The clavicle (also called collarbone), is a structure that connects the arm to the thorax of the body by way of the sternum (breastbone) joint, and another joint called the acromio-clavicular joint at the shoulder. The clavicle helps stabilize the arm and shoulder, and also helps protect bundles of nerves and blood vessels routing to the shoulder. Clavicle fractures happen frequently and comprise of 4% of total fracture types and 35% of shoulder injuries. A clavicle fracture usually happens as a result of trauma - either from sports in a direct hit to the shoulder, or from a car accident. Because active individuals involved in contact sports tend to be in the demographic of under age 20 and male, clavicle fractures tend to happen mostly in this group. In the older demographics, mechanism of injury causing a clavicle fracture tend to happen as a result of falls, and women are affected more than men in this older age group because of decreased bone density comparatively.
Some clavicle fractures are tended to without surgical intervention, but with or without surgery physical therapy is needed to help with healing and return to full sports and activities through guided exercise, range of motion activities and functional activity practice.
Classification of Clavicle Fractures
Classification of clavicle fractures depend on the location of break:
clavicle fractures describes a break in the middle of the bone and comprises 75 to 80% of all clavicle fractures. These fractures tend to happen to younger individuals from trauma.
clavicle fractures describes a break that is near the shoulder (acromio-clavicular joint) and comprises 15 to 25% of all clavicle fractures.
clavicle fractures describes a break near its joint at the breastbone (sterno-clavicular joint) and is rare due to the joint’s inherent stability and stiffness. These breaks comprise 5% of all clavicle fractures.
The fractures themselves are further classified into different types according to the type of break:
fractures are fractures where the broken bone segments are lined up with each other.
fractures are when the broken bone segments are not lined up with each other.
fractures involve splintered pieces of bone at the fracture site and is akin to being shattered. This is dangerous because these splintered pieces can pierce thin layer skin at the collarbone, causing a ompound fracture of the clavicle.
Symptoms of a Broken Clavicle
The most immediate feeling is pain at the area of the fracture. Bruising starts at the site and can spread into the shoulder and arm. This is due to the flow of dried, internal blood from the fracture. Swelling is most likely to occur at the area of the break and like bruising, may move to include the shoulder or arm because of the flow of interstitial fluid. There could also be a visual bump at the fracture site where the bone is jutting into the skin. It is very common to feel the movement and shifting of the broken pieces as the arm is moved, and this could be very painful because of sensitivity of bone. The fracture will be very tender to the touch and almost all patients suffering from a broken clavicle will find it too painful to lift their arm, and thus keep the arm guarded by their bodies and supported.
How Can a Physical Therapist Help?
Some broken clavicle are treated without surgery, especially those that are nondisplaced fractures. The patient’s arm will have to be supported in a sling to minimize strain on the fracture. Physical Therapy is initiated early to reduce pain, swelling and muscle guarding.
The patient is then progressed to range of motion therapy, which involves passive and later active-assisted manual therapy, so that patient is able to tolerate increased movement of the shoulder and arm. Gentle exercises will be prescribed by the physical therapist to improve ease of motion and to maintain movement of the elbow so stiffness of joints is avoided.
As the clavicle fracture heals, the patient will feel less pain and experience less swelling. As exercise and range of motion progresses, and as X-Ray results show continual bone healing, the patient is weaned off of the sling. Exercises will be progressed and increased in difficult to include heavier weights, as tolerated by the patient.
After 8 weeks and when the clavicle bone has shown full healing on an X-Ray, more strenuous activity like pushing against body weight may begin, the goal being for the patient to slowly be introduced back to sport. This stage has to come slowly to avoid excessive strain on tissues and more muscle to slowly grow and adapt to more strenuous training. The physical therapist will judge and analyze movement of daily tasks of living, work and sports to practice functional maneuvers and throws if necessary.
Healing times do vary among different people because of inherent differences in age, smoking habits (which do decrease bone healing due to inadequate oxygen perfusion), health and complexity of fracture (see classifications above). Most active and healthy patients are able to return to resuming non-strenuous daily activities after 6 weeks of physical therapy, and fully return to strenuous activities of sports at 12 weeks.
Post-operative physical therapy for a fractured clavicle.
Physical therapy plan of care is similar to that of nonsurgical cases, though this time a protocol set by the surgeons is followed. Physical therapy is started soon after surgical fixation of the hardware into the clavicle, to reduce pain and reduce scar tissue formation in and around the shoulder. The period of healing and physical therapy typically takes 8-12 weeks.
Much like nonsurgical rehab, the first week’s focus of physical therapy is to minimize pain and control for swelling. Since hardware is installed into the bone for stability and bone union, the patient may be able to begin some gentle range of motion exercises, depending on the tolerance of the patient. The patient may still wear a sling for support at this time. The physical therapist will then progress range of motion and strengthening exercises much like the rehab for nonsurgical fractured clavicle.
Full range of motion exercises and manual therapy is pushed once X-rays shows good position and healing, typically after 4 weeks. More strenuous and resistive exercises are prescribed at 6 to 8 weeks post-op, and X-rays should show full healing of the bone.
Again, these time frames will vary among individuals also according the reasons mentioned before.
Can clavicle fractures be prevented?
Since broken clavicle are typically caused by trauma, these injuries cannot always be prevented. Safe common sense is integral to preventing all contact type of injuries - proper use of protective gear in sports, including shoulder pads in contact football. In older individuals, since clavicle fractures happen due to falls, be cognizant of your fall risk and perform frequent checks at your physician visits for bone density. A physical therapist can also help to minimize your fall risk through a series of balance and strengthening exercises.
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