By Dr. Eric W. Edmonds
All bones in the human body start out as cartilage. In fact, most bones have not even begun to turn into bone (or ossify) at the time that a baby is born. But, the first bone to ossify in the womb is the collarbone or clavicle.
The clavicle is the only contact between our entire (axial) skeleton and the arm. It connects the breastbone (sternum) to the shoulder blade (scapula). There are no other bony contacts, as the shoulder blade is otherwise suspended in space by muscle. This makes the collarbone one of the most common bones to fracture or break in the human body. Some research suggests that it happens 20 percent of the time. It can happen while landing on an outstretched hand or by direct force to the shoulder. It can also happen during the birth of your child.
Nonsurgical management has been the mainstay of treatment for centuries. This can be done by using either a sling or a figure-of-eight brace. Many will advocate the latter because it draws the shoulder backward potentially lining up the broken bone ends better. However, research has demonstrated that most children do not tolerate the figure-of-eight device and ultimately stop using it early in the treatment course. Similar studies have shown equal outcomes when comparing the sling to the figure-of-eight.
Traditionally, if the fracture punctures the skin, or pushes on vital structures, then surgery is considered a better treatment. In general, surgery approximates the two ends of the collarbone and secures it in place with either screws or a plate-and-screw construct. Recently, there has been some good research in adults suggesting a change to the indications for surgical treatment. Data suggests that nearly 15 percent of adult clavicle fractures do not heal properly without surgery. New indications suggest that if the fracture is short by an inch in length, then surgery should be considered.
In children, and perhaps even adolescents, there is no research to support this change in indication to perform surgery. In fact, for children under the age of 10, most studies suggest that surgery is rarely necessary. The age group of 10 to 18 is a gray area (not quite a child and not quite an adult – since the clavicle does not stop growing until the mid-20s). Many surgeons will translate the adult literature to kids in this age group, especially if the injury is on the dominant arm, or if the child is an overhead athlete.
You should see your doctor if there is an obvious deformity of the collarbone or, without deformity, if the pain is not improving after two weeks of rest, or the pain is associated with a fever.
Dr. Eric W. Edmonds is a pediatric and adolescent orthopedic sports medicine specialist at Rady Children’s Hospital-San Diego and an assistant professor of orthopedics at UC San Diego. He can be reached at sports@rchsd.org.