Welcome back to Mangled Mondays, where every Monday for the next few months I’ll be posting an Injury Profile to keep you well-informed — and your characters absolutely miserable.
For previous episodes, why not check out [the Mangled Mondays tag]?
What Is It?
The clavicle, or collarbone, is a very reliable bone in a very delicate place. The clavicle helps stabilize the shoulder and form the structure of the shoulder girdle. It serves as the anchor for some of the strongest muscles in the neck, including the sternocleidomastoid (SCM or “strap”) muscles, which help hold up the head.
The clavicle also serves a second purpose. The clavicle provides bony protection for the subclavian artery and vein and the brachial plexus nerve bundle, which are hidden beneath it. The arteries proceed from the aorta, the biggest artery in the body, behind the clavicle and toward the arm, where they become the humeral artery and vein; the veins come from the arm and connect to the superior vena cava before entering the right ventricle of the heart.
Fractures of the clavicle, then, are not only extremely painful (because of the forces applied to it by the muscles). Clavicle fractures can kill, since bone fragments can lacerate the subclavian artery. Even if they do not lacerate, they can compress or cause other forms of circulatory havoc.
Neurovascular compromise with a clavicular fracture isn’t overwhelmingly common when the force applied is blunt, as from a fall or a strike with a bat. However, when that force is penetrating, such as a gunshot wound, the likelihood of displacement of the fracture – and thus of damage to the artery-vein-nerve package known as the neurovascular bundle – is much higher.
Displaced vs. Nondisplaced
A displaced fracture is one in which the ends of the bone have shifted out of their original position, whereas a nondisplaced fracture is one in which the bone is broken but remains unmoved.
Nondisplaced fractures are the more common type of clavicular fracture in younger kids, and heal quite well with conservative management; that is, without surgery or other invasive procedure. They also run no risk of damaging the blood vessels, since bone fragments are not created.
Displaced fractures, however, cause additional risk, and the majority of clavicular fractures in adults are displaced.
Bone fragments can be driven into the subclavian artery and vein or the brachial plexus (nerve), and bone fragments can even puncture the lung if enough force was applied to the clavicle. (See Part 2.2 Penetrating Trauma > Chest entry on Tension Pneumothorax.)
Fractures that drive the ends of the bone through the skin, known as open or compound fractures, will always require surgery, as will tenting fractures, where the bone end puts pressure on the skin and pulls it taut.
Comminuted fractures are those that shatter the bone, breaking it into three or more pieces. Comminuted fractures are common in clavicular fractures.
If the character has an open, tenting, or comminuted clavicular fracture, they will need surgery (discussed below) to repair it.
- Tenderness over the clavicle.
- Bone crepitus (a crunching feeling when pressing on the bone caused by bone ends scraping).
- Shortening of the clavicle (displaced fractures).
- Deformity of the clavicle (displaced fractures).
- Swelling over the fracture site.
- Pain, worsened by moving the arm, chest, or neck on the same side.
- Inability to move the affected arm due to pain.
- If the nerve is damaged: pain, numbness, or inability to move the arm and hand on the affected side.
How Does It Happen?
Most commonly, the clavicle is fractured.. [Tumblr Mobile: Read More]
…when the character falls onto their shoulder or outstretched arm. However, car crashes are a common cause, and, of course, characters may suffer direct blows to the clavicle with any blunt instrument.
Less frequently, the clavicle is broken by a sharp or penetrating force, such as a gunshot wound or stab wound. These fractures tend to be comminuted (shattered), and these injuries are more likely to also produce neurovascular problems for the arm.
All clavicle fractures should be treated by the application of sling and swathe to the affected arm, which reduce the risk of motion (and therefore pain).
Characters will require X-rays to evaluate the structure of the bone, so they should be taken to a clinic or emergency department. Characters with other forms of trauma, or whose clavicle fracture was caused by a gunshot wound, should go by ambulance if possible.
Surgery / Hospitalization
Nondisplaced fractures are managed without surgery.
Displaced fractures, such as a comminuted fracture where the bone fragment is fairly small and the break is almost nondisplaced, may be managed conservatively as well.
Displaced fractures requiring surgery due to damage to the neurovascular bundle, or to gross deformity of the bone, will be managed with surgery under general anesthetic; this can wait for several hours or even a day or two after the injury if the fracture is not threatening the neurovascular bundle in the arm.
