The author - John Yardley
This page is for those unfortunates who have a fractured clavicle (or broken collar-bone) and are looking for some helpful information from a fellow sufferer rather than a clinician. As someone that has broken both clavicles and experienced both extremes of the healing process, I now consider myself a bit of an expert.
The page was originally written in 1998 - partly because I found out a lot about clavicle fractures that I wanted to share and partly for my own amusement. To my everlasting amazement, the page seems to get hundreds of hits daily from all over the world and I get many mails from sufferers asking questions or relating their own experiences. It is clear from these mails that doctors often do not take the injury at all seriously.
I would like to thank all the correspondents and, where relevant, I have tried to incorporate some of their very useful feedback and information in the text.
I have also tried to reference information obtained from other Internet sites with appropriate links. However, although I periodically update the site, some of the referenced sites get deleted or restructured so links may break and I am not always able to locate a replacement source. I try to remove links that break but leave the information unsubstantiated on the basis that the site is not intended to be a definitive clinical description of the injury and its treatment - just a collection of bits of information I have picked up. Please don't trust any of it - see a doctor.
Fractures can occur in a number of ways from a simple break to a compound fracture and the treatment will depend on the position of the fracture in relation to the end of the bone and many other factors.
Clavicles fractures are also classified according to where the break occurs and , not surprisingly, most occur around the middle of the bone.
A broken clavicle cannot be fixed in the same way as a leg or arm say, by surrounding the limb is a plaster cast. This is practical with limbs because a limb bone is normally held by the muscles in compression along its axis. The clavicle is subject to all sorts of forces and the geometry is much more complex. Even if the whole shoulder could be encased in plaster, it would be unlikely to hold the bone in position.
Be that as it may, it seems that the various muscles surrounding the clavicle generally do a pretty good job of keeping the bone in place and the broken fragments in contact. Indeed, there is a 90% chance that a fractured clavicle will form a good union without any assistance - and this natural repair is often stronger than the original.
Soon after the break, the ends of the bone "bleed" and gradually a fibrous tissue builds up around the end of each break. These tissue formations act as part of the mechanism to restore a blood supply to the site of the fracture and typically after 14 days, they intermingle and bridge the gap. Once the bones are held together by the fibrous tissue, the tissue starts to calcify (i.e. turn into bone). Even if the two ends do not butt up perfectly, the calcification seems to build up in such a way that, after healing, a good cross-section is maintained along the bone. The surplus fibrous tissue dissolves away over the subsequent years.
After about 2-3 months, the fracture should be completely healed, although there is rarely perfect alignment of the broken sections.
The normal treatment for a broken clavicle is simply to keep the arm in a sling or clavicular rings (or similar variants) for 2-3 weeks. For most sufferers the sling is more comfortable and statistically, just as likely to foster a good union.
In some cases, the two ends of the bone join up in some awkward way. Perhaps a sharp end is protruding, perhaps the geometry is all wrong or the broken segments actually overlap causing a shortening of the clavicle. This is termed a mal-union.
In other cases, the two ends of the bone never get close enough to allow the bridge of fibrous tissue to form. This is termed a non-union. Both a mal-union and non-union can remain untreated indefinitely, but will usually cause varying amounts of pain and discomfort. A non-union is generally worse because the unjoined ends of the bones can act like a vice, trapping nerves and other tissues.
In most non-union cases treatment is necessary and the most common option is to perform a surgical operation to mechanically fix the two (or more) sections with a plate or a pin. In the case of mal-union, the clavicle has to be re-broken before this fixation can take place. The surgeon must first expose the bone, break it if it is a mal-union, clean it up, attach the plate or pin and then sew the patient up. Once the operation has been performed, the two ends of the bone are in good mechanical contact, and the plate is relieving some of the forces that are trying to pull the union apart, there is a 99% chance that a good union will form.
This operation is called Open Reduction Internal Fixation (ORIF). Open refers to the fact that you have to be cut "open". Reduction is the medical term for lining up the two ends of the bone. By contrast, a Closed Reduction would be where the bone ends are manipulated without breaking the skin. Internal Fixation means that the plate or pin is fixed directly to the bone from within.
