What type of clavicle fractures are there and how are they treated?
Clavicle fractures (collar bone fractures) occur after direct trauma is transmitted through the upper limb. This can occur from simple measures such as falling, such as whilst playing sport such as Australian Rules Football, or after high velocity trauma such as a motor bike accident. A very common sporting injury that results in clavicle fractures is a fall from a push bike and with the increase in popularity of cycling over the last decade, the number of clavicle fractures has increased with the time.
What types of clavicle fractures are there?
The fractures can be broadly described by the location in which they occur, such as a fracture of the clavicle occurring in the middle of the bone compared to fractures occurring at either end. Fractures that occur closest to the shoulder joint are known as lateral clavicle fractures, while ones closest to the sternum or chest bone are known as medial clavicular fractures. The most common type of fracture are the ones at the middle of the clavicle known as mid-shaft, with the second most common being lateral clavicle fractures and the least being the medial.
Does the position of the clavicle fracture determine how it is treated?
Yes. Lateral clavicle fractures lead to greater instability (movement) of the break and are at much higher risk of the fracture not healing. Therefore, most lateral clavicle fractures are treated with surgery unless they are completely undisplaced (haven’t moved significantly from their original position). Mid-shaft medial clavicle fractures can heal without surgery.
What are the ways of healing a bone?
All bones heal on their own. Surgery cannot make a bone heal. Surgery reduces a bone into a stable and acceptable position so that the bone then heals. If a fracture is greatly displaced (if there is too much movement of the break) then there is a greater chance that the bone may not heal. In this scenario it may require surgery to place the bone into a more acceptable position to allow it to heal.
Are there things that prevent the healing of bone?
Yes. Smoking has a significant part to play in affecting the healing of a bone. It has been shown that any number of cigarettes, including just one a day, reduce the healing response. As such, with any fracture it is strongly recommended that a patient does not smoke. There are genetic factors that also stop the healing of bone and certainly with age the healing response is not as good, but these other factors are difficult to control, while smoking is certainly a major factor which can be controlled.
Other factors which could play a role in affecting healing are non-steroidal anti-inflammatory medication, but this is minimal compared to the smoking factor.
What determines whether a patient requires surgery or whether they can be treated without surgery?
Most broken bones can be treated without surgery. The question remains, though, whether it will heal in an appropriate position so that function is restored and pain is minimal to non existent. Mid-shaft fractures where there is no significant shortening or gap, can be treated with a sling for comfort, coming out of the sling as symptoms improve and as the fracture becomes more stable.
Following a fracture, a large blood clot occurs around the broken bone. This has healing factors in it that stimulates the response of the body to cause healing. The blood then differentiates or changes to form healing bone cells which then lay down healing tissue known as callus. After approximately 2 to 4 weeks the bone becomes surrounded by this “glue” of healing bone which allows it to become more stable. As such most clavicle fractures will go on to heal, assuming that there is not too much movement or there is not excessive smoking or abnormal genetic factors.
The position the bone heals in will affect function long term. If the clavicle is healing in a particularly shortened position (the length is actually reduced by more than several centimetres), it has been shown to lead to abnormal function and increased stress on the whole of the shoulder girdle. In such scenarios, this may warrant surgery. Displacement (the bones are translated but not shortened and so that they appear like a zig zag fashion on x-ray) doesn’t necessitate surgery. Whilst the x-rays can look abnormal the bone can heal in a reasonable position and whilst there may be some deformity on the collar bone as it heals, the final functional position will be very good.
Often the patient is very concerned about the picture, but they can be reassured that whilst the x-ray may look abnormal if it is not shortened and it goes on to heal that there can be very good function and most patients will do extremely well with treatment this way.
Often the patient is concerned about a lump in the clavicle because of the deformity. Does this necessitate surgery to reduce the cosmetic abnormality?
Whilst cosmesis or deformity of the clavicle is often the patient’s concern, surgery would involve an incision and scar over the clavicle or an insertion of a metal plate. Whilst this may make the clavicle better aligned, the plate can become more prominent at a later date and therefore may necessitate a second operation to have this removed. The scar itself will lead to numbness below the scar which usually improves but may not fully resolve. Therefore, chasing a better appearing clavicle, the scar associated with the underlying plate and the associated numbness may negate the benefit that you get from plating. As such, in Dr Nimon’s experience, plating a clavicle for appearance alone is not warranted. What does necessitate treatment are factors that affect healing of the bone such as excessive movement, too large a gap or excessive shortening.
If a gap doesn’t matter in most cases because of the large blood clot around the clavicle, why would it necessitate treatment in other cases?
In most cases, a gap which looks excessive on x-ray does not hinder healing and the bones do go on to unite. However, if the gap is more excessive than normal, it may mean that soft tissue has got interposed or placed between the two broken bones which then stop the two bones becoming sticky and healing together. In this situation, one may wish to consider surgical intervention.
Apart from the scar, are there any other risks of surgery?
Yes there are. Clavicular fracture surgery should never be undertaken lightly. There have been reported cases of major bleeds or vascular events, and there is a risk of even excessive bleeding or developing or emboli which can lead to life threatening complications. As such we believe it is appropriate that the patients understand that surgery is not without risk in this scenario and that surgical intervention is not undertaken lightly.
The above sounds serious. Are there benefits of operating?
Yes. In the vast majority of people, once surgery is undertaken their pain is significantly better and, with the restoration of the alignment of the clavicle, this then leads to better function in the shoulder. If the alignment and the position of the clavicle is not severely displaced then the patient is best treated without an operation.
In those cases that have not had surgery and the fracture has not healed, when surgery is undertaken a similar approach is used but because of the scar tissue around the bone, it is impossible to get the bone out to full length. Therefore, in those cases the clavicle always heals in a shorter position.
What is the treatment after surgery?
The patient requires an overnight stay in hospital. The following morning, they will be reviewed by a physiotherapist who will fit them with a removable sling which will allow them to come out for exercises and dressing. They will be instructed on how to wash. It is important to wash in the axilla (armpit) and use spray on deodorant often supplemented with tinea powder to absorb moisture. We would then recommend that clothes be worn normally to reduce the risk of skin against skin perspiration because this can lead to thrush developing in the axilla.
The patient will then return for a review at Glenelg Orthopaedics 8 days after surgery, for review of the wound and referral to a physiotherapist of their choice. The sling is worn for 4 to 6 weeks, coming out for exercises and the patient returns to driving after the 6 week mark. If they can return to work prior to this and they are able to do so, then they should not do heavy manual duties. Assuming the fracture is going on to heal without complication, they should be able to go back to simple duties at the 6 to 8 week mark, not lifting heavy items, and can return to full duties 3 months after surgery. At this stage one would expect to have full range of motion of the shoulder and would then suggest review at the 9 month mark, should the patient warrant removal of the metal plate at a later date.
In summary, clavicle fractures are becoming more common. The vast majority lie in an acceptable position and do not require surgery but there are some, the ones that are shortened or occur laterally, that are more likely to require surgical intervention. At Glenelg Orthopaedics you can be reassured that we will present a balanced discussion about the pros and cons of surgery so that you can make an informed decision about how you would like to proceed. Call us today on 08 8376 9988.
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