Clavicle fractures
Clavicle fractures are common adult injuries,
they often may heal better with surgical fixation.
Clavicle fractures
In Queenstown this is a common mountain biking injury. It frequently occurs when a rider goes over the handlebars landing onto the tip of the shoulder. In the uninjured shoulder the clavicle acts as a strut between shoulder girdle and the rest of the body and easily susceptible to injury.
The middle clavicle is pulled upwards by the neck muscles and tip drags downwards by the shoulder. This causes an obvious visible deformity and shortening of the shoulder. Occasionally the skin may be threatened by a sharp tip of bone, or ribs fractures may cause lung puncture in high energy injuries.
Injury types
Clavicle fractures are described by which part of the bone is affected:
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Middle 1/3: account for about 80%. They usually displace upwards and shorten.
lateral 1/3: less than 20%. They occur in the region of the coracoclavicular ligaments and AC joint. These injuries have a higher chance of not healing.
Medial 1/3: less than 5% of injuries. These can be life-threatening injuries if they affect the windpipe or major neck blood vessels. They are rare and usually heal otherwise. These are also known as distal 1/3.
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Should I have surgery?
Not all clavicle fractures require surgery. Fractures in the midshaft region only benefit from fixation when they are significantly displaced or shortened. A fracture in good position will heal in a sling most of the time.
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Displacement of the entire width of the bone, or greater than 10% shortening do better with fixation. Multiple comparision trials have shown benefits in strength, function and rate of healing. Plate fixation may decrease the rate of non-union by as much as 3-fold. However many fractures may still unite given enough time.
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Distal clavicle fractures in healthy people generally merit stabilisation as more than a 1/3 won't heal by themselves. They frequently involve rupture of the coraco-clavicular ligaments similar to AC joint dislocations. These injuries may require additional fixation or ligament reconstruction.
Surgery
The most common method of fixation for clavicle fractures is plate and screws. These are per-contoured, low-profile plates with compression and fixed angle screws. They are usually made of titanium alloy.
The surgical approach is normally a horisontal incision along the clavicle, or in distal fractures in line with a bra-strap/singlet.
Particularly in distal clavicle fractures fixation may be difficult in the small lateral piece. Fixation is achieved using small locking screws or tape around the fragment. Sometimes fixation to the coracoid with synthetic ligament is required.
Rarely fixation can only be achieved by hooking the plate under the acromion of the shoulder blade. In this circumstance later surgery is required to remove the plate before full shoulder mobilization is recommended.
What are the risks of surgery?
Fixation of the middle and distal 1/3 of the clavicle is common with low complication rates. There are standard surgical risks including medication reactions, blood clots, stroke/death. These are all of course very rare and most patients have a short and reliable surgery and recovery. There are also risks of anaesthetic that your anaesthetist will discuss.
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There have been very rare reports of risk to the axiallary blood vessels beneath the clavicle. In experienced surgical hands the risk of this is less than most other types of orthopaedic surgery. For example the number of nerve or blood vessel injuries in clavicle surgery is much less than that published for knee arthroscopy.
Frequently patients have grazes over the tip of the shoulder the increase the risk of infection. Infection of the fixation and fracture would require treatment with antibiotics at least and potentially further surgery and hospitalization. The skin needs to be healed, dry and infection free before surgery.
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There will be a scar from surgery which may be visible. Frequently you may have a small area of decreased sensation below the scar. In very slim people the plate may be felt once the swelling goes away, it can be removed after 1 year.
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The body still needs to heal the injury. The plate only stabilises the fracture in the best position to heal. Fracture union may still be delayed 3-4 months, but plate fixation reduced the risk of non-healing down to 5%. If your fracture still does not heal after fixation bone graft surgery is a revision option.
Stabilization does not make one immune from repeating the initial injury. Furthermore if the stabilization is especially strong a repeated fall may lead to fracture of the clavicle at the end of the plate.
General advice regarding AC joint stabilization
The information here is general and varies depending on individual factors such as: time to treatment, strength of repair, occupation, age and sporting demands.
Will surgery benefit?
Displaced middle 1/3 and lateral 1/3 fractures do better with operation
Immobilisation
Sling for 6 weeks
Driving
no Driving for 6 weeks
Aim for surgery
Increase fracture healing and restore normal shoulder function;
Hospital stay
Day/overnight surgery only
Return to Work
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1 handed duties at 2 weeks
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light duties at 6 weeks
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full duties at 12 weeks
Investigations
letterbox x-ray for comparison
Therapy
Shoulder exercises after 6 weeks
Return to Sport
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return to training at 3 months.
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4 months for high impact