How can you effectively rehabilitate a broken collarbone. What exercises are recommended for collarbone fracture recovery. Which techniques promote healing and restore mobility after a clavicle injury.

Understanding Collarbone Fractures and Rehabilitation

A collarbone fracture, also known as a clavicle fracture, is a common injury that can significantly impact shoulder function and mobility. Proper rehabilitation is crucial for a full recovery and return to normal activities. This comprehensive guide explores effective exercises and techniques to aid in the healing process and restore strength and range of motion following a collarbone fracture.

Key Exercises for Collarbone Fracture Rehabilitation

Rehabilitation exercises play a vital role in recovering from a collarbone fracture. Here are some key exercises recommended by healthcare professionals:

1. Shoulder Blade Squeeze

This exercise helps improve posture and strengthen the muscles between the shoulder blades.

• Stand with arms at your sides
• Squeeze your shoulder blades together
• Avoid raising your shoulders
• Hold for 6 seconds
• Repeat 8 to 12 times

2. Wall Angels

Wall angels are excellent for improving shoulder mobility and strengthening the upper back muscles.

• Stand with your back against a wall
• Raise your hands above your head
• Keeping arms against the wall, bend elbows and lower arms while squeezing shoulder blades together
• Repeat 8 to 12 times

3. Shoulder Flexion (Lying Down)

This exercise helps improve shoulder range of motion and flexibility.

• Lie on your back, holding a wand (PVC pipe or broom handle) with both hands
• Keep elbows straight and slowly raise arms over your head
• Hold for 15 to 30 seconds
• Repeat 2 to 4 times

4. Chest Stretch (Lying Down)

Stretching the chest muscles can help improve posture and reduce tension in the shoulder area.

• Lie on your back with elbows bent and arms out to your sides
• Raise hands above your head until you feel a stretch in your chest
• Hold for 15 to 30 seconds
• Repeat 2 to 4 times

Wand Exercises for Collarbone Fracture Recovery

Wand exercises are particularly effective for improving shoulder mobility and strength after a collarbone fracture. Here are some recommended wand exercises:

1. Wand Exercise – Flexion

• Stand upright, holding a stick in both hands with palms down
• Lift arms over your head, keeping them straight
• Hold for 5 seconds
• Return to starting position
• Repeat 10 times

2. Wand Exercise – Extension

• Stand upright, holding a stick behind your back
• Move the stick away from your back
• Hold for 5 seconds
• Return to starting position
• Repeat 10 times

3. Wand Exercise – External Rotation

• Lie on your back, holding a stick in both hands with palms up
• Keep upper arms on the floor with elbows at your sides, bent 90 degrees
• Use uninjured arm to push injured arm away from your body
• Keep elbow of injured arm at your side
• Hold stretch for 5 seconds
• Repeat 10 times

4. Wand Exercise – Internal Rotation

• Stand with uninjured arm behind your head, holding a stick
• Place injured arm behind your back at waist level, grabbing the stick
• Pull the stick up behind your back
• Hold for 5 seconds
• Return to starting position
• Repeat 10 times

Importance of Proper Form and Guidance

When performing collarbone fracture rehabilitation exercises, it’s crucial to maintain proper form and follow the guidance of healthcare professionals. Why is this so important?

• Prevents further injury or complications
• Ensures exercises target the correct muscle groups
• Maximizes the effectiveness of the rehabilitation process
• Allows for safe progression of exercises as healing occurs

Always consult with your healthcare provider or physical therapist before starting any exercise program. They can provide personalized advice and ensure you’re performing exercises correctly and safely.

Progression and Modifications in Collarbone Fracture Rehabilitation

As you progress through your rehabilitation, your healthcare provider may recommend modifications to your exercise routine. How can you safely progress your exercises?

• Gradually increase repetitions and sets
• Slowly add resistance using light weights or resistance bands
• Incorporate more complex movements as strength and mobility improve
• Listen to your body and avoid pushing through pain

Remember, everyone’s recovery is unique. Your healthcare provider will guide you through appropriate progressions based on your individual healing process and needs.

Complementary Techniques for Collarbone Fracture Recovery

In addition to specific exercises, other techniques can support your recovery from a collarbone fracture. What complementary approaches can enhance your rehabilitation?

1. Ice Therapy

Applying ice to the affected area can help reduce pain and swelling, especially in the early stages of recovery.

2. Heat Therapy

As healing progresses, heat therapy can help improve blood flow and reduce muscle tension.

