PT Classroom - The Broken Collarbone: Orthopedic Management & Rehabilitation of Clavicle Fractures ׀ by Jennifer Werwie, DPT

Known to the general population as the ‘collarbone’, the clavicle serves as an essential strut connecting the sternum (‘breastbone’) and the scapula (‘shoulder blade’) to allow for freedom of motion at the shoulder joint (1). It is the vital link between the appendicular skeleton (upper arm) to the axial skeleton (trunk). Along with the subclavius muscle, the clavicle serves to protect underlying neurovascular structures, such as the brachial plexus and the subclavian vessels (2). Its Latin word “clavicula” translates to “little key”, describing the clavicle’s rotary motion when the arm is abducted. Another unique feature of the clavicle is that it is the only long bone in the body that lies horizontally (3).

 

Injuries, and specifically fractures, to the clavicle are rather common, and make up almost 5-10% of all fractures (2). They occur most commonly in children and young adults, and typical mechanism of injury involves an indirect blow to the clavicle, such as a FOOSS or FOOSH (Fall Onto Outstretched Shoulder; or Fall Onto Outstretched Hand) versus a direct blow to the area (4-6). The following incidences are common causes of clavicle fractures: falling off a bike (often over the handlebars), automobile accidents, contact sports such a football and wrestling, and even in babies during passage through the birth canal.

Depending on the severity and type of fracture, patients may experience various levels of pain at the fracture site. Other symptom presentation often includes (2,7):
• Decreased range of motion and strength of the involved upper extremity
• Shoulder depressed (“sagging”); inferior and anterior translation of shoulder
• Callus deformity formation (“bump”) over the fracture site
• Swelling, bruising and tenderness over fracture site
• Reported grinding sensation and palpable crepitus with attempted shoulder range of motion

Radiographs are used to identify the fracture site and characteristics. The Allman classification system divides the clavicle in to thirds (2,8):
Group I. Midshaft Fractures: occurring in the middle third of the clavicle (75-80%)
Group II. Distal Fractures: occurring in the lateral third of the clavicle (15-25%)
Group III. Proximal Fractures: occurring in the medial third of the clavicle (<5%)
 

Group I, midshaft fractures, account for about 75-80% of all clavicle fractures, and usually experience some degree of displacement. This middle third region not only contains the least amount of medullary bone, but also lacks muscular and ligamentous support, making it the most vulnerable zone of injury in the clavicle. Fractures have various sub-classification characteristics that can affect fracture management (9):

Nondisplaced	Contains some cortical contact
Displaced	>100% transaction between fragments*
Open	Bone has broken through skin
Closed	None has not broken through skin

Both nondisplaced and displaced closed fractures have traditionally been treated nonoperatively, allowing the clavicle to heal itself through a natural reparative and remodeling ossification process. Hippocrates once wrote that “the patient with a fractured clavicle could be treated with observation and that the treating physician would be sorry at the neglect of the patients, for, although deformity was universal, healing and return to normal function were equally expected” (10). Immobilization treatment with sling-and-swath or figure-of-eight splint was widely advocated, and excellent outcomes of healing and recovery were reported (2,4,9). Today, nondisplaced fractures are still managed this way. However, recent studies in literature have connected nonoperative treatment of displaced fractures with greater complications in symptomatic malunion, nonunion, infection, re-fracture and poorer overall functional outcomes (2,6,9,11-12). Concurrently, advances in osteosynthetic surgical approaches have allowed the open reduction/internal fixation (ORIF) procedure to more effectively restore length and alignment, and ultimately result in shorter time to union (9). Closed reduction and intramedullary fixation are other techniques used less commonly.

A clinic study conducted by Althausen et al. (13) comparing outcome measures of nonoperative to operative patients revealed that operative patients had less chronic pain (6.1% vs 25.3%), less cosmetic deformity (18.2% vs 32.5%), less weakness (10.6% vs 33.7%), less loss of motion (15.2% vs 31.3%), and fewer nonunions (0% vs 4.8%), missed fewer days of work (8.4 days vs 35.2 days) and required less assistance (3 days vs 7 days) for care at home. Overall, the cost was $12,976.94 for operative patients and $18,068.27 for nonoperative patients (13). In brief, this study presents operative treatment of clavicle fractures as the approach of choice for positive physical, functional, and fiscal outcomes.

