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Clavicle Fracture

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Introduction

A clavicle fracture, or broken collar bone is a type of fracture involving the clavicle bone which is located between the sternum (chest bone) and scapula (shoulder blade). The purpose of this bone is to connect the arm to the torso. Clavicle fractures are very common, representing 44%-66% of all shoulder fractures and approximately 10% of all fractures (Ropars et al., 2017) occurring mostly in those aged under 25 and over 70.

 

 

Fractures of the clavicle are typically divided into three groups:

  • Middle third or midshaft fractures are in Group I.
  • Distal or lateral third are in Group II.
  • Proximal or medial third are in Group III.

 

A middle third clavicle fracture is more common. Typically, a diagnosis can be made by your GP, specialist physiotherapist or A&E doctor. Imaging will be required to determine the extent of the injury and in more severe cases MRI may be required.

Causes

A clavicle fracture most often occurs from a direct blow to the shoulder. The second most frequent injury mechanism is a fall onto an outstretched arm or directly onto the shoulder. In younger individuals, this is most likely to occur during sports or road traffic accidents; however in the elderly, this injury is often sustain from a low-energy slip or fall.

Signs & Symptoms

  • Significant pain particularly when trying the move the arm on the affected side. You may feel the need to hold the arm close to the body for comfort.
  • There may be associated swelling and often a bony lump/abnormality (depending on fracture type).
  • You may experience ‘referred pain’ down the affected arm due to the close proximity of the brachial plexus (network of nerves in your neck which supply power & sensation to the arm & hand) that travels under the clavicle. These symptoms can include reduced muscle strength and altered sensation.
  • Nausea and blurred vision are common due to the associated pain levels.
  • Depending on the mechanism of injury, you may experience difficulty breathing as a result of a potential pneumothorax, however this is very rare.
  • In rare cases you may experience discoloration of the hand and arm with associated decreased pulses. This may be indicative of a subclavian artery/vein injury.

Assessment & Diagnosis

Your Physiotherapist will take a detailed history of the injury and your symptoms, followed by a comprehensive physical assessment. The injured shoulder will be observed for any deformities, your range of movement and function will be examined and special tests will be  performed, all to assist with diagnosis.

 

In acute cases, an X-ray is recommended to facilitate a diagnosis and to assess to extent of the damage. When there are symptoms associated with neural or vascular damage, other medical investigations may be carried out at hospital also.

Treatment & Management

Typically, conservative management is employed with use of a sling to immobilise the shoulder to enable the fracture to heal which takes place during the first 6-12 weeks post-injury. You may be required to have a further X-ray during the immobilisation period to assess whether the fracture is healing in the desired way.

 

You will be given advice on what to do for the first 3 weeks post-injury; typically involving rest, ice, wearing the sling and to start specific elbow and wrist exercises to prevent muscle and strength wastage that will otherwise cause additional complications post-immobilisation.

 

Once immobilisation is no longer required, Physiotherapy input is recommended to help you to regain shoulder movement and strength, aiming to restore full function. To achieve this, your Physio will create a bespoke and progressive self-management and rehabilitation programme.

 

In severe cases, surgery may be required if there is a poor outcome with conservative management, there is comminution (multiple bony pieces), an open fracture (skin penetration), or associated nervous and vascular trauma. Surgery typically involves stabilising the bone using plates and screws. They are typically left in unless they cause irritation by which they are removed once healing has taken place.

(Gao et al., 2019)

References

Gao, B., Dwivedi, S., Patel, S. A., Nwizu, C., & Cruz Jr, A. I. (2019). Operative Versus Nonoperative Management of Displaced Midshaft Clavicle Fractures in Pediatric and Adolescent Patients: A Systematic Review and Meta-Analysis. Journal of Orthopaedic Trauma33(11), e439-e446.

 

Ropars, M., Thomazeau, H., & Huten, D. (2017). Clavicle fractures. Orthopaedics & Traumatology: Surgery & Research103(1), S53-S59.

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