3. Gentle Massage

Light massage around the collarbone area can help alleviate muscle tension and promote relaxation.

4. Posture Awareness

Maintaining good posture throughout the day can support proper alignment and reduce strain on the healing collarbone.

5. Nutrition

A balanced diet rich in calcium, vitamin D, and protein can support bone healing and overall recovery.

Monitoring Progress and Adjusting Your Rehabilitation Plan

Regular assessment of your progress is essential for a successful collarbone fracture rehabilitation. How can you effectively monitor your recovery?

• Keep a journal of your exercises, pain levels, and any changes in mobility
• Attend all follow-up appointments with your healthcare provider
• Communicate any concerns or unexpected symptoms promptly
• Be patient and celebrate small improvements along the way

Your healthcare provider may adjust your rehabilitation plan based on your progress and healing rate. This personalized approach ensures you’re receiving the most appropriate care throughout your recovery journey.

Returning to Daily Activities and Sports After Collarbone Fracture

As you progress through rehabilitation, you may wonder when you can return to your normal activities and sports. What factors influence this decision?

• Degree of bone healing, as determined by X-rays
• Range of motion in the affected shoulder
• Strength in the shoulder and surrounding muscles
• Pain levels during activity
• Type of activity or sport you wish to return to

Your healthcare provider will assess these factors and provide guidance on when it’s safe to resume specific activities. It’s crucial to follow their recommendations to prevent re-injury or complications.

Gradual Return to Activities

When cleared to return to activities, it’s important to take a gradual approach. How can you safely reintroduce activities?

• Start with low-impact activities and gradually increase intensity
• Use proper form and technique to avoid unnecessary strain
• Wear protective gear as recommended by your healthcare provider
• Listen to your body and stop if you experience pain or discomfort
• Continue with maintenance exercises to support long-term shoulder health

Potential Complications and When to Seek Medical Attention

While most collarbone fractures heal well with proper rehabilitation, it’s important to be aware of potential complications. What signs should prompt you to seek medical attention?

• Increased pain or swelling around the collarbone
• Numbness or tingling in the arm or hand
• Visible deformity or a bump at the fracture site
• Difficulty moving the shoulder or arm
• Signs of infection, such as fever or redness around the fracture site

If you experience any of these symptoms, contact your healthcare provider promptly for evaluation and guidance.

Long-Term Outlook and Maintenance After Collarbone Fracture Rehabilitation

After completing your rehabilitation program, it’s important to maintain the strength and flexibility you’ve gained. What strategies can help ensure long-term shoulder health?

• Continue with a regular exercise routine that includes shoulder strengthening and stretching
• Practice good posture and ergonomics in daily activities
• Avoid activities that put excessive stress on the collarbone until fully healed
• Participate in regular check-ups with your healthcare provider
• Stay active and maintain overall physical fitness

By following these guidelines and continuing to care for your shoulder, you can minimize the risk of future injuries and maintain optimal shoulder function.

Psychological Aspects of Collarbone Fracture Recovery

The recovery process from a collarbone fracture can be challenging not only physically but also mentally. How can you address the psychological aspects of recovery?

• Set realistic expectations for your recovery timeline
• Practice stress-reduction techniques such as deep breathing or meditation
• Seek support from friends, family, or support groups
• Focus on progress rather than limitations
• Consider speaking with a mental health professional if you’re struggling with anxiety or depression related to your injury

Remember that mental well-being plays a crucial role in physical recovery. Don’t hesitate to seek support if you’re experiencing emotional challenges during your rehabilitation journey.

Innovative Approaches in Collarbone Fracture Rehabilitation

As medical science advances, new approaches to collarbone fracture rehabilitation are emerging. What innovative techniques show promise in enhancing recovery?

1. Virtual Reality Therapy

Virtual reality programs can provide engaging and interactive exercises that improve range of motion and strength while reducing perceived pain.

2. Biofeedback

This technique uses sensors to provide real-time feedback on muscle activity, helping patients improve their control and engagement of specific muscle groups.

3. Aquatic Therapy

Exercising in water can provide a low-impact environment for early rehabilitation, allowing for increased range of motion with reduced pain.

4. Vibration Therapy

Controlled vibration applied to the affected area may help improve blood flow, reduce pain, and enhance bone healing.

5. Electrical Stimulation

Low-level electrical currents applied to the muscles around the collarbone can help reduce pain and promote muscle activation.

