New Treatment Ideas for Clavicular FracturesYou've probably seen a few folks along the way with a broken clavicle (collarbone). Most of the time, these injuries were left alone to heal on their own. Patients might have been given a sling to wear for a while. They were probably told what motions to avoid during the healing process. But that traditional view is no longer accepted. Now we know that these injuries occur on a continuum. Some people may need special care.
For example, not everyone gets better with conservative (nonoperative) care. Studies show that there's a subgroup of patients for whom the results can be very unsatisfactory. The bone doesn't heal, a problem called nonunion. In some cases, the bones knit together but not properly. This is called a malunion. In either case, the end result can be pain, decreased motion, and loss of shoulder function.
The authors of this article put together a detailed discussion of clavicle fractures. They gathered statistics from many other studies to highlight who is affected and what happens as a result of these injuries.
Several different classification schemes (e.g., Allman's, Neer's, and the Edinburgh classification) used by doctors to describe the type and severity are presented. Many drawings are provided to show various types of fractures. Some are undisplaced (broken bones do not separate or pull apart), displaced (two ends of bone shift apart), intra-articular (at the joint) or extra-articular (outside the joint). The fracture could be angulated, wedge-shaped, or comminuted (multiple fragments).
X-rays are used to identify the type of clavicular fracture. The surgeon performs a clinical exam to look for signs of damage to the nerves or blood vessels. If the fracture occurred as a result of trauma, there could be chest or rib injuries as well. Additional imaging studies with CT scans, MRIs, duplex scanning, or arteriography may be needed.
Once the diagnosis has been made, then the treatment plan is determined. The main decision is surgery or conservative care? Conservative care with a simple sling and activity modification is still good for some patients. The fracture heals well and the patient can slowly resume normal motion and activities.
But enough studies have been done in the past 10 years to support the need for surgery to stabilize the fracture. More cases of nonunion and poor outcomes have been reported with nonoperative treatment. Who should surgery be recommended for? And what should be done?
Once again, there's enough new evidence to suggest that patients with displaced fractures are at increased risk for a poor outcome. This is especially true for displaced fractures with shortening of the bone. These patients can end up with shoulder weakness and decreased staying power (endurance) for activities requiring shoulder strength.
There are numerous ways the surgeon can approach the problem. A metal plate can be used along the top of the clavicle to hold things together while the bone heals. A newer invention is the site-specific precontoured locking plate. This plate was designed to remain inside the body (no removal required). It is less prominent (sticks up less) and can be used with older adults who have osteoporosis (brittle bones).
Sometimes the curved shape of the clavicle doesn't allow the use of plates. The surgeon may have to use a nail or pin that is narrow and flexible enough to pass through the bone lengthwise. At the same time, it has to be strong enough to hold the bone together during healing despite forces placed upon it. This technique is called intramedullary fixation. The nails offer a minimally invasive way to treat patients who have many other injuries in the shoulder and arm.
Other techniques discussed by the authors include Kirschner wire fixation, coracoclavicular screw, plate and hook-plate fixation, and suture and sling ligament grafts. Some of these are used for specific types of fractures such as those that don't heal and for patients who want to return to work or sports quickly.
All of these surgical techniques have their pros and cons. There are potential complications with each one. These include infection, plate failure, scar tissue formation, and implant loosening for starters. Other problems mentioned are nonunion of the bone despite fixation, refracture of the bone, and on more rare occasions, injury to the blood vessels during the procedure. Problems reported with intramedullary fixation include breakage, nerve damage, and skin breakdown where the pin enters the body.
Risk factors for nonunion must be taken into consideration. Older women with displaced or fragmented fractures have the highest rate of nonunion. Anyone with this type of fracture can end up with loss of shoulder motion, weakness, deformity, nerve damage, pain, and a clicking sensation in the shoulder. Daily activities are disrupted. They may be unable to sleep, drive, or engage in sexual activity because of pain and instability.
With each patient who needs surgery, the surgeon tries to find the right fixation device. The goal is to stabilize the fracture. They try to do this with an implant that's too rigid. It's best if some movement is allowed. If possible, the device selected is one that doesn't have to be removed later, which would require a second surgery.
In the end, it simply isn't possible to say what is the optimal or best treatment for each type of clavicular fracture that requires surgery. Specific guidelines just aren't available yet. More studies are needed to help sort this out. Predicting which patients will have a good result with surgery (and what type of surgery to do) is not possible using any kind of formula or assessment tool yet.
It does appear that undisplaced clavicular fractures can be treated nonoperatively. In the case of displaced fractures, surgeons will continue to test out new and better ways to hold the fractured bone(s) in place until healing takes place. Review articles like this one will help everyone keep up with the latest information on this topic.
L.A. Kashif Khan, BSc(Hons), MRCSEd, et al. Current Concepts Review: Fracture of the Clavicle. In The Journal of Bone and Joint Surgery. February 2009. Vol. 91. No. 2. Pp. 447-460.
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