Clavicle Protrusion: Causes and Treatment
A protruding clavicle is most commonly caused by a clavicle fracture with displacement, and treatment depends on the degree of displacement—nondisplaced fractures can be managed with a sling, while displaced fractures with >1.5cm shortening or complete displacement require surgical fixation to prevent nonunion and restore function. 1
Primary Causes of Clavicle Protrusion
The most likely explanation for a newly prominent clavicle is a displaced midshaft clavicle fracture, which accounts for 69-82% of all clavicle fractures and typically results from direct trauma to the shoulder or a fall. 2 The fracture creates what is described as a "Z" deformity due to the pull of the pectoralis major and the weight of the arm, causing the bone fragments to shift and become more visible. 3
Other potential causes include:
- Lateral (distal) clavicle fractures with disruption of the coracoclavicular ligament complex, which allows significant displacement 1
- Malunion from a previous fracture that healed in an abnormal position, creating permanent deformity 3
- Nonunion (failure to heal), which occurs in up to 15% of displaced fractures managed conservatively 3, 1
Diagnostic Evaluation
Obtain upright radiographs rather than supine films, as they better demonstrate the true degree of displacement and shortening. 1 The physical examination will typically reveal visible deformity, tenderness, and possibly crepitus at the fracture site. 4
Key radiographic findings that determine treatment:
- Displacement >100% (no cortical contact between fragments) requires urgent orthopedic follow-up 1
- Shortening >1.5cm is an indication for surgical treatment 1
- Comminution (multiple fragments) increases risk of nonunion 2
Treatment Algorithm
For Nondisplaced or Minimally Displaced Fractures
Use a simple sling for immobilization rather than a figure-of-eight brace, as this is the preferred method according to the American Academy of Orthopaedic Surgeons. 1 These fractures have excellent outcomes with conservative management and very low nonunion rates. 3, 2
Conservative management protocol:
- Sling immobilization for 4-6 weeks 5
- Regular acetaminophen for baseline pain control with carefully titrated opioids as needed 5
- Discontinue sling by 4 weeks for routine activities, but avoid lifting, pushing, or pulling 1, 5
- Full weight-bearing activities allowed at 8-12 weeks based on radiographic healing 1, 5
For Displaced Fractures
Surgical treatment is indicated for displaced midshaft fractures with shortening exceeding 1.5cm, as this provides higher union rates and better early patient-reported outcomes compared to conservative management. 1 Nonsurgical management of widely displaced fractures results in nonunion rates up to 15%, symptomatic malunion affecting shoulder strength and function, and cosmetic concerns. 3, 1
Surgical options include:
- Plate fixation with manufacturer-contoured anatomic clavicle plates, which have lower rates of implant removal or deformation 1
- Anterior inferior plating may result in lower implant removal rates compared to superior plating 1
- Intramedullary nailing provides equivalent long-term clinical outcomes to plate fixation with similar complication rates 1
Displaced lateral fractures with disruption of the coracoclavicular ligament complex also require surgical fixation, as these will not heal properly without stabilization. 1, 6
Important Considerations
Smoking significantly increases nonunion rates and leads to inferior clinical outcomes, so smoking cessation counseling is critical for all patients with clavicle fractures. 1
Surgical treatment provides faster functional recovery and earlier return to work, which may be particularly important for active adults, though long-term patient-reported outcomes and satisfaction are similar between surgical and nonsurgical approaches. 3, 1
Do not use low-intensity pulsed ultrasonography (LIPUS) for nonsurgical management, as it does not accelerate healing or reduce nonunion rates. 1
Post-Treatment Rehabilitation
Rehabilitation should include:
- Muscle strengthening exercises initiated after appropriate healing time 1
- Long-term continuation of exercises to restore full shoulder function 1
- Patient education about pain management strategies 1
- Monitoring for signs of complications requiring medical attention, including persistent pain, loss of motion, or signs of infection after surgery 1