While these innovative approaches show promise, it’s important to discuss their appropriateness with your healthcare provider before incorporating them into your rehabilitation plan.

Collarbone Fracture: Rehab Exercises | Kaiser Permanente

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Introduction

Here are some examples of exercises for you to try. The exercises may be suggested for a condition or for rehabilitation. Start each exercise slowly. Ease off the exercises if you start to have pain.

You will be told when to start these exercises and which ones will work best for you.

How to do the exercises

Shoulder blade squeeze

slide 1 of 4

slide 1 of 4, Shoulder blade squeeze,

1. While standing with your arms at your sides, squeeze your shoulder blades together. Do not raise your shoulders up as you are squeezing.
2. Hold 6 seconds.
3. Repeat 8 to 12 times.

Wall angels

slide 2 of 4

slide 2 of 4, Wall angels,

1. Start this exercise with your back against a wall and your hands raised above your head.
2. Keeping your arms against the wall, bend your elbows and slowly lower your arms while squeezing your shoulder blades together.
3. Repeat 8 to 12 times.

Shoulder flexion (lying down)

slide 3 of 4

slide 3 of 4, Shoulder flexion (lying down),

To make a wand for this exercise, use a piece of PVC pipe or a broom handle with the broom removed. Make the wand about a foot wider than your shoulders.

1. Lie on your back, holding a wand with both hands. Your palms should face down as you hold the wand.
2. Keep your elbows straight, and slowly raise your arms over your head until you feel a stretch in your shoulders, upper back, and chest.
3. Hold for 15 to 30 seconds.
4. Repeat 2 to 4 times.

Chest stretch (lying down)

slide 4 of 4

slide 4 of 4, Chest stretch (lying down),

1. Lie on your back with your elbows bent. Your arms should be out to your sides, and your arms and elbows should be resting on the surface you are lying on, such as the floor.
2. Raise your hands above your head until you feel a stretch in your chest.
3. Hold for 15 to 30 seconds.
4. Repeat 2 to 4 times.

Follow-up care is a key part of your treatment and safety. Be sure to make and go to all appointments, and call your doctor if you are having problems. It’s also a good idea to know your test results and keep a list of the medicines you take.

Collarbone Fracture Exercises – Tufts Medical Center Community Care

Collarbone Fracture Exercises – Tufts Medical Center Community Care

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Your healthcare provider may recommend exercises to help you heal. Talk to your healthcare provider or physical therapist about which exercises will best help you and how to do them correctly and safely.

