Home > Blog > Physiotherapy > Conditions > Shoulder Pain > Collar Bone Pain Physiotherapy > Clavicle Fracture Physiotherapy

Clavicle Fracture Physiotherapy

A clavicle fracture (or broken collar bone) is a common injury usually caused by

• sustaining a fall
• a direct blow or
  
• a car accident

Frankly, broken collarbones are most common in children in young adults.

The collar bone is the most commonly fractured bone in the body. Whilst clavicular fractures may be very painful, yet they are rarely serious and in most cases, they are managed conservatively with a sling rather than requiring corrective surgery.

Here we will

• look at the common causes and symptoms of clavicle fractures
• how they are diagnosed and treated
• how to make the best recovery and
  
• common problem associated with a broken collarbone

Anatomy

Our clavicle, and often commonly called the collarbone, sits right in front of the shoulder joint. 

It is a long, thin bone that sits in-front of the top of the ribcage and they connect the sternum (breastbone) to the acromion (front part of the scapula) forming two joints,

• the sternoclavicular and
  
• the acromioclavicular joints (AC joint)

It is slightly curved in shape, sort of like a stretched-out “S” and is supported/held in place by various ligaments and muscles. It helps to hold the shoulder blade in place, like a strut, so that the arm can hang freely, as well as protecting underlying nerves and blood vessels.

Common Causes of Clavicle Injuries

Clavicle fractures are most commonly caused by an injury or trauma such as

• a fall
• sports injuries or
  
• car accidents
  

They may be caused by:

1. A sideways fall: where you land on the outer side of the shoulder (this is the most common cause of clavicle/collar bone injuries)
2. A fall: onto an outstretched arm
3. A direct blow: to the clavicle
4. During birth: particularly with breech babies

Broken collarbones are often caused by contact sports such as

• rugby
  
• football
• boxing/MMA
  
• wrestling
• ice hockey
  
• winter sports such as skiing and snowboarding
  
• cycling (particularly mountain biking).
  

Children may fracture their collarbone when playing or falling out of bed. 

Weakness in the collar bone from conditions such as

• osteoporosis
• low bone mass osteopenia or
  
• cancer

can also cause a clavicle fracture.

Symptoms Of A Broken Collar Bone

The most common symptoms of a clavicle fracture include:

• Noise: Clavicle fractures are often accompanied by a “snapping” (crack) or “grinding” noise
• Pain: there may be immediate sharp pain at the time of injury which gradually ease into a dull aching or throbbing pain. This pain usually increases with any movement of the arm or upper chest or with any pressure over the fracture area.

• Deformity: swelling and bruising may develop around the fracture site. The arm will often hang forwards and down compared to the uninjured (normal) side. There may be a small bulge/bump over the fracture site. In severe cases the bone may be so displaced that it punctures the skin and there may be associated bleeding but this is very rare.
• Numbness and/or Pins and Needles: if there is damage to the surrounding nerves , patients may experience some altered sensation such as numbness
  
• Decreased Movement: patients will find it difficult and painful to lift the arm. 
  

Diagnosing Clavicle Fractures

If you suspect that you or someone you know have a clavicle fracture, please immediately see your doctor immediately. If you're not sure you can contact us for an appointment and we can assess to determine and even refer you to our medical network of orthopedic doctors as well.

The treating doctor will ask questions about how you injured yourself. He or she will then examine your arm looking at the position and your arm movements as well as gently feeling along the length of the bone. 

It's highly likely that you will be sent for an x-ray to determine the type of fracture and to check for any associated damage. Of course note that diagnosis in children may be done with an ultrasound rather than x-ray.

Clavicle Fracture Categories

Clavicle fractures can be classified into three groups, known as the Allman Classification, depending on the location and severity of the fracture:

Group 1

Location of Fracture: middle third of the clavicle

Incidence: This is the most common type pf collar bone / clavicle fracture, and it accounts for at least 80-85% of clavicle fractures in both children and adults as this is the weakest part of the bone

Presentation: If the fracture is displaced the outer (lateral) side of the clavicle is usually pulled down due to the weight of the arm and the inner (medial) side is usually pulled up by one of the surrounding muscles (sternocleidomastoid).

Group 2

Location of Fracture: Outer (lateral) third of the collarbone – the side nearest the arm

Incidence:  Accounts for 10-15% of clavicle fractures

Presentation: These fall in to three sub categories

• Type 1: non-displaced or with minimal displacement (i.e. the broken parts of the collarbone are lined up normally) as the ligaments remain intact
• Type 2: displaced - the inner (medial) part of the clavicle raises upwards due to damage to the surrounding ligaments
• Type 3: articular surface fractures - associated damage to the acromioclavicular joint where the collarbone meets the acromion (part of the scapula)

Group 3

Location of Fracture: Inner (medial) third of the collarbone – the side nearest the breastbone

Incidence: Rare – accounts for approximately 5% of clavicle fractures

Presentation: If displaced there may be associated injuries to the surrounding tissues

Treatment Options For A Broken Collarbone

In most cases, broken collar bones are treated conservatively which is without any surgery.

Non-Surgical Treatment

1) Protective Sling

The affected clavicle and arm will typically be protected and immobilised in a sling to hold the arm in place, giving the affected bone time and best healing position to heal by laying down new bone (ossification) to re-join the broken sections. 

Either a simple triangle sling or a figure of eight sling (that wraps around both shoulders and the neck to hold the shoulders back) will be used. 

