescribes diagnostic examinations.

Device diagnostic examinations

If a collarbone fracture is suspected, radiography must be performed. Initially, the X-rays may appear inconspicuous, even if the clinical examination reveals a suspicion.
In this case, the arm should be immobilized and radiography repeated after 7-10 days, if symptoms persist.

A CT scan may be necessary because radiography of the collarbone cannot always clearly show a fracture due to the superimposition of the surrounding structures.

An echography can diagnose any collarbone fractures only in children. In contrast to radiography, ultrasound is harmless and has a 95-96% accuracy compared to X-rays.

Further examinations may be necessary, if clinically indicated, to evaluate possible concomitant injuries:

  • chest X-ray, if pneumothorax is suspected;
  • Angiography, if vascular injuries are suspected.

Non-surgical treatment for collarbone fracture

If the ends of the broken bones have not shifted and are correctly aligned, surgical intervention may not be necessary.

Usually, for the relief of the patient and to keep the bone fragments in contact position, the following is used:

  • a simple orthosis for the arm;
  • a bandage that fixes the arm to the chest;
  • a backpack bandage.

No plaster cast is applied to the collarbone.
These tools are used to support the humerus (humerus) and hold it in place during the healing process.
A painkiller (such as acetaminophen) can help relieve symptoms as the fracture grows together.
During the time of immobilization by the orthosis, a lot of muscle power is lost.
The backpack bandage can lead to loss of sensitivity in the hands and fingertips. This is usually a temporary symptom that gradually passes after removal of the bandage.
Once the bone begins to heal and the pain subsides, the doctor may recommend light physiokinetic exercises for the shoulder and elbow.
These exercises help prevent stiffness of the muscles and joints as well as muscle weakness. Heavier exercises can be started gradually when the fracture is almost healed.

During recovery, regular medical examinations and check-ups must be carried out. When the fracture has healed, radiography must be performed again for control to ensure that the fracture has grown together in the correct position.
After recovery, daily activities can be gradually resumed.
Before healing is complete, a bone fragment could move away from its anatomical position. It is therefore important to set up a rehabilitation program with the doctor that keeps the bone in its position.
If the bone fragments move and the bone grows together in an incorrect position, pseudarthrosis is formed.
In this case, treatment is determined after the bony “malformation” and its influence on the mobility of the arm.
When the fracture has healed, a bony elevation may be felt above the area of the injury.
This usually decreases over time, but a small elevation can remain permanently.

How to sleep?
The best sleeping position is in the supine position (stomach up). Some patients may also sleep on the healthy side while wearing the orthosis.

Surgery for a displaced collarbone fracture

If the fragments are not properly aligned, the doctor may recommend surgery.
With the help of surgery, the ends of the bone parts can be aligned and fixed in the correct position for the duration of healing. This treatment can improve shoulder strength after the fracture has healed.

When to operate?
Today, surgeons prefer not to operate to avoid the risk of injury to nerves and blood vessels.
During the procedure, the bone stumps are placed in place and fixed with special screws and plates or Kirschner wires (metal wire).
After surgery, it is possible that a small area of skin around the incision remains numb.
This disturbance passes over time. Since there is little fatty tissue above the collarbone, you can sometimes feel the surgical plate through the skin.

Removal of screws and plates
The plates and screws are usually removed after recovery only if they cause discomfort. Sometimes backpacks and seat belts can irritate the area of the collarbone. If this happens, the plates and screws can be removed after the fracture has healed.
Nails are used to keep the fracture in the correct position after the bone ends have been repositioned.
In most cases, the incisions for inserting the nails are smaller than those used for the plates.
The nails often irritate the skin where they were inserted and are usually removed after the fracture has healed.

Consequences of the operation

The risk of complications is greater in patients who smoke, have diabetes or are elderly.
Consequences may occur during and after surgery.
In any case, talk to the doctor about the risks and benefits of surgery for a collarbone fracture before undergoing a procedure.
In addition, there are risks that are possible with any type of surgical procedure, including:

  • Infections
  • Haemorrhage
  • Shoulder pain
  • Deep vein thrombosis
  • Damage to blood vessels or nerves
  • Nausea

The specific risks of surgery for a collarbone fracture are:

  • Difficulties in bone healing
  • Lung injury
  • Irritation caused by plates and screws

Movements with the arm raised and strenuous activities that take place before the doctor has given his consent can lead to a displacement of the bone fragments.
Once the fracture has healed completely, one can safely return to sports activities.

How long does it take to heal? Prognosis

The recovery time depends on the severity of the fracture, the age of the patient, gender and the treatment performed.
The healing time may be extended if the patient is a smoker or diabetic.

In most cases, those affected can return to their normal employment within 3 months of the accident.
The doctor decides when the fracture is sufficiently stable so that you can resume your daily activities.
Only rarely does an orthopedist decide to operate on the collarbone, especially if one of the more common injuries is present with only two fragments.
An undisplaced collarbone fracture heals in adolescents and adults in about two months.
If it is a displaced fracture, 3 to 6 months may be required. If the patient uses magnetic therapy, the time to form bone callus can be reduced by up to 50%.

Physiotherapy and rehabilitation

Some exercises from physiokinesitherapy and rehabilitation can help restore blood circulation and strengthen the shoulder.

The doctor may prescribe a training program at home, but it is recommended to put yourself in the hands of a physiotherapist for the different stages of rehabilitation.
Usually, rehabilitation programs begin with gentle movements. Strengthening exercises for the muscles are inserted while the fracture heals.
Although rehabilitation may seem lengthy, it is essential to be able to return to normal everyday activities.
There are no movements to avoid. Rather, the arm can be moved in all directions where no pain is felt.

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