TIP OF THE MONTH: April/May 2014 
Clavical Fractures: To Fix or Not to Fix?

by Lisa Joyce, RT(R), OTC, CFo

Anatomy
The clavicle is part of the pectoral girdle in the body. It is a slender, elongated S-shaped bone that starts at the base of the neck and runs horizontally between the sternum and the shoulder. It articulates with the sternum (sternoclavicular joint) and the acromion process of the shoulder (acromioclavicular joint). It assists the scapula to hold the shoulder in place and provides muscle attachments for the muscles in the upper limbs, chest and back. It is a structurally weak bone. Fractures of the clavicle are common.

Situations where a fracture can occur include:
• Falling onto the shoulder or falling on an outstretched hand (snapping back arm).
• Participating in contact sports like football, rugby, wrestling and hockey.
• Direct blows to the shoulder area or a collision with a hard object (MVA, skiing accident)
• Children are more susceptible to clavicle fractures as bones are not hardened and matured.

Symptoms
Fractures of the clavicle are easy to see as the clavicle lies just under the skin, so deformities are easy to detect. Patients might complain of swelling, tenderness, bruising, a deformity or bump may be visualized, inability to raise arm due to pain, a grinding noise as they try to lift their arm or they will hold their injured arm close to their chest for protection. X-rays of the entire shoulder are performed to visualize the fracture.

Types of Clavicle Fractures
There are three types of clavicle fractures:
• Near the sternum (less than 5%)
• Near the AC joint (2nd most common)
• Mid shaft

Non-Surgical Treatment
Most clavicle fractures will not require surgery. A good arm support (sling) will also provide comfort. Figure-eight supports were used in the past, but were uncomfortable for patients as well as cumbersome to apply. Pain prescription medication may be given to relieve pain, although over-the-counter medicine can relieve most of the pain. Rest, icing and sleeping in a recliner is also recommended. After healing begins, physical therapy may be required to regain strength and mobility.

Frequent visits to the orthopaedic physician are required as well as follow-up x-rays to confirm that the fracture is healing and staying aligned. Complications can occur if the bone comes out of alignment or non-union of the fracture. The “bump” will eventually disappear over time; however, a smaller bump may be the end result.

Surgical Treatment
Surgery is indicated for a fracture with a displacement of 2cm or more of shortening, non-union or a comminuted fracture. Other indications may be competitive athletes, dominant arm or other injuries are involved. The procedure performed is an Open Reduction Internal Fixation. The fractures are realigned during the surgical procedure and held together with a system of plates and screws. Some surgeons may use pins and then remove them once fracture is healed.

Surgical complications can include infection, lung collapse, irritation from hardware, frozen shoulder or incision numbness.

Outcomes
Within a few days, the patient should be able to move their fingers, wrist and elbow without much discomfort. Recovery usually takes up to three months. Healing for diabetics and smokers tends to take longer. Patients need to listen to their surgeon’s instructions on lifting arm as lifting too soon may result in refracture or breaking of the plate. Sports and exercise should not be done until authorized by the surgeon. Exercises like push-ups or bench presses may not be allowed for up to six months. Once fully healed, there should not be any limitations. Full range of motion returns, and the patient can get back to normal daily activities.

About The Author
Lisa Joyce, RT(R), OTC, CFo, is a Clinical Supervisor at the New Hampshire Technical Institute (NHTI), Orthopaedic Tech Program. She currently serves as President of the New England Society of Orthopaedic Technologists. Lisa is employed as an OTC and Orthotic Fitter at Granite State Orthopaedics, located in both Nashua and Derry, New Hampshire.

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