• Wand exercise, flexion: Stand upright and hold a stick in both hands, palms down. Stretch your arms by lifting them over your head, keeping your arms straight. Hold for 5 seconds and return to the starting position. Repeat 10 times.
• Wand exercise, extension: Stand upright and hold a stick in both hands behind your back. Move the stick away from your back. Hold this position for 5 seconds. Relax and return to the starting position. Repeat 10 times.
• Wand exercise, external rotation: Lie on your back and hold a stick in both hands, palms up. Your upper arms should be resting on the floor with your elbows at your sides and bent 90 degrees. Use your uninjured arm to push your injured arm out away from your body. Keep the elbow of your injured arm at your side while it is being pushed. Hold the stretch for 5 seconds. Repeat 10 times.
• Wand exercise, internal rotation: Stand with your uninjured arm behind your head holding the end of a stick. Put your injured arm behind your back at your waist and grab the stick. Pull the stick up behind your back by straightening the elbow of your uninjured arm and bending the elbow of your injured arm. Hold this position for 5 seconds and then go back to the starting position. Repeat 10 times.
• Wand exercise, shoulder abduction and adduction: Stand and hold a stick with both hands, palms facing away from your body. Rest the stick against the front of your thighs. Use your uninjured arm to push your injured arm out to the side and up as high as possible. Keep your arms straight. Hold for 5 seconds. Repeat 10 times.
• Wand exercise, horizontal abduction and adduction: Stand and hold a stick in both hands. Stretch your arms straight out in front of you at shoulder height. Keeping your arms straight, swing the stick to one side. Feel the stretch and hold for 5 seconds. Then swing the stick to the other side, feel the stretch, and hold for 5 seconds. Repeat 10 times.
• Shoulder flexion: Stand with your arms hanging down at your sides. Keep your arms straight and lift them in front of you and up over your head as far as you can reach. Hold this position for 5 seconds and then bring your arms back down in front of you and to your sides. Do 2 sets of 15.
• Shoulder abduction: Stand with your arms at your sides. Bring your arms up, out to the side, and toward the ceiling. Hold for 5 seconds. Return to the starting position. Repeat 10 times.
• Horizontal shoulder abduction: Stand with your arms held straight out in front of you at shoulder height. Pull your arms apart and out to the sides as far as possible. Hold your arms back for 5 seconds, then bring them back together in front of you. Repeat 10 times. Remember to keep your arms at shoulder height throughout the exercise.
• Shoulder extension: Stand with your arms at your sides. Move the arm on your injured side back, keeping the arm straight. Hold this position for 5 seconds. Return to the starting position and repeat 10 times.
• Scapular active range of motion: Stand and shrug your shoulders up and hold for 5 seconds. Then squeeze your shoulder blades back and together and hold 5 seconds. Next, pull your shoulder blades downward as if putting them in your back pocket. Relax. Repeat this sequence 10 times.
• Side-lying horizontal abduction: Lie on your uninjured side with the arm on your injured side relaxed across your chest. Slowly bring this arm up off the floor so that your hand is pointing toward the ceiling. Keep your arm straight as you do this. Do 2 sets of 15. Hold a weight in your hand as the exercise becomes easier.
• Prone shoulder extension: Lie on your stomach on a table or the edge of a bed with the arm on your injured side hanging down over the edge. Slowly lift your arm straight back and toward the ceiling. Do not bend your elbow. Return to the starting position. Do 2 sets of 15. As this becomes easier, hold a weight in your hand.
• Single-arm shoulder abduction: Stand with your arms at your sides, your palms resting against your sides. Lift the arm on your injured side out to the side and toward the ceiling. Keep your arm straight. Hold the position for 5 seconds and then bring your arm back to your side. Repeat 10 times. Add a weight to your hand as the exercise gets easier.
• Resisted shoulder internal rotation: Stand sideways next to a door with your injured arm closest to the door. Tie a knot in the end of the tubing and shut the knot in the door at waist level. Hold the other end of the tubing with the hand of your injured arm. Bend the elbow of your injured arm 90 degrees. Keeping your elbow in at your side, rotate your forearm across your body and then slowly back to the starting position. Make sure you keep your forearm parallel to the floor. Do 2 sets of 8 to 12.
• Resisted shoulder flexion: Holding tubing connected to a door knob at waist level, face away from the door, keep your elbow straight and pull your arm forward. Do 2 sets of 15.
• Resisted shoulder extension: Stand facing a door. Tie a knot in the end of the tubing and shut the knot in the door at shoulder height. Use the hand on your injured side to hold the tubing at shoulder height. Pull your arm back, keeping your arm straight. Do 2 sets of 15.
• Resisted shoulder external rotation: Stand sideways next to a door with your injured arm farther from the door. Tie a knot in the end of the tubing and shut the knot in the door at waist level. Hold the other end of the tubing with the hand of your injured arm. Rest the hand of your injured arm across your stomach. Keeping your elbow in at your side, rotate your arm outward and away from your waist. Slowly return your arm to the starting position. Make sure you keep your elbow bent 90 degrees and your forearm parallel to the floor. Repeat 10 times. Build up to 2 sets of 15.

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Exercises after a fracture of the collarbone – Rehabilitologist Osteopath Maxim Podduev (Kyiv)

Shoulders, shoulder blades, chest, Rehabilitation

The effectiveness of treatment and recovery after a fracture of the collarbone depends on many factors: the severity of the injury, the professionalism of doctors, the age of the patient and proper rehabilitation. These exercises are specially designed for soft tissue rehabilitation and effective restoration of range of motion in the shoulder girdle and limb.

Clothing must be loose, it is advisable to remove shoes. All exercises (especially the first days) should be performed smoothly and gradually. Remember the important principle: “Tolerate mild pain, do not allow severe pain.”

Stick Curl

Stand straight with your feet shoulder-width apart. Hold the stick with both hands, palms facing the floor. Raise your arms as high as possible above your head and hold for 5 seconds. Return to starting position. Repeat 10 times.

Stick Extension

Stand straight with your feet shoulder-width apart. Take the wand with both hands behind your back. Move your arms as far away from your back as possible and hold for 5 seconds. Repeat 10 times.