A Closed Reduction is not generally much use because, without direct access to the bones, there is no way to fix the reduction in place. The effectiveness of a closed reduction depends entirely on how the bones are naturally aligned by the surrounding muscle. In theory clavicular rings are designed to create and maintain a closed reduction, but in practice they do seem any more effective than no treatment at all.
Often the ORIF requires a bone graft too. This involves filling in the gaps between the two ends of the fracture with ground-up healthy (living) bone from some other site. Apparently, if there is not a ready source suitable bone at the fracture site, then the hip is considered fair game.
The plate, usually of titanium, is screwed to the top-side of clavicle across the site of the fracture (see later). The pin is inserted down the centre of the bone by drilling into the shoulder end. The pin seems to require less surgery and produces a cosmetically better result, but is intrinsically less strong than a plate. Examples of pins are the "Hagie" and "Rockwood" pins.
Over recent years, plates specifically sculpted for clavicle fractures (so-called congruent clavicle plates) have become available that are far less obtrusive than generic plates.
Once the fracture has mended, the plate may be removed. Whether or not it is actually removed, depends on the individual patient and how comfortable he feels with it. This, of course, requires a second operation - but one that can be performed quickly under local anesthetic. Other methods of fixation include sutures and wires.
These can be administered with less invasion than plate and pins. I have received several reports of patients receiving these treatments, but not found any definitive description of the procedures.
Also, there are various electrical bone growth stimulators that allegedly improve the chances of natural union. I have not heard of any success stories for patients with fractured clavicles.
An important point to remember is that, unlike the bones such as the femur, clavicles are not a mechanical necessity. Some people are actually born without clavicles (Sprengel's deformity) and they manage to live reasonably normal lives.
If the clavicle is broken and does not form a union, then, after the healing process has completed, the most likely source of discomfort is action of the flailing bone ends on the surrounding nerves.
Much of the mail correspondence I receive is from patients suffering from a mal-union where the overall length of the clavicle is significantly shortened, or the union itself is very obtuse. Indeed, from this experience, I would venture that the chances of a perfect union following a clavicle fracture are small indeed.
This view is partially backed by an academic paper entitled "Closed treatment of displaced middle-third fractures of the clavicle gives poor results" by Hill JM; McGuire MH; Crosby LA. Which, incidentally, concludes:
"We now recommend open reduction and internal fixation of severely displaced fractures of the middle third of the clavicle in adult patients."
(This paper was kindly brought to my attention by by Joseph Rakocy of Oregon.)
My view is that there is a very crucial stage when the bones are highly disposed to knit - typically after 10-14 days. At this point, if there is some mechanical contact, then a union will form and provided it is not stressed too much, will get progressively stronger. If the union is short-lived due to over exertion, then it seems less and less likely to re-establish itself. For this reason, it seems probable that the "first union" often occurs during relative inactivity such as sleep.
The ideal healing scenario would be to be able to detect when the bones are highly conditioned to join, align them by external manipulation (i.e. closed reduction) and keep perfectly still for 24 hours. While this may be difficult to achieve, in the long term, the wait would be worthwhile. The problem remains, however, of how to know when the bone is ready to knit. Clearly, it is impractical to remain immobile for several days.
Fig 1: Picture of the author taken minutes before hitting slush (click to magnify)
I broke my left clavicle in 1968 in a motor cycle accident, when I hit a car at about 30 mph. At the same time, I broke my left leg, so I was effectively immobilised for about 5 weeks. This must have given the clavicle fracture site a much better chance to form union since I was laying in bed most of that time. After that, I was using crutches, which must have imposed quite some stress on the clavicle, yet did not seem to stop it joining up, albeit something of a malunion. As best I can recall, the fracture was very painful but the pain subsided within two or three days. It was replaced by a worse pain due to muscle spasm in the stomach. It may be that this was brought about by the total injury, not just the clavicle. I completely recovered within 2 months, although the clavicle was heavily misaligned. To this day it is obvious from the outline under the skin that the bone has misaligned. However, I have never suffered any discomfort or restricted movement. It took another year to sue the motorist for £400 compensation, with which I bought a Triumph Herald.
My right clavicle, I broke in a skiing accident in Meribel in the French Alps on 18th February, 1998. As far as I can recall, the pain was much greater than I recollect experiencing in 1968. Indeed it was the worst pain I have ever experienced. Maybe I am just a baby, but I found it was so painful that it was totally impossible to move.
