Broken collarbone

The collarbone is a thin curved bone running between the breastbone and the shoulder blade, and it is the only rigid strut holding the shoulder out away from the trunk. It breaks easily and often: a fall from a bike onto the shoulder, a knock in a match, or an awkward landing on an outstretched hand is enough. It is one of the commonest injuries in teenagers, athletes and cyclists, and in newborns the collarbone is sometimes broken during birth itself. The good news is that the great majority of these fractures heal without surgery. The bad news is the neighbourhood: large blood vessels, the nerve bundle to the arm and the top of the lung all run directly beneath the bone.

What it looks like and what it feels like

It is usually obvious almost at once. The person cradles the injured arm with the good one, holds it against the body and tilts the head towards the injured side, because that eases the pull of the muscles.

• sharp pain over the collarbone that gets worse with any attempt to lift the arm;
• a step, a lump or a sharp edge that can be felt, or even seen, under the skin;
• the shoulder on that side looks dropped and somehow shorter;
• swelling and bruising appear within hours and later track downwards onto the chest and arm;
• sometimes there is a grating sensation or sound on movement.

Children under five are harder to read: the bone bends and cracks like a green twig, there is no deformity, and the child simply stops using the arm and cries when picked up under the armpits. In a newborn the fracture is sometimes only found in the second week, when a firm swelling appears over the collarbone — by then it is already healing callus.

When the injury is more dangerous than it looks

Complications of a broken collarbone are rare, but they are the reason not to put off being seen. Call the emergency number, 112, if any of the following follows a shoulder injury:

• shortness of breath, chest pain on breathing in, or coughing up blood, which can mean the top of the lung has been injured;
• the arm on that side is numb or weak, the fingers will not obey, or they have gone cold and pale;
• swelling above the collarbone is growing as you watch and the skin is tight and dusky, which is how bleeding from a damaged vessel shows itself;
• the bone is tenting the skin from underneath into a white cone, or has broken through it.

The last point matters: even with the skin still intact, a sharp fragment pushing it outwards is treated as urgent, because skin stretched over bone dies quickly and a closed fracture becomes an open one. An emergency department visit is needed without these signs too, just less urgently: a broken collarbone always needs an X-ray.

What to do before you reach a doctor

There is one job here: immobilise the arm and stop the fragments moving.

• support the forearm in a sling or scarf, elbow bent at a right angle, hand slightly higher than the elbow;
• hold the arm against the body, not tightly, just enough to stop the shoulder swinging as you walk;
• apply something cold through a cloth for 15–20 minutes, repeating every two or three hours;
• paracetamol is a reasonable painkiller; ask a doctor about the others;
• take rings and a watch off that hand before the swelling builds.

Do not try to pull the shoulders back to "set the bone", do not pull on the arm and do not test how far it will lift. If bone is visible in a wound, cover it with a clean cloth and leave it alone. Until it is clear whether surgery is needed, it is better not to eat or drink.

What happens at the hospital

The diagnosis is confirmed with a plain X-ray, which shows where the break is, how many fragments there are and how far they have separated. A CT scan is rarely needed: for fractures at the breastbone end, or when the position of the fragments is in doubt.

After that, most people are given a simple supporting sling for two or three weeks, painkillers and rest for the shoulder. The collarbone heals in that position on its own; the fragments do not have to be held perfectly aligned, because this bone remodels remarkably well.

The figure-of-eight bandage, which pulls the shoulders backwards, deserves a separate word. It was once used widely and has largely been abandoned: it does not improve healing, it presses on the vessels and nerves in the armpit, and it is tolerated worse than an ordinary sling. If one is offered to you, ask what exactly justifies it in your case.

A check X-ray is arranged after one or two weeks. By then the sling is usually being weaned off: first at home, then for the whole day.

When surgery really is needed

Only a minority of broken collarbones are operated on, and the decision rests on specific findings rather than on how the shoulder looks:

• an open fracture, or a fragment tenting the skin from inside;
• injury to the blood vessels or nerves of the arm;
• fragments that have separated widely, with the collarbone noticeably shortened;
• the collarbone and the shoulder blade both broken on the same side;
• a fracture that has not healed after several months, or has healed in a position that interferes with daily life and work.

The bone is fixed with a plate and screws or with a pin passed inside it. Surgery speeds the return to loading and lowers the risk of the bone failing to unite, but it brings its own drawbacks: a scar, numb skin below the incision, and sometimes a second operation to remove the plate. That is why it is discussed rather than arranged automatically.

Recovery, the lump and failure to unite

In adults the bone usually unites in six to eight weeks; in children, in three or four. Full loading of the shoulder, lifting, push-ups and a return to contact sport are allowed later, most often at three months and only after a review.

None of that time should be spent doing nothing. While the arm is in a sling, bend and straighten the elbow, wrist and fingers every day: otherwise, by the time the sling comes off the elbow will move worse than the fracture site. Once the pain settles, the doctor will add pendulum movements of the shoulder and gradually widen them. Past fifty, prolonged immobility turns easily into a lasting stiff shoulder, and freeing that up afterwards is harder work than the fracture itself.

Almost everyone is left with a firm, visible thickening at the fracture site. This is healing callus. It is harmless and smooths out a little over time, but as a rule it does not disappear completely. A slight difference in the level of the shoulders often persists too and does not affect how the arm works.

What should raise concern is different: movement still felt at the fracture site after two or three months, pain that does not settle when weight goes through the arm, and an X-ray showing the bone has not joined. This happens more often when the fragments were widely separated, in smokers and in people with diabetes. Failure to unite is treatable, but usually by surgery, so there is no point waiting for it to "come good on its own". Stopping smoking while the bone heals is one of the few things a patient can genuinely do for it.

Online consultation

An online appointment is useful both before and after the X-ray. The doctor will go through how the injury happened and judge, from your description and a photograph of the shoulder, how much it fits a broken collarbone and whether there are signs that mean going in straight away. If the X-ray is already done, they can help you make sense of the report: how far the fragments have moved, and what the argument between sling and surgery actually turns on. It is also worth getting in touch if pain is no better at two weeks, if the arm starts to go numb, if the shoulder stops loosening up after the sling comes off, or if you are unsure when it is safe to train again.

This material is for information only and does not replace medical advice.