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Clavicle Fracture Physiotherapy

Clavicle fractures are also known as broken collar bones, are very common injuries (especially in children and young adults). Most of the time, the causes are

  • car accidents (typically drivers)
  • falling on outstretched hand
  • direct blows such as sports injuries or accidents

Note: collar bone fractures are the MOST commonly fractured bone in the body

The good thing is that though clavicular fractures can be painful, but they’re often not serious. That being said, clavicle fracures ARE the most common causes of collar bone pain. In most cases of clavicle fractures, they are managed conservatively with an arm sling rather than needing invasive surgery.

Anatomy

The clavicle aka collarbone, is located right in front of the shoulder joint

It’s a longish, thin bone right in front of the shoulder joint, at the top of the front of the ribcage that connects the sternum (breastbone) to the acromion (front part of the scapula) that forms two joints:

  1. the sternoclavicular and
  2. the acromioclavicular joints (AC joint)

The clavicle is often slightly curved, like an “S-shape”, and the curvature can be very high depending on genetics and load carried. It’s held in place by ligaments and muscles that allows the shoulder to hang freely plus protect underlying nerves and vessels.

Common causes of clavicular fractures

A broken collarbone is one of the most common fractures seen in children. It is less common in patients who are over the age of 20, but still accounts for 2-5% of adult fractures.

The most common causes are injuries or trauma such as car accidents, falls or sports injuries…or even during birth, such as in with breech babies. Contant sports such as rugby, boxing, mixed martial arts (MMA), wrestling, soccer, skiing and cycling is one of the highest chances of causing collar bone fractures.

In fact, we’d seen kids where they fractured their collar bones playing…or falling out of bed.

Aggravating factures include osteoporosis, low bone mass or cancer, which can soften and weaken bones such that it makes it easier for bones to break.

Symptoms of broken clavicles

  • Cracking Noise: snapping, grinding, and cracking noises in the collarbone
  • Pain: when the collarbone fractures, there’s always going to have an immediate sharp pain in the beginning, and the pain may escalate until it stabilizes and ease into a sense of throbbing or aching pain. The pain increases with movement of the arm or pressure over the fractured area.
  • Deformity: there may be an obvious bruising, swelling and discoloration around the fractured site. Some patients may feel no power in the clavicle, leading the arm to “hang” frontwards down when compared to the uninjured clavicle. For severe cases, the fracture collarbone may pierce through the skin with bleeding. 
  • Numbness and/or Pins and Needles: some patients may experience tingling, numbness or warmth or cold if the nerves are affected
  • Weakness / Difficulty Moving: patients will find it difficult and definitely weak or painful to lift the arm.

Note to parents: if a kid hurt their collarbone, they may guard and not move their shoulder for an extended period of time, so keep a lookout for this

Diagnosing Clavicle Fractures

Patients have to seek medical attention immediately, to get an xray and confirm if the collarbone is fractured or not.

The assessing and treating doctor will ask you questions on how your collar bone got injured, before assesssing your collarbone and its movement. The doctor will also palpate along the bone as well.

A collarbone xray would be the best to gain clarity (and certainty) if it’s fractured or not (first); and to check how bad is the fracture eg simple fracture, multiple fractures etc. For kids, the doctor may order an ultrasound imaging instead of xray imaging.

Clavicle fracture categories

Clavicle fractures can be classified into three groups, known as the Allman Classification, depending on the location and severity of the fracture:

Group 1

  • Location of Fracture: middle third of the clavicle
  • Incidence: most common type of collar bone (clavicle) fracture, accounting for at least 80% of clavicle fractures in both children and adults as this is the weakest part of the bone
  • Presentation: If the fracture is displaced the outer (lateral) side of the clavicle is usually pulled down due to the weight of the arm and the inner (medial) side is usually pulled up by one of the surrounding muscles (sternocleidomastoid).

Group 2

  • Location of Fracture: Outer (lateral) third of the collarbone – the side nearest the arm
  • Incidence: Accounts for 10-15% of clavicle fractures
  • Presentation: These fall in to three sub categories

    • Type 1: non-displaced or with minimal displacement (i.e. the broken parts of the collarbone are lined up normally) as the ligaments remain intact
    • Type 2: displaced – the inner (medial) part of the clavicle raises upwards due to damage to the surrounding ligaments
    • Type 3: articular surface fractures – associated damage to the acromioclavicular joint where the collarbone meets the acromion (part of the scapula)

Group 3

  • Location of Fracture: Inner (medial) third of the collarbone – the side nearest the breastbone
  • Incidence: Very rare – accounts for approximately 5% of clavicle fractures
  • Presentation: If displaced there may be associated injuries to the surrounding tissues

Treatment options

Most of the time, broken collar bones are managed conservatively ie no surgery. Surgeries for collarbone fractures are only required in about 5-10% of the time.

Non-surgery, conservative management

  1. Protective arm & shoulder sling to protect, restrict and and immobilise in an optimal healing position, giving the clavicle bone the best healing posture for laying new bone (ossification) to re-join the broken sections. Patients should keep using the sling until there is no pain with arm movements. In the beginning, you will need to wear the sling all the time (including at night time when you sleep), only to be taken out during exercise….but progressively, you will wear it less and less and eventually no longer when the doctor xrays the clavicle bone and confirm stable bone healing or healed.
  2. Medication such as pain killers and anti-inflammatories can help provide some pain relief. Your doctor will be prescribing them to you.
  3. Cold therapy using cold packs should be applied to the clavicular area as soon as possible after injury and used every 4 hourly for the first couple of weeks to help reduce pain and swelling.
  4. Clavicle and shoulder physiotherapy to start gentle range of movement exercises almost immediately in order to minimize shoulder and arm joint stiffness. You’d start with gentle pendulum exercises for the shoulder as well as gentle exercises for the elbow and hand, slowly progressing to more range of movement and resisitve exercises as the fracture heals and pain decreases. You definitely will need to continue with physiotherapy until you have regained full range of movement and strength – this usually takes up to three months.
  5. Treatment for newborns if a baby or newborn has a broken collarbone due to delivery, medical and physio treatments are very gentle, usually with positioning, pain relief and extra careful handling.

