Clavicle (Collarbone) Fractures:
Sling or Surgery?

What the clavicle does

The clavicle (collarbone) is the S-shaped bone that runs across the top of the chest, from the breastbone (sternum) to the tip of the shoulder blade (the acromion). It is the only bony connection between the arm and the trunk, acting as a strut that holds the shoulder out to the side and lets the arm move freely. Because it sits just under the skin, it is easy to feel — and when it breaks, the deformity is often visible. In Japanese the injury is called sakotsu kossetsu (鎖骨骨折).

Fractures are usually described by location. The middle third (midshaft) is by far the most common site; fractures of the outer (lateral) end near the shoulder are less common, and fractures of the inner (medial) end near the breastbone are rare. Doctors also note whether the broken ends have shifted out of contact (displaced), whether the bone has shortened, and whether it is broken into several pieces (comminuted).

Who gets it and how

In an 11-year study of 535 clavicle fractures treated at a large hospital in Rome, the clavicle accounted for 2.6% of all fractures and 44% of fractures around the shoulder girdle. Most patients (68%) were male, 81% of fractures were in the middle third and only 2% in the medial third, and traffic accidents were the most common cause. Midshaft fractures were especially dominant in childhood, when more than half were undisplaced (Postacchini et al., Journal of Shoulder and Elbow Surgery, 2002).

The typical mechanism is a direct blow or fall onto the side of the shoulder, which compresses the clavicle along its length until it buckles. A fall onto an outstretched hand can do the same. In Tokyo, bicycle and e-scooter falls, rugby, football, judo, mountain biking, and winter sports trips are familiar scenarios.

Symptoms and warning signs

Typical symptoms are sudden pain over the collarbone, swelling and bruising, a visible or palpable bump, a grinding sensation on moving, and difficulty lifting the arm. People often support the injured arm against the body with the other hand, and the shoulder may look lower or rounded forward.

Most clavicle fractures are isolated injuries, but some features need prompt emergency assessment:

Diagnosis

Diagnosis is usually straightforward: an examination followed by X-rays of the clavicle, often including an angled view to judge displacement and shortening. A CT scan may be used for fractures near either end of the bone, where the joints are hard to see on plain X-rays, or when the injury pattern is complex. Fractures of the inner end and injuries to the joint between the clavicle and breastbone in particular are often assessed with CT, because important blood vessels and the windpipe lie just behind this area.

Treatment options

The choice depends on the location of the fracture, how far the ends have moved, the person's age and activity demands, other injuries, and personal preference. Below is a simplified overview — individual decisions are made with the treating surgeon.

Fracture type	Usual first approach	When surgery is considered
Undisplaced midshaft	Sling for comfort, early gentle movement	Rarely
Displaced midshaft	Sling, or plate/intramedullary fixation after shared decision-making	Marked displacement or shortening, threatened skin, open fracture, multiple injuries, high-demand patients, or non-healing
Outer (lateral) end	Sling if ligaments holding the clavicle down are intact	When the main fragment is pulled upward because the stabilising ligaments are torn
Inner (medial) end	Usually sling	Uncommon; mainly when displaced fragments threaten structures behind the breastbone

Non-operative treatment

Non-operative care means a sling for comfort, pain relief, and gradual return of shoulder movement as pain allows. The fracture usually feels much more comfortable within a few weeks, though full bony healing takes longer. A bump at the fracture site is normal as healing bone (callus) forms, and in displaced fractures some permanent prominence or shortening often remains.

The traditional figure-of-eight bandage, which pulls the shoulders back, is still sometimes used. Evidence comparing it with a sling is limited.

Surgical fixation

The most common operation for a displaced midshaft fracture is open reduction and plate fixation — the fragments are realigned through an incision and held with a contoured metal plate and screws. An alternative is an intramedullary device (a rod or pin inside the bone). Outer-end fractures with torn ligaments are fixed with specialised plates or devices that hold the clavicle down to the shoulder blade.

For many years almost all midshaft fractures were treated in a sling, based on older reports of very low non-healing rates. Later studies of displaced fractures in adults found higher rates of non-healing and dissatisfaction than expected, which prompted randomised trials.

Later pooled analyses have put these results in perspective. Surgery consistently lowers the chance of non-healing, but the average gain in long-term shoulder function is small, and secondary operations are common in both groups — for symptomatic non-union after sling treatment, and for plate removal or wound problems after surgery.

Displaced midshaft	Sling	Plate fixation
Risk of non-healing	Higher	Lower
Early return of function	Slower on average	Often quicker
Function at 1 year+	Similar on average; small differences of uncertain importance
Main downsides	Symptomatic non-union or malunion; visible bump	Operative risks, infection, scar numbness, prominent plate, possible removal surgery

In practice, factors that push the discussion toward surgery include large displacement or shortening, multiple fragments, skin at risk, open fractures, several injuries at once, and patients who need the fastest possible return to heavy work or sport. Smoking and older age are often cited as risk factors for slow healing. Many people with displaced fractures still reasonably choose a sling, knowing that surgery remains an option if the bone does not heal.

Children and adolescents

Clavicle fractures are very common in childhood, and young bones heal quickly and remodel well. Even displaced fractures in adolescents are usually treated without surgery.

Recovery

Recovery timelines vary with age, fracture pattern and treatment, but some general principles apply. Gentle elbow, wrist and hand movement can usually start immediately. Shoulder motion is increased gradually as pain allows, often guided by a physiotherapist. Heavy lifting and strengthening usually wait until X-rays show healing. Contact sports and activities with a risk of falls — rugby, judo, mountain biking — are typically resumed only after the treating doctor confirms solid union, because re-fracture through incompletely healed bone can occur. Driving a car or riding a bicycle should wait until you can control the vehicle safely and react to an emergency.

Persistent pain, clicking or movement at the fracture site several months after injury can be a sign of non-union and is worth reviewing with a surgeon, as it can often be treated successfully.

When to see a doctor

Any suspected collarbone fracture should be examined and X-rayed. Go to an emergency department immediately if the skin is broken or tightly tented, the arm is numb or weak, or you have breathing difficulty. Otherwise, an orthopaedic clinic (整形外科) can usually make the diagnosis on the same day; for displaced fractures, ask whether a review with an orthopaedic trauma or shoulder surgeon would help you weigh the options. Bring any previous X-ray images or reports if you have been seen elsewhere first.