Clavicle Fracture

Causes and Symptoms

In most cases, a direct force on the clavicle is the cause of the fracture, such as after a bicycle fall with impact to the shoulder or a "tackle" in contact sports. Less commonly, the clavicle fractures due to indirect force, such as after a fall on the outstretched hand.

A clavicle fracture is prevalent during birth in newborns. Maternal factors include height, age, and abnormal pelvic shape; in addition, the higher birth weight of the newborn is a risk factor. Most clavicle fractures occur without symptoms and heal on their own, and only in rare cases does the newborn require surgery.

A clavicle fracture in children, adolescents, or even adults is characterized by pain, swelling, and restricted movement in the affected shoulder.

How Is a Clavicle Fracture Diagnosed?

The diagnosis is usually made based on patient history, including the course of the accident and a clinical examination. Hematomas, a crackling rubbing sound (crepitation), and a relieving posture of the patient can often be noticed. Specific signs that indicate a clavicle fracture include a palpable step formation or even visible skin bulging in the fracture area, a lowering of the affected shoulder, and a visible deformation of the shoulder girdle. If the clavicle is fractured at the outer portion of the bone shaft, the injury is often accompanied by a tear of the ligaments that stabilizes the acromioclavicular joint. In such cases, the physician may detect the elevation of the clavicle, in which the outer portion of the bone protrudes upward in the direction of the head and can be resiliently pressed downward.

An X-ray examination is initiated to show the exact location and severity of the fracture and any concomitant injuries as a diagnostic measure.

How Is a Clavicle Fracture Treated?

Whether and how a clavicle fracture needs to be operated on is determined by the attending physician on an individual basis and following guidelines after comprehensive diagnostics.

Conservative therapy, i.e., treatment without surgery, is initiated if the fracture fragments are not displaced or only minimally displaced in relation to each other, there is no soft tissue damage, there is intact circulation as well as sensitivity and mobility of the affected arm, or there is a lower functional demand on the shoulder, as may be the case in elderly patients. Conservative therapy focuses on immobilizing the fracture using a unique sling for up to 4 weeks to allow the fracture to heal correctly. In addition, the shoulder should be cooled regularly and rested at all times, and patients should take pain medication as needed. After about 3 weeks, physiotherapy is first initiated with passive exercises to improve mobility and later completed with active strength training.

When Does a Clavicle Fracture Require Surgery?

Suppose the fracture fragments are severely displaced against each other. If there is an open fracture, or if the sharp-edged fracture fragment threatens to pierce the skin or injure soft tissues such as vessels and nerves, surgery is absolutely necessary. In addition, the fracture fragment can penetrate the pleura and lead to pneumothorax, in which the lung collapses. Such cases also require urgent surgery. Another indication is a floating shoulder, in which not only the clavicle and the glenoid cavity of the scapula fractures, leading to a very unstable shoulder.

Surgical fracture treatment can be performed using various techniques, depending on the severity and location of the fracture. Plate osteosyntheses are often used, in which metal plates are fixed over the fracture gap with screws to stabilize the fracture on the one hand and exert pressure on the other so that the fracture fragments can heal together better.

How Long Does the Healing Process Take?

With conservative treatment, it usually takes about 6 weeks before patients can move their arms again without pain almost to its full extent. Following this, active exercises to build up strength are started as part of physical therapy.

In the case of surgical treatment of the clavicle fracture, the shoulder must first be immobilized and rested for up to 3 days. Then, under physiotherapeutic supervision, active movements are started, adapted to the patient's pain. About 9 weeks after surgery, the shoulder can be exercised under full weight-bearing, but contact sports cannot be resumed until 4 months after surgery.

Are There Risks and Possible Secondary Damage After a Clavicle Fracture?

As with other bone fractures, unesthetic malpositioning of the clavicle can occur or pseudoarthrosis, i.e., a pathological mobile connection of the fracture fragments, which cannot heal stably even after 6 months. In addition, particularly in the case of open fractures or fracture fragments displaced in relation to one another, there is a risk that they will injure neighboring tissues with sharp-edged bone fragments. These include blood vessels and nerves; if they are damaged, they can lead to hemorrhage or motor and sensory disturbances. But also pulmonary pleura, if perforated, causes the pneumothorax mentioned at the beginning.

Sources

• Schröcksnadel, H., et al. Die Claviculafraktur - Ätiologie Und Prophylaxe.
• www.amboss.com/de/wissen/Claviculafraktur/