Clavicle Fracture Treatment: When Is Surgery Necessary?
Clavicle fractures, or broken collarbones, are among the most common broken bones that occur. They represent about five percent of all broken bones and are especially common in younger, more active adults. Most fractures of the clavicle occur in the central portion of the collarbone.
Traditionally, these fractures have been treated nonsurgically. For many decades, the results of nonsurgical treatment found that the majority of clavicle fractures healed more reliably with less of a complication rate when compared to clavicle fractures treated with surgery.
More recently, however, several studies have questioned if more clavicle fractures should be treated surgically. The studies have suggested that people who had surgery tended to heal faster with more predictable results. What does this mean? When should surgery be avoided, and when should it be recommended?
The clavicle is the bone in the front of the chest on top of the rib cage. The clavicle is important in helping to support normal shoulder function and is the attachment point for several important muscles including the deltoid and pectoralis muscles.
People sustain clavicle fractures from a variety of injuries ranging from falls, automobile accidents, sports injuries, and other traumatic injuries. When a clavicle fracture occurs, it is common to have pain and swelling at the site of the injury. People can often see a deformity of the bone, especially soon after the injury before swelling has worsened.
Over time, bruising may show up around the fracture site and even into the chest and arm. People with a clavicle fracture have a hard time using their arms because the movement causes pain at the site of the fracture. Your doctor will X-ray the clavicle to determine if a fracture is present and to determine the most appropriate treatment. Additional tests such as CT scans or MRIs are seldom needed to identify a fracture or determine treatment recommendations.
When Not to Have Surgery
Most clavicle fractures can be treated without surgery. For the vast majority of clavicle fractures that are not out of place, or only minimally out of place, the safest and most effective treatment is with the use of a sling.
There are steps you can take to speed your healing, but managing these injuries with nonsurgical treatment is often the best course of action.
Surgery can have its advantages, but there are also risks of surgery that should not be ignored. A complication of surgery can be worse than the original injury, and while these complications may be uncommon, there might not be a reason to take the risk. Secondly, surgical hardware used to repair a clavicle fracture often has to be removed at some point down the road.
Therefore, patients are typically warned that having clavicle fracture surgery may require a second surgery at later on to remove the hardware used to repair the break. When there is displacement or malalignment of the broken bone, surgery may be considered to prevent problems with healing of the fracture. Recent studies have found that the risk of nonunion of a fracture (lack of healing) is high when the fracture is poorly aligned.
When to Have Surgery
Most orthopedists agree that when there is a badly displaced fracture of the clavicle, surgical treatment should be considered. Some factors that may be considered include if the fracture is in the dominant arm, the age of the patient, the patient’s overall health and function, and the likelihood of nonunion of the fracture. If there is a high risk of nonunion, or if there is a concern about loss of function, surgery may be a reasonable treatment. Specific risks for nonunion of a fracture include:
- if the patient is female.
- if the patient is older.
- if there is displacement of the fracture (broken ends not touching).
- if there is comminution (multiple, small fragments of bone).
- if the patient smokes.
Specifically, surgery should be strongly considered if the fracture is shortened by 2 centimeters or more, displaced more than 100 percent, when there are specific fracture patterns (such as Z-type fractures), or when the fractures are highly comminuted (shattered).
When people are at a higher risk of nonunion, either because of the break, or their individual characteristics, surgery can help to lower that chance of nonhealing. This is certainly a change in treatment from decades ago when surgery was once the cause of many nonunions of fractures. With modern surgical techniques and improved hardware to repair fractures, the likelihood of a nonunion after surgery is much lower.
It was once the case that injuries undergoing nonsurgical treatment had a higher chance of healing, and surgery increased the risk of nonunion. Currently, this scenario has been flipped—surgery is now thought to lead to more predictable healing with a lower chance of nonunion.
When contemplating surgery, the possible disadvantages also need to be considered. There are still many risks of surgery.
By far the most common problem with surgery is that many people are bothered by the hardware used to repair their broken clavicle. Most often, a plate and screws are placed along the bone to hold it in position, and these can typically be felt under the skin.
A person is likely to feel annoyed by the hardware as they feel it under a bra strap, backpack strap, or seatbelt chest strap. Many people will choose to have the hardware removed after the break has healed, which is usually at least six months after their initial surgery and most commonly about a year after surgery.
Infection of hardware can cause significant problems. Because the metal hardware is close to the skin, the chance of infection is not insignificant. About 3 percent of people who have clavicle fracture surgery develop an infection from their surgery.
Major nerve damage is very uncommon, but the skin nerves that provide sensation just below the collarbone are often damaged at the time of surgery. Many people who have clavicle fracture surgery will notice a patch of numbness or tingling just under their incision. Over time, the may become smaller and less noticeable, but it tends to persist.
Complications of surgery are more common in people who have other medical conditions such as diabetes, smokers, and those with other chronic medical conditions. In these people, risks of complications may outweigh the benefits of surgery, even in situations where the fracture is badly displaced.
Clavicle fractures are common injuries and will often heal with nonsurgical management. However, orthopedic surgeons are recommending surgery more commonly as a means to provide more predictable healing timelines and recovery of function.
When a fracture is displaced (the ends of the broken bone are not touching) and there is a higher risk of nonunion, surgery can lead to more reliable healing of the fracture. While surgery has advantages in these situations, there are also risks of clavicle fracture surgery that should be considered. Your orthopedic surgeon can help you decide the most appropriate treatment for your fractured collarbone.
- McKee RC, Whelan DB, Schemitsch EH, McKee MD: Operative versus nonoperative care of displaced midshaft clavicular fractures: A meta-analysis of randomized clinical trials. J Bone Joint Surg Am 2012;94:675–684. doi:10.2106/JBJS.J.01364.