Fractured Clavicle – Do I Need Surgery?

By Joshua Lindsey, MD – Orthopedic Surgeon at the Orthopedic Institute at Southwest Health

The clavicle or “collarbone” is an S-shaped bone that connects our arm to the body.  It is therefore under a lot of physical stress.  The clavicle is just like a strut in your car – a strut is what holds the tire away from the car frame.  It is the first bone to ossify (change from cartilage to bone after birth) and the last bone to stop growing after we have reached skeletal maturity.   Injuries typically happen from a fall directly onto the shoulder, car accidents, and less commonly when a linebacker jumps on top of you as you are trying to throw the ball.

The treatment of clavicle fractures continues to be a controversial topic among orthopaedic surgeons.  Each fracture is just as unique as the patient that has the fracture.  We are not at a place in time to be able to say that specific types of fractures undoubtedly do or do not require surgery.  A specific clavicle fracture in one patient could be best treated with surgery, but that same type of fracture in another patient may not be best treated with surgery.  Adolescents (teenagers) and adults are not treated the same.  Distal clavicle fractures are also not treated the same as midshaft clavicle fractures – the most common varieties.  So, what do we know about these injuries?

Historically, the vast majority of clavicles have been treated without surgery.  This was largely done because the clavicle is an S-shaped bone and we only had straight plates.  The result is a knot or bump at the fracture site and the clavicle is shortened from its original length.   Surgery was only done when the clavicle failed to heal and these surgeries proved to be very challenging.  Not only were doctors trying to put a straight plate on a curved bone, but they were also trying to get something to heal that should have healed without surgery.  So in those instances, we clearly know there is a problem with that patient’s biology or health that may have predisposed them to not heal properly.  Smoking is the BIGGEST single risk factor for clavicle fractures to not heal (the evidence supporting the fact that smoking is bad for your bones is indisputable).

At this point, companies decided to make an S-shaped plate for clavicles!  Surgery for all!  Well, it is not that simple, as surgery does have a list of potential complications that are not trivial.  The clavicle is after all, just above the lung, the brachial plexus (all the nerves to your arm) and next to very large blood vessels that exit the heart.   When surgery is needed, I typically place more restrictions on activities until the fracture heals, then compared to a clavicle fracture treated in a sling.  In addition, the need for secondary surgery is high, as there is not a lot of tissue between your skin and the clavicle.  Plate removal for irritation from the plate rubbing on clothing is very common, but it is recommended that patients wait at least a year to have a plate removed if their plate is symptomatic.

The good news is, studies are ongoing, trying to help sort out the facts.  Here is what we know about midshaft clavicle fractures (the most common type):  The rate of healing is 70% at 3 months in both surgically treated and non-surgically treated fractures.  At 9 months, healing is 98-99% in surgically treated patients, and 90% in non-surgically treated patients (smokers making up the majority of the fractures that do not heal).  Functional outcomes are better at 3 months for operative treated patients, but there is not a significant difference at 9 months post-op.  Most studies show little difference in functional outcome at a year after injury/surgery.  The degree of fracture displacement is also a risk factor for not healing properly– the more displacement, the higher the rate of not healing.

Distal clavicle fractures are treated with surgery more often, as this type of fracture does not do as well functionally when treated without surgery. These fractures behave very differently than the common midshaft clavicle fractures. Since the variations of fracture patterns are very different depending on where the fracture occurs and what ligaments are torn, there are less studies looking at these specific fractures.   This subgroup of fractures will be on the research horizon to try to sort out.

So, why is Aaron Rodgers having surgery on his right clavicle, but three years ago when he broke his left clavicle he did not?  There’s too many unknown variables about his injury to accurately speculate on the differences.  He may have sustained a distal clavicle fracture on his right and a minimally displaced midshaft fracture on his left?  Maybe his skin is tented and at risk?  Too much unknown exists, but it sounds like he will not be playing for a while.

The good news is that if you fracture your clavicle, you can make an appointment with me or another orthopaedic surgeon to discuss your specific fracture and if surgery is recommended for you.  We’ll provide you the pros and cons of surgery to help you make the best informed decision about your care.

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