Lying spin

Lie on your back on the floor. Hold the wand with both hands, palms facing. Shoulders and elbows rest on the floor. Use your good hand to rotate the patient in different directions. Hold your hand in the maximum tilt position for 5 seconds. Repeat 10 times.

Stick Stretch

Stand straight with your feet shoulder-width apart. Take the wand behind your head with your healthy hand, take your sore hand behind your back and take the other end of the wand. With your healthy hand, pull the wand up, thereby increasing the flexion of the sore arm. Hold for 5 seconds. Repeat 10 times.

Vertical rotation

Stand straight with your feet shoulder-width apart. Take the wand with both hands, palms away from you. With your healthy hand, move your injured hand to the side as much as possible. Try to lift as high as possible, hold for 5 seconds. Repeat 10 times.

Horizontal rotation

Stand up straight, hold the stick with both hands and raise it to shoulder level. Rotate the wand to the side until a stretch is felt. Hold the reached position for 5 seconds. Then repeat the exercises on the other side. Repeat 10 times.

Shoulder Curl

Stand straight with your feet shoulder-width apart and your arms hanging freely. Raise your arms straight in front of you and as high as possible. Hold for 5 seconds and then return to the starting position. 2 sets of 15 reps.

Vertical spread

Stand straight, feet shoulder-width apart, arms hanging freely. Take your hands to the sides (as shown in the figure) and lift as high as possible. Hold for 5 seconds. Return to starting position. Repeat 10 times.

Horizontal spread

Stand up straight and raise your straight arms to shoulder level. Spread them apart as far as possible. Hold for 5 seconds, then bring your hands back in front of you. Repeat 10 times. Try not to put your hands down throughout the exercise.

Shoulder Extension

Stand straight with your feet shoulder-width apart. Extend the arm being developed back (as shown in the figure) and hold for 5 seconds. Then return to the starting position. Repeat 10 times.

Shoulder rotation

Raise your shoulders up and hold for 5 seconds. Squeeze your shoulder blades together and hold for 5 seconds. Then pull the shoulder blades down, as if trying to put your hands in the back pockets of your trousers, and also hold for 5 seconds. Repeat 10 times each action.

Lying arm abduction

Lying on the healthy side, the arm to be trained is relaxed in front of you. Slowly raise the arm being developed up as far as possible. 2 sets of 15 reps. Take a small weight in your hand when the exercise is no longer difficult.

Shoulder Raise

Lie on your stomach on a table or on the edge of a bed with your arm hanging down. Slowly raise your arm back and up without bending your elbow. Return to starting position. 2 sets of 15 reps. Take a small weight in your hand when the exercise is no longer difficult.

Shoulder Abduction

Stand up straight, arms at your sides, palms facing you. Take the straight, developed hand to the side, and then as high as possible. Hold for 5 seconds, return to starting position. Repeat 10 times. Take a small weight in your hand when the exercise is no longer difficult.

Internal rotation

Stand with your working arm towards the door. Fasten the end of the expander behind the door at waist level, take the other end of the expander with your developed hand and bend it at the elbow at 90 degrees. Keeping the elbow pressed, rotate the forearm from the door to the body, and then slowly return to the starting position. It is important to keep the forearm parallel to the floor. 2 sets of 8 to 12 reps.

Flexion resistance

Stand with your back to the door. Fasten the end of the expander behind the door at waist level, take the other end of the expander with your developed hand. Pull your arm forward, bending it at the shoulder. 2 sets of 15 reps.

Extension resistance

Stand facing the door. Fasten the end of the expander behind the door at shoulder level, take the other end of the expander with your developed hand. Pull your arm back, extending it at the shoulder joint. 2 sets of 15 reps.

External Rotation

Stand with your working arm away from the door. Fasten the end of the expander behind the door at waist level, take the other end of the expander with your developed hand. Bend it at the elbow at 90 degrees and lay it on your stomach. Keeping your elbow pressed in, rotate your forearm away from the door and out. Then slowly return your hand to its original position. It is important to keep the forearm parallel to the floor. 2 sets of 15 reps.

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Clavicle Fracture – Physiotherapist

Clavicle fractures are very common in adults (2-5%) and children (10-15%) and account for 44-66% of all shoulder girdle fractures. This is the most common fracture among pediatric patients. Most often, a clavicular fracture is caused by a fall on the lateral side of the shoulder. X-rays confirm the diagnosis and help in further examination and treatment. While most clavicle fractures are treated conservatively, severely displaced or comminuted fractures may require surgical fixation [1].