The first lesson here is always take a credit card with you when skiing in France. Even if, as I did, you have a world famous consultant anaesthetist with you, he won't have a clue about fractures and even less of an idea how to get you off a mountain. You will be forced to rely on the highly efficient French Mountain Rescue Service who's first task is to look at your ski pass to see if you took out the optional rescue insurance. If your ski pass does not show the necessary credentials, then here your consultant anaesthetist really comes in handy. He can fish out your credit card and show it to them.
Once you have done this, you are OK. They still lock your skis away, but at least get you off the mountain. The ambulance men however, have no such collateral, so insist on taking an imprint of your card. Don't worry if your injury makes signing an impossibility, "Zer cross vill do, zank you monsieur".
Figure 2: First X-Ray after injury (click to magnify)
Fig 3: X-Ray after the application of the Clavicle Rings (click to magnify)
Immediate treatment, at the Meribel Clinic consisted of an hour waiting for the doctor, then an X-Ray by his wife to assess the extent of the damage. This is shown in the first X-ray which (like the rest) you can click on if you want more detail. You can see that the top half has slid over the bottom half (Fig 2).
This was described as "Ce n'est pas mal" by the doctor. His wife was clearly distressed by his overt cynicism. She looked quite embarrassed as administered the standard treatment of fitting clavicle rings. (This was effectively a "closed reduction" - which relies on pulling the shoulders back and allowing the clavicle to naturally align.) As compensation for her husband, she managed to secure an infusion of Methadone for me - gratefully received in the buttocks in full view of a dozen other patients. After the treatment, another X-ray (Fig. 3) revealed that it had joined up very nicely.
If you progress the same from here, you will not be able to do much for the next few days. It is incredibly difficult to get up from bed, or to cut any half-decent food with your left hand (if you are right handed). Nevertheless, with any luck you should be able to survive the drive home to Blighty. Here again, your friendly consultant anaesthetist comes to your aid by only making you drive on the straight bits, and for never more than 5 hours at a time. But to ease the pain, you can always listen to his incredible selection of country music. Your temporary disability may not permit you to override his choice of music.
Fig 4: X-Ray 6 days after the accident (click to magnify)
When you get back to England, if you can't face the thought of waiting 3 months for a NHS appointment, then go see a consultant orthopedic surgeon. He will get some updated X-rays and decide on the best course of action. In my case, the X-ray (Fig 4) showed that the perfect union was short-lived.
Despite what seemed like needing an act of God, my consultant assured me that there was a 90% chance each end of the broken bits would find one another and it would join up. The only other option, was to open me up and fix it with a plate.
Since I had never undergone an operation in my previous 48 years, there seemed no point in pushing my luck now given the 9 in 10 chance it would heal up naturally. Anyway, I was told to come back in 6 weeks for another X-ray. One consolation was that I got rid to those disgusting clavicle rings and replaced them with sling.
This was an uncomfortable 6 weeks for me. Severe discomfort, which could be kept down with strong painkillers, lasted about 3 weeks, most of which time I kept my arm in the sling. After that time, there was a constant ache that really started to wear me down by the end of the day. None of this was helped by a 10 day stint at an exhibition in Hannover - something that almost put me off the place for life.
Fig 5: X-Ray 6 weeks after the accident (click to magnify)
After the 6 weeks were up, I went back to the consultant for another X-ray (Fig 5) and consultation.
Still no visual improvement to the untrained eye, yet the consultant saw a glimmer of hope in a shard of bone that showed some signs of forming that vital bridge. I therefore accepted his advice to wait a further 6 weeks to see if there was any improvement. Anything to avoid the scalpel.
However, another 6 weeks on, and still no improvement. Prior to the appointment with the consultant, I had mentally resigned myself to the inevitability of an operation. The pain was totally unpredictable. Sometimes I forgot about the injury and inadvertently would lift heavy objects, yet other times, something as simple as taking a book from a shelf was tortuous. In the end, after 3 months, it simply got me down. The X-ray (Fig 6) revealed that, unsurprisingly, there was still no obvious improvement.
