CLAVICLE FRACTURE surgery

“When the fracture is significantly displaced, shortened, or in multiple pieces, fixating the fracture can lead to a much faster recovery from the pain and return to full function than treating the fracture with just a sling.”

— Dr. John Drkulec

What is the Clavicle

Pectoral girdle front viewThe Clavicle is often referred to as the collar bone.  There are two clavicles in the body that connect the sternum to the shoulder.  The clavicle is classified as a long bone due to it being longer than it is wide.  Unlike other long bones in the body the clavicle is the only one that is anatomically horizontal.  The clavicle acts as a ridged support to keep the shoulder and the scapula in place away from the body to maximize range of motion of the arms.  Due to the clavicle being a ridged support for the shoulder it can be overloaded with pressure and break if the shoulder is impacted too hard at the right angle or if one falls with an outstretched arm.  This is in addition to direct trauma to the collarbone itself.  A fracture of the clavicle is particularly painful and can impact the range of movement in the arm of the affected side of the body. 

Fracture terminology

Open fracture vs. Closed fracture

  • Open Fracture – the fracture has broken through the skin.  Open fractures require trips to the emergency room to lower the risk of infection.
  • Closed fracture – the fracture is contained within the body.  While a closed fracture is not at risk of infection, it is still to be taken seriously and seen by a physician for imaging to understand the level of risk involved.

Location

  • Proximal- closer to the midline or place of attachment.  In the case of the clavicle the proximal side would be the third of the bone closer to the sternum.
  • Distal – farther from the midline or place of attachment.  In the case of the clavicle the distal end would be the third of the bone that is closest to the shoulder.
  • Midshaft, or Medial – the center third of a bone.  So, roughly the middle.
  • Intra-articular – inside of a joint.  In the case of a clavicle fracture the break could be within the acromioclavicular joint, also known as the AC joint to keep it pronounceable.

Types of fractures

  • Comminuted – comminuted fractures have more than two pieces from splintering or shattering of the bone.
  • Transverse – transverse facture is going to present as a straight line across the bone perpendicular to the length of the bone.
  • Oblique – oblique fractures of a long bone are similar to a transverse fracture but instead of a perpendicular fracture to the length of the bone the fracture occurs at an angle.
  • Spiral – spiral fractures are just like they sound.  Imagine a cork screw shaped fracture from the twisting of a bone.
  • Segmental – a segmental fracture is similar to a comminuted fracture, but instead of splintering or shattering a segment of bone has broken cleanly in two places leaving a floating bone.

Clavicle Fractures

A clavicle fracture treatment is going to vary from non-surgical intervention to surgical intervention.  This variation is tied to how bad the fracture is and weather or not the bone is still in a reasonable position.

Non- Displaced

A non-displaced fracture independent of fracture pattern is most likely going to end in a six week recovery in a arm sling to immobilize the arm while the clavicle heals.  Since the clavicle is not out of alignment, there is no gaps or overlapping pieces of bone, the bone can heal relatively easily without compromising the body mechanics of the upper extremity.

Displaced

Displaced fractures, usually caused by high energy impacts to the shoulder, can heal in a sling as well under certain circumstances.  Historically, all clavicle fractures were left to heal in a sling unless there was severe angulation which could cause serious damage to surrounding structures.  Unfortunately, the results were mixed with an increase chance of non-union or mal-union outcomes.  A non-union is when the two pieces of bone heal, but they didn’t reconnect.  A non-union fracture increases the complexity of intervention if surgery is needed to suppress issues.  A mal-union is when the bone fragments heal back together in a manner that is biomechanically hindering.  An example of this would be the bones healing twisted, or at an odd angle, changing the range of motion in the arm in a negative manner; over time wearing away at the joints causing arthritis. 

WHEN TO CONSIDER CLAVICLE SURGERY

A good rule of thumb is that if a clavicle is significantly displaced, shortened, or in multiple pieces then surgical intervention should be considered for an optimal patient outcome.  Some patients over the age of 40 can experience a frozen shoulder after long periods of immobility for recovery.

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