Contents

Clinically relevant anatomy

The clavicle lies under the skin between the sternum and shoulder blade and connects the upper limb to the body. [1]

The clavicle, the first of the bones in the human body, begins to ossify in the connective tissue membrane directly from the mesenchyme as early as the fifth week of fetal life. Like all tubular bones, the clavicle has both a medial and a lateral epiphysis, but lacks a distinct medullary cavity. The epiphyseal plates of the medial and lateral epiphyses of the clavicle do not fuse until the age of 25. The clavicle differs from tubular bones in its characteristic S-shaped double curvature, convex in the medial direction and concave in the lateral direction. This shape allows the clavicle to serve as a support for the upper limb, as well as to protect the axillary vessels and the brachial plexus and ensure their passage from the medial side. [2]

Etiology

Young patients suffer fractures due to moderate or high energy injuries such as car accidents or sports injuries, while older people suffer from low energy falls.

Traditionally, the cause of the fracture was considered to be a fall onto an outstretched arm, but it has been found that most often the clavicle is injured as a result of applying a direct compressive force directly to the shoulder. [2] Approximately 87% of clavicle fractures result from a fall directly on the lateral side of the shoulder. [1

Trauma mechanism.

1. Fall on a straight arm.
2. Shoulder drop.
3. Direct blow to the shoulder.

Epidemiology

Clavicle fractures account for 2% to 10% of all fractures. Clavicle fractures [1]

• Found in 1 in 1000 people per year
• Are the most common fractures among pediatric patients
• Approximately two thirds of all clavicle fractures occur in men.
• There is a bimodal distribution of clavicle fractures, with 2 peaks occurring in men under 25 years of age (sports injuries) and patients over 55 years of age (falls).
• The middle third of the clavicle breaks in 69% of cases, the distal third in 28%, and the proximal third in 3%. [1]
• They account for up to 10% of all sports-related fractures and have the third longest return to sport, with up to 20% of athletes with such injuries not returning to sport. [3]

The clavicle is the only bony link between the upper limb and the trunk Due to its superficial subcutaneous location and the numerous ligamentous and muscular forces applied to the clavicle, this bone breaks easily. The middle third of the clavicle is the thinnest area that does not have ligamentous attachments, so its fractures are most likely. [1]

Classification

Clavicle fractures are usually described according to the Allman classification system, which divides fractures into 3 groups based on location. The system was later revised by Nier (Group II was further classified into 3 types). [1

1. Group I: Fractures in the middle third of the diaphysis (most common),
2. Group II: Fractures of the distal or lateral third. Frequent site of nonunion.
3. Group III: Fractures of the proximal or medial third.

The Robinson classification was more specific for different types of fractures in the middle third, while the Craig classification was for fractures of the lateral third. [4]

Clinical History and Physical Examination

The patient has the following symptoms and signs:

• The patient can hold the injured limb with a healthy hand.
• Patient may report clicking or popping sound when injured.
• The shoulder may appear to be shortened relative to the opposite side and dropped.
• There may be swelling, ecchymosis, and tenderness over the clavicle.
• Abrasion over the clavicle may be noted, indicating that the fracture occurred by a direct mechanism.
• With careful manipulation, the sound of crepitus from rubbing the ends of the fracture against each other can be noted.
• Difficulty or decreased breathing on the affected side may indicate lung injury, such as pneumothorax.
• Palpation of the scapula and ribs may reveal associated lesions.
• Stretching and pallor of the skin at the site of a fracture may indicate an open fracture, which most often requires surgical stabilization.
• Non-use of the hand of the affected side is a neonatal manifestation.
• Associated distal nerve dysfunction indicates damage to the brachial plexus.
• Decreased heart rate may indicate damage to the subclavian artery.
• Venous congestion, discoloration and swelling indicate subclavian vein damage. [5]

Differential diagnosis

Diagnosis is based on the patient’s history and physical examination. [6]

The differential diagnosis of a clavicle fracture includes acromioclavicular joint injury, rib fractures, scapular fracture, shoulder dislocation, rotator clavicle injury, and sternoclavicular joint injury.