The procedure to fix a clavicle fracture is called an ORIF (open reduction with internal fixation, pronounced oh-riff; this procedure is the surgical reduction of any fracture, not just of the clavicle). After exposing the fractured bone, bone fragments will be moved back into place, and plates and screws will be installed to keep the bone ends in alignment.
Most characters can get by with a week’s worth of analgesia with a moderate opiate, such as hydrocodone or oxycodone, and acetaminophen or ibuprofen after that, though they may have their eye set on the clock at first, aching for the moment they can take the next dose.
In the Austere Environment
A sling and swathe is usually the only available treatment. A well-meaning individual may attempt to set the bone and use some form of rudimentary clamp over the skin to hold the bone fragments in place in case of displaced fractures, but this is unusual.
The Rocky Road to Recovery
Characters will retain the use of the opposite arm; leg function and neurocognitive capabilities are not damaged.
If no damage has been done to the nerves of the arm, the hand of the affected arm can be moved and used (for example, can flick through images on a phone) because what is damaging is movement of the upper arm, not the hand.
Gross movement of the affected arm is restricted by the sling and swathe setup. Characters cannot lift or shift with their affected arm for weeks.
Gun-wielding characters may be able to lift and fire a gun, but the recoil is likely to refracture the clavicle, and their ability to aim will be significantly reduced.
Characters with well-treated fractures may have no permanent disabilities, but some room exists for disabilities to become permanent.
The most common complication is malunion of the bone, in which the bone ends grow together imperfectly from a displaced fracture. This can be aesthetically displeasing (with the affected area lumpy or deformed), and, if the bone shortens because of displacement, can reduce range of motion in the affected arm.
Arthritis is always a possibility, especially in a poorly healed fracture.
Features of Recovery: Hospital Stay
Unless neurovascular trauma was present, it’s unlikely that the character will require hospital admission.
Features of Recovery: PT/OT
Once the fracture is fully healed, physical therapists will assist the character with rotation and motion exercises to make sure that the arm regains its flexibility and strength. This is regardless of whether the fracture required surgical intervention or not.
In addition, the character will be encouraged to start performing weight-bearing exercises such as light weightlifting in order to help them regain strength in the affected arm.
The New Normal
The character may move through life as though nothing has happened, or may have some visible deformity forever.
Characters living with malunion, or poor fusion, of bone ends will not only have limited range of motion of the shoulder, but will likely have chronic pain.
Rarely, a character with a clavicular fracture can be at risk for impingement of the brachial plexus: the character’s bone or tissue forms a callus that entraps the brachial plexus, the major nerve bundle under the clavicle. As this develops, the character might experience increasing pain, numbness, tingling, or weakness in the arm.
Characters who rebreak their clavicle, even in the New Normal phase after bone healing has occurred, are at elevated risk of poor healing, loss of range of motion, and nonunion (failure of the bone ends to fuse) of the fractures.
Total Recovery Time (Typical)
Simple / nondisplaced: 2–3 months; 3–6 weeks in children
Complex / displaced: 4–6 months
The bone may protrude through the skin (compound fracture).
The clavicle may be grossly deformed (displaced fracture).
The clavicle may appear to have nothing significantly wrong with it, especially if the character is wearing a shirt.
Bones tend to crack or crunch as they break.
Bone crepitus, the moving of bone ends, sounds like grinding.
Imagine having the ends of your bones ground against each other. That’s how crepitus feels.
If the skin was broken, for surgery or by the injury, the wound may itch as it heals.
ORIF, as above.
- Clavicular fractures are mighty painful, and take a character’s arm out of commission for weeks.
- In severe cases, damage to the subclavian artery or vein or brachial plexus is possible.
- However, they generally have strong recoveries and good outcomes.
- The worse the fracture, the longer the healing time and the more likely they are to need surgery.
- The hand will work while the arm is in a sling, but the arm must be immobilized to prevent reinjuring the clavicle as it heals.
xoxo, Aunt Scripty
This post is an excerpt from Blood on the Page Volume One: A Writer’s Compendium of Injuries. The book details thirty-one injuries with which to maim, mangle, and maul your characters, as well as nine indispensable articles of Wound Wisdom covering everything from burn stages to suture selection.
The book will be out 10/23, just in time for NaNoWriMo!