If your clavicle fracture needs surgery

Surgery for broken collarbones are rare, and only necessary is usually 5-10%. When is surgery required?

  • Skin penetration ie the broken sharp edges of the collarbone has pierces through skin (this is called open fractures)
  • Severe displacement when the two broken parts don’t align or line up naturally together
  • 2 or more pieces sometimes the force can be so high, the collarbone can break into multiple fragments
  • Clavicle shortening more than 2 cm, either due to overlapping of the bone fragments, or if the bone has shattered and moved
  • Additional damage to nearby nerves or blood vessels
  • Fracture non-union if the fracture hadn’t joined or healed after 6-12 weeks

If corrective surgery is medically required, your orthopedic surgeon will realign the bone fragments and fix them together with either:

  • Intramedullary fixation using a nail or rod to fix the bone together. It’s sometimes called “bouquet” technique because it goes through the middle of the bone (called canal) to stabilize and secure the broken clavicle bone pieces together.
  • Metal plate and screws made of titanium or sometimes steel is placed over the top of the aligned collarbone to hold the bones in the correct alignment. It’s secured in place with screws. Usually you can discharge within the same day or next day as long as medically stable. Most of the time, the ORIF will be left there indefinitely, but in the rare situation where it causes problems such as pain, stiffness, irritation or moves out of place, then you will need to remove it once the bone has healed.

Immediately after surgery, you will need to wear a sling for at least 3-4 weeks and your physiotherapist will prescribe you a clavicular fracture exercise program to help restore full movement and strength in your shoulder and clavicular joints.

How long for the clavicle fractures to recover?

Patients always ask this golden question: how long does the clavicle fracture takes to recover?

  • kids: 4-8 weejs
  • adults: 6-12 weeks

It’d take about 12-24 weeks to fully regain movement and function. Most patients make a full recovery within 12 weeks (3 months), and if they wanna go back to aggressive contact sports, we’d recommend to continue another 12 weeks of sports-specific physiotherapy and strengthening.

Some individuals may have slower fracture healing due to issues such as smoking habits or medical conditions such as diabetes, osteoporosis etc.

Tips for best clavicular fracture recovery:

  • Support – protect and support your arm and clavicle as often as you can by wearing a sling, except when you’re doing exercises your physio taught you. Over time, your sling time will gradually be decreased, but whenever you clavicle feels sore, quickly put on the sling again. The good thing about slings is that it’s a clear visual sign for most people to steer clear away.
  • Medication – use medication that’s prescribed by your doctor to keep the pain and swelling in control, which in turn will help you keep moving your shoulder and clavicle. You can get some off painkillers and anti-swelling meds off the shelf too.
  • Exercises – always follow close the physio exercise plan prescribed to you by your physical therapist, and do not overdo your exercise. Many patients think that “if exercise is good, so if I do more, then it’d be better” which isn’t the right thing. Doing the right amount combined with rest is best.
  • Rest / sleep time – prop yourself up with bed wedges to get yourself into a comfortable position.
  • Be careful: limited/protected movements and NO lifting – until the doctor or physio allows you to. Do only the exercises the physio taught you.
  • Sports – if you’re active and sporty, then you’d best be placed on a sports-specific physiotherapy program for about 12 weeks after your bone has healed. Don’t rush back into exercise the same day you hear your bone has healed! Best to gradually strengthen and load it first before going back to sports.

Possible collarbone fracture complications

Non-surgical complications

  • Bony bumps – you may feel and see a small lump over the fracture site. This usually would slowly shrink over months and years but in some cases may remain permanently.
  • Fracture non-union – about 1-5% of of collar bone clavicle fracture cases do not heal. This means that the two broken parts remains two distinct and separate pieces, and though some may think “if there’s no symptoms, can leave the non-union bones be” but I strongly disagree because the structure of the bone is compromised and will not be able to carry load. Plus it may cause a lot of pain and discomfort in time, so if there’s non-union, the best is to quickly do a surgery to secure the bones together with metal plates and screws.
  • Mal-unions are just as problematic as non-union fractures. Wait, maybe worse. Mal-unions mean that the fracture parts didnt heal in alignment, usually in a wrong alignment be it slightly bent / rotated, which can lead to other mechanical movement problems
  • Decreased shoulder movement and strength – this is one of the issues that physio can deal with and is a fairly common post-fracture issue.

Surgery complications

Any surgery has risks, be it delayed healing, infection, bleeding, blood clots and damage to the surrounding nerves and/or blood vessels. Specific risks associated with surgery for a broken clavicle include:

  • Implant problems: in around 30% of clavicular repairs, the implant may need to be removed due to pain, irritation, discomfort or blocks certain structure or movement. In fact, sometimes the implant may break as well without warning.
  • Injury to nearby tissues: a continuation to the above point of implant problem, sometimes the implant may irritate or press on nearby structures, causing pain, weakness even nerve related issues such as numbness and tingling
  • Non-union – yes, this may happen to some patients even though they have had the implant done. If there is non-union, the surgeon may do another surgery and apply “bone glue” or bone implant to help stimulate bone growth
  • Frozen shoulder – about 4-5% of patients who did clavicular surgery develops frozen shoulder

Where To Next?

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