You should keep using the sling until there is no pain when you move your arm. Initially you will need to wear it all the time (including at night), except when you are doing your exercises, but as it heals you will be able to wear it less and less (eventually you won't be needing to wear it any more, once the doctor does an x-ray and confirms good stable healing)

2)  Medication

Pain relieving pain killers and anti-inflammatory medication can help following a clavicle fracture. Your doctor will be prescribing them to you.

3) Cold Therapy

Cold therapy should be applied to the area as soon as possible after injury and used regularly for the first couple of weeks to help

• reduce pain
  
• reduce swelling

4)  Clavicle Physiotherapy

You will be referred for physiotherapy and encouraged to start gentle range of movement exercises almost immediately in order to minimize joint stiffness. 

Typically you will start with gentle pendulum exercises for the shoulder and exercises for the elbow and hand, and then gradually progressing on to range of movement exercises as the fracture heals and pain allows. 

As the bone heals you will gradually progress on to strengthening exercises to regain full strength in the arm. 

You definitely will need to continue with physiotherapy until you have regained full range of movement and strength – this usually takes up to three months.

Surgical interventions for collar bone fractures

Surgical treatment of broken collarbones is only necessary in 5-10% of cases. 

Surgery is required if there is:

• Skin Penetration: the broken collarbone broke through the skin (this is known as an open fracture)
• Severe Displacement: when the two broken parts don’t line up
• Multiple Fractures: when the collarbone is broken into a few different fragments (2 or more fractured parts)
  
• Clavicle Shortening: that is more than 2 cm, caused by either overlapping of the bone fragments, or if the bone has shattered and moved
  
• Associated Damage: to surrounding nerves and/or blood vessels
• Non-Union: the fracture has failed to heal after around 3 months

Recovery Process

It usually takes 4-8 weeks in children and 6-12 weeks in adults for the fractured collar bone (clavicle) to fully heal.

It takes about 3-6 months in total to regain full function. 

Most patients make a full recovery within three months, at which point it is safe to return to contact sports (but we're a little more conservative so we tend to recommend 4+ months to return to contact sports; of course this depends on the severity of the fracture and your physiotherapy compliance rate).

Here is some advice on how to make the best recovery:

• Support: Keep your arm well protected and supported in the sling the first few weeks except for when you are doing your exercises. 
  
  Gradually wean yourself off the sling as the pain reduces, starting with short periods, but as soon as your arm feels sore, pop it right back into the sling.
  
  Patients often report that other people tend to be more mindful and steer clear away from their slings and injured parts when it's more obvious.
  
  
• Medication: Use medication as directed by your doctor: this helps keeps pain and swelling under control and will enable you to get going with your exercises
  
  
• Exercises: Follow the exercise plan given to you by our senior physical therapist and keep going with it until you have regained full strength and movement – don’t be tempted to stop too soon.
  
  We aim to help you achieve 100% recovery (anything less than that is not acceptable to us because it'd hamper/limit your movements in all areas of your life, be it work, relationships, play etc).
  
  
•  Don't Forget The Uninjured Parts and Joints: Start moving your fingers, hand and elbow as soon as possible to prevent them from stiffening up in the sling. 
  
  Remove your arm from the sling to do this a few times a day
  
  
• At Night / Sleeping Time: At night prop yourself up with pillows to get yourself into a comfortable position.  You will need to wear your sling in bed initially.
  
  Some people use pillows, some prefer our bed wedges - check and try and see which you prefer.
  
  
• Really Limit And Restrict Range of Movement: Avoid lifting your arm above should height for the first few weeks, until your doctor or our senior physiotherapists gives you the go-ahead
  
  
• Limit/No Lifting: Avoid any heavy lifting: anything over 5lbs for at least 6-8 weeks
  
  
• Sports: Avoid contact sports at least 12-16 weeks - check in with your doctor or our senior physiotherapists first please before returning to them
  
  
• Posture: Be mindful and often think about your posture - avoid the temptation to let your shoulders drop forwards and your upper back to round

Possible Complications

Long-term problems following a clavicle fracture are rare with most people making a full recovery.

Non-Surgical Complications

1. Bony Prominence: you may feel and see a small lump over the fracture site. This will slowly shrink over months and years but in some cases may remain for long term.
   
   
2. Non-Union: in 1-5% of of collar bone clavicle fracture cases the bone unfortunately does not join back.  If there are no symptoms associated with this, no further treatment is indicated but if there are ongoing symptoms such as pain or reduced movement, corrective surgery may be required.


3. Mal-union: in some rare cases, the broken bone may heal in a displaced (wrong) position which may lead to ongoing shoulder problems
   
   
4. Decreased Shoulder Strength and/or Movement: The risk of this can be reduced by regular clavicle/shoulder physiotherapy with our senior physiotherapists. This is the most common condition affecting patients with shortening of the collarbone

Surgical Complications

Any surgery is associated with risks such as infection, bleeding, blood clots and damage to the surrounding nerves and/or blood vessels.  Specific risks associated with surgery for a broken clavicle include:

1. Implant problems: in around 30% of cases the metal work may need to be removed due to discomfort, or if it hinders specific structures inside or if it has loosened and shifted position. Occasionally, the implant may also break.
   
   
2. Injury to the Surrounding Tissues: in around 3% of cases there may be some damage to the surrounding blood vessels or nerves during surgery, leading to altered sensation and movement.
   
   
3. Non-union: similar frequency to those treated non-surgically
   
   
4. Frozen Shoulder: approximately 4% of surgical patients develop a frozen shoulder aka adhesive capsulitis after surgery for a clavicle fracture