Whether operative or nonoperative, the clavicle can take several months to completely heal. It is important that a doctor or physical therapist is involved in evaluating a patient to be cleared for safe return-to-activity. Return to activity recommendations depend on patient age, functional activity level (i.e. job tasks, sport), level of contact, and presumed trauma risk (2). For return-to-sport, an athlete should have full range of motion, normal shoulder strength, clinical and radiographic evidence of bony healing, and no tenderness to palpation (2).

Physical therapy is becoming increasingly employed to accelerate the healing process and safe return-to-activity. The Guide to PT Practice highlights practice pattern and suggested management of fractures under Pattern 4G: Impaired Joint Mobility, Muscle Performance, & Range of Motion Associated with Fracture (13). Based on practice patterns, the guide provides an estimate of three to six months post-fracture for return to highest individual function. The guide also estimates that 80% of patients will reach established goals and outcomes within a 6 – 18 visit range (14).

For surgical clavicle fractures, each surgeon will have a specific protocol based on the surgical technique and severity of the fracture. Clicking on the link here will display a rehabilitation protocol adopted from the Massachusetts General Hospital Sports Physical Therapy program and the American Academy of Orthopedic Surgeons for non-surgical rehabilitation of clavicle fractures (7,15). 


Last revised: December, 16 2012
by Jennifer Werwie, DPT

References:
1) Moore KL, Dalley, AF, Agur AM. Clinically Oriented Anatomy. 6th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2010, 687.
2) Pecci, M, Kreher JB. Clavicle Fractures. Am Fam Physician. (2008). Jan 1:77(1)65-70.
3) Wikipedia: Clavicle Fracture. Last updated Oct 13, 2012. <http://en.wikipedia.org/wiki/Clavicle>
4) McKee, MD. Clavicle fractures in 2010: sling/swathe or open reduction and internal fixation? Orthop Clin North Am. 2010. Apr;41(2):225-31. doi: 10.1016/j.ocl.2009.12.005.
5) Hallisy, K. Orthopedic Physical Therapy Core Notes: PT 677. University of Wisconsin-Madison. Mar 2011; (54).
6) Van der Meijden OA, Gaskill TR, Millett PJ. Treatment of clavicle fractures: current concepts review. J Shoulder Elbow Surg. 2012 Mar;21(3):423-9. doi: 10.1016/j.jse.2011.08.053. Epub 2011 Nov 6.
7) Massachusetts General Hospital: Orthopedics Sports Medicine. Clavicle Fracture Protocol Non-surgical. <www2.massgeneral.org/sports>
8) Allman FL. Clavicle Fractures: Allman Classification. Journ of Bone & Joint Surg. 1967 (A) 49:774-784.
9) Toogood P, Horst P, Samagh S, Feeley B. Clavicle Fractures: A Review of the Literature and Update on Treatment. 2011. Physician and Sportsmedicine: 39(3).
10) Adams F. The genuine works of Hippocrates. New York, NY: William Wood and Co. 1886.
11) Pandva NK, Namdari S, Hosalkar HS. Displaced clavicle fractures in adolescents: facts, controversies, and current trends. J Am Acad Orthop Surg. 2012. Aug; 20(8)498-505.
12) Vander Have KL, Perdue AM, Caird MS, Farley FA. Operative versus nonoperative treatment of midshaft clavicle fractures in adolescents. J Pediatr Orthop. 2010. Jun;30(4):307-12.
13) Althausen PL, Shannon S, Lu M, O’Mara TJ, Bray TJ. Clinical and financial comparison of operative and nonoperative treatment of displaced clavicle fractures. Sept 2012. Reno Orthopaedic Clinic. Reno, NV. USA.
14) American Physical Therapy Association: Guide to Physical Therapy Practice: Practice Pattern 4G. 2003. 3rd Edition.
15) American Academy of Orthopedic Surgeons. Clavicle Fracture (Broken Collarbone). <http://orthoinfo.aaos.org/topic.cfm?topic=a00072#Nonsurgical Treatment>