Potential complications of clavicle fractures, including pneumothorax, brachial plexus injury, and subclavian vessel injury, should also be fully assessed. [1]

Depending on the severity of the clavicle fracture, laboratory tests are ordered. If vascular damage is suspected, a general clinical blood test (CBC) should be performed to check hemoglobin and hematocrit values. If lung injury is suspected or detected, an arterial blood gas test and an exhaled posterior-anterior chest x-ray should be performed. Imaging studies are also performed to evaluate a clavicle fracture, such as:

• Clavicle and shoulder X-ray
• Computed tomography (CT) with 3-dimensional (3-D) reconstruction
• Arteriography
• Ultrasound scanning [5]

Medical treatment

Clavicle fracture is treated surgically or conservatively depending on the location (middle, distal, proximal), nature (displaced, non-displaced, comminuted) of the fracture, presence of open or closed injury, age and neurovascular disorders. [3]

Traditionally, clavicle fractures have been treated conservatively with immobilization with a bandage and subsequent rehabilitation. For non-displaced fractures, such treatment gives satisfactory results, but for fractures of the middle part of the clavicle with displacement, it leads to an increase in the likelihood of re-injury, time to return to sports and the development of suboptimal shoulder function secondary to malunion and shortening of the clavicle with subsequent scapular thoracic dyskinesia. It has also been shown that conservative treatment of lateral displaced fractures in an athlete results in high rates of nonunion and subsequent impairment of shoulder function.

Thus, surgery is performed for lateral fractures with displacement in athletes, and is also recommended for fractures of the middle third of the diaphysis with complete displacement, shortening > 2 cm, or the presence of splinters. [3]

Surgical treatment

The main goal of this treatment is to achieve fusion of the clavicle in a normal anatomical position.

Indications for surgical treatment of clavicle fractures: [7]

1. Severe displacement caused by crushing followed by angular bending and severe stretching of the skin, threatening its integrity, and in the absence of a response to closed reduction.
2. Symptomatic nonunion such as shoulder girdle dysfunction, neurovascular disorders.
3. Neurovascular injury or impairment that progresses or does not recover after closed fracture reduction.
4. Open fracture.
5. Type II distal clavicle fracture (displaced).
6. Multiple injuries where mobilization is desired and closed methods of immobilization are not practical or possible.
7. “Floating shoulder”
8. Inability to tolerate closed immobilization, eg neurological problems of parkinsonism, convulsive disorders.
9. Aesthetic reasons
10. Relative readings include shortening greater than 15-20 mm and displacement greater than the width of the clavicle.

Surgical procedures include:[8]

• Internal fixation with plates and screws. (most common)
• Intramedullary (MI) fixation.

For displaced fractures of the middle shaft, removal of metal structures is recommended if intramedullary nails are used, but not fixation plates. While in case of a lateral fracture of the clavicle with a displacement, the removal of metal structures was carried out with fixation with a hook-shaped plate, rods, cerclage and tie wire, but not with fixation with plates that did not capture the ACJ, and with a suture. These methods of fixation are necessary for a lateral fracture of the clavicle, as they capture the acromioclavicular joint and various ligaments that can be damaged during a fracture. [3]

Physical Therapy / Rehabilitation

The main goal of rehabilitation is to improve and restore the function of the shoulder for everyday, professional and sports activities. The rehabilitation protocol may differ slightly in the first few weeks depending on the main approach to treatment, i. e. conservative or surgical.

Rehabilitation after conservative treatment

In case of non-operative treatment, the healing of fractures may take longer. With conservative treatment, midshaft clavicle fractures usually heal between 18 and 28 weeks after injury. Therefore, it is necessary to regularly check whether the fracture site heals correctly or not. Thus, the rehabilitation protocol may also vary depending on individual comorbidities.

In the first few weeks (2-4 weeks) of an acute clavicle fracture, the POLICE principle can be used, which is explained below in the context of a clavicle fracture.

Protection

The patient’s shoulder is immobilized in a bandage or 8-band until clinical union is achieved. It is believed that the 8-bandage prevents or reduces the secondary shortening of the fracture during its healing. But it is associated with great discomfort and pain, including nerve compression with temporary paralysis of the brachial plexus and obstruction of venous blood return. [9]]Studies have shown that in the treatment of clavicle fractures, there is no difference between the two methods in terms of healing time and percentage of nonunions. Thus, a brace is commonly used, and immobilization in internal rotation for 2-4 weeks is recommended.[9] [1] The bandage is worn during the day, except for exercise and personal hygiene. The patient independently decides to leave it at night or not, but care should be taken. [9]

During severe coughs and sneezes, patients should also be careful (since respiratory excursions can cause movement of the collarbone) to avoid them as much as possible, and to learn active-passive coughing techniques.