Fig 6: X-Ray 12 weeks after the accident (click to magnify)
Although there were some signs of union, the shoulder end of the clavicle seemed to pivot from the site of the fracture. There was some evidence of a build up of fibrous tissue, but not enough to keep the union in good contact.
I was advised that an operative procedure (ORIF) would be highly likely to be successful in providing full union. The risks, such as they were, were mainly those of infection - about a 1 in 200 chance.
I therefore decided to accept the surgeon's recommendation for an ORIF operation. This was scheduled for 25th May, just over 3 months from the date of the injury.
The operation took place at 9.30 am and involved a general anaesthetic and a local anaesthetic of the shoulder. I believe the complete procedure took about an hour and by 1 pm, I was fully awake and tucking into lunch.
Fig 7: X-Ray after the operation (click to magnify)
Fig 8: The author drinking a pint four years after the accident (click to magnify)
I returned home the same day and rested for the rest of the week. Most of the pain was kept under control with regular oral pain-killers - paracetamol and codeine. I got severe discomfort from the right side of my neck.
The (second) physiotherapist attributed this to nerves that had contracted and were being stretched at the site of the operation. This was sorted the following week.
6 weeks after the operation, I had full mobility, although still rigidly sticking to the advice to lift nothing more than a "pint" (i.e. pint of beer - Fig 8).
My general reluctance to have the surgery at the time was somewhat clouded by the fact that I had never, in my near half-century, been operated on before. With hindsight, I would have preferred to have had the operation done as soon as possible, or at least, within the first six weeks. This was not really an option since the medical advice was to give the natural union a chance. Having now experienced the operation, I feel that the discomfort and general immobility of the non-union is definitely worse than the operation itself and recovery.
As much as one can ever recommend an operation, I would this one.
One thing to consider is that your surgeon might take some bone off your hip for the bone graft. I am told that, in this case, the hip can be as painful as the clavicle. As is turned out for me, there was enough debris around the fracture site to make a decent graft.
Don't underestimate the recovery time after an operation. I was under the misapprehension that if I was let out of hospital the day after the operation, I must be fit for work. I would reckon on at least a week off.
Given the choice of clavicle rings and a sling, I would opt for a sling. Not only is it more comfortable, possible to take off when bathing or showering, it stops you looking like an american footballer. People who don't know you have broken your collar bone, wonder why you have all this padding.
Nearly a year on, the operation had completely healed and I was going down the gym, mixing concrete and yes, even skiing. Even after 2 years, however, it is still quite obvious that there is "something" inside my shoulder and their is still some slight restriction of movement, but it does not cause any serious discomfort. Some things - like car seat belts and shoulder bags - are particularly uncomfortable because they tend to exert force directly on the flesh between the plate. The surgeon, Mr Curtis, offered the option of returning at any time after a year to have the plate removed - this apparently can be done under local anaesthetic. At this stage, I would rather stick with the plate that have another operation. However, it should be remembered that leaving well alone is not necessarily the best policy. If dislodged in a subsequent accident, a loose titanium plate could have possible fatal consequences. A main artery lies in close proximity to the clavicle.
From the extensive correspondence I have received since first publishing this page, my opinion is that the Hagie Pin operation is better all-round option than the traditional plate and pins. The problem is that relative few surgeons are able to perform it, and of course, the cost can be high. If you are a supermodel, have lots of money and your clavicles are often on view, you should ask your specialist to consider using a intramedullary pin rather than a plate.
Thanks especially to Mr Mark Curtis, who did a first rate operation and almost as importantly, took the time to explain what the was doing. Thanks also to Mark for keeping me up to date on the technology. To Dr Andrew Davey, who put up with my skiing and was (despite my jokes) the best person to be with such a thing happens. To Odette, who convinced me that physiotherapy really does work and to Teresa who put up with me winging and avoiding mowing the lawn for months.
Thanks also to the many people that have emailed me with their appreciation, their experiences, and their questions - people that have broken their clavicles doing the strangest of things; people that have had plates break inside them (one had a plate break twice); and even people that had surgeon remove the broken parts of their clavicle completely! Particular thanks to Wyatt Everhart, who made a point of seeking out Dr Basamania, one of the few surgeons performing the Hagie Pin procedure, to fix his shortened clavicle. In the process, Wyatt was kind enough to sent me all the correspondence detailing his story.
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