Optimal loading

Therapy/Consultation within 1-2 weeks after injury:

• Using a shoulder brace as mentioned above (must be worn most of the time).
• Self-mobilization is required to avoid stiffness of the elbow and wrist joints several times a day.
• Raising the elbow above shoulder height may be painful.
• During the first 1-2 weeks, the development of the range of motion of the shoulder is limited to pendulum exercises.
• Teaching correct neck position and range of motion.

Therapy/Counseling 3 to 6 weeks after injury:

• Decreased bandage wear time (use in independent position).
• Return to light daily activities using the arm and shoulder.
• During the first 6 weeks, active-passive movements in the shoulder joint are recommended with an amplitude of active movements in one plane with a deviation of no more than 90 degrees.
• Scapular mobilization exercises are provided.
• Isometric Shoulder Exercise with Tolerable Resistance Beginning at 4-6 weeks
• Heavy exercise should be avoided for a full 6 weeks.
• A gradual increase in the intensity of cardiovascular endurance training can begin with a brisk walk and a stationary bike.

Therapy/Counseling between 6 and 12 weeks after injury:

• As a rule, after 6 weeks with tolerable passive BP, active and active-passive range of motion of the shoulder in all planes is allowed.
• Progressive resistance exercises (isotonic) for the stabilizing muscles of the scapula, biceps, triceps, and rotators are given after 6 weeks.
• Arm stress should be avoided until clinical healing of the fracture.
• Sports and activities that require arm loading and use are usually suspended until pain subsides and radiological signs of progressive fracture consolidation are obtained, usually after 6 to 12 weeks.

Therapy/Counseling after 12 weeks or more:

Start a more intense strengthening program, cardiovascular endurance training as tolerated, and progressive athletic training.

• The period of return to specific sports is determined by the physiotherapist using functional tests based on the needs of the patient, according to which a specific progressive sports training is planned. [12]
• Preliminary activities such as muscular endurance exercises (upper body ergometer) and cardiovascular endurance exercises (treadmill, cycling) may be prescribed.
• Contact sports should be avoided for 3-4 months. Return to full contact sports requires that the athlete demonstrate radiographic evidence of bone healing, no tenderness to palpation, full range of motion, and normal shoulder muscle strength [9][1].

Rehabilitation after surgery

• For fractures of the middle third of the clavicle, the initial open reduction with internal fixation with a plate (fixation compression plate) and screws provides more stable fixation and immediate postoperative mobilization. [7] With surgical treatment, fractures heal faster than with conservative treatment. Thus, the duration of immobilization is shorter compared to conservative treatment, and mobilization and strengthening exercises can be prescribed earlier. A program similar to conservative treatment to increase the intensity of exercise can be prescribed, but much earlier.

Return to sports

According to a systematic review by Robertson and Wood in 2016, the majority of patients with acute clavicle fractures return to sports, with about four-fifths of all patients able to return to their pre-injury level of sports activity. [3]

Studies have shown that the period to return to sport is from 6 to 12 weeks with surgery and 3-4 months with conservative treatment. [3] [1]

Conservative treatment of displaced midshaft fractures has been shown to reduce the percentage and increase the time to return to sport compared with surgery. Conservative treatment of displaced midshaft fractures can lead to re-fracture (more than half of cases) and delayed surgery (more than a quarter of cases). In terms of surgical technique recommendations for midshaft fractures, both plate fixation and intramedullary screws demonstrated nearly 100% recovery and similar recovery times. [3]

For lateral displaced clavicle fracture, surgical management is standardized and shows an increase in percentage and a reduction in return time. Non-ACC plate fixation and suture fixation provide better outcomes for athletes than other methods of fixation, which is likely due to preservation of ACC function. A lateral fracture of the clavicle is more difficult than a fracture of the middle shaft, so the outcome of the latter is better. [3]

Conclusion

• Patients with collarbone fractures are best referred to an interprofessional team that includes an orthopedic surgeon, an emergency room physician, a general practitioner, a nurse practitioner, and a physical therapist.
• Immediate orthopedic consultation should be performed for patients with neurovascular disease, open fractures, skin stretch, or any skin tear near the fracture.
• For non-displaced fractures, non-surgical treatment is the first choice.
• While surgical treatment is generally accepted for lateral displaced fractures in athletes and is recommended for midshaft displaced fractures. Surgical treatment results in improved percentage and time of return compared to conservative treatment.