MINERVA ORTOP TRAUMATOL 2012;63:217-27
Clavicular fractures: a review of the literature
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G. D. OLIVER, J. A. COHEN
Clavicular fractures account for 5-10% of all fractures and over 30% of shoulder injuries. The main goals after a clavicle fracture are to maintain full union and restore the normal clavicle length. Previously, the trend in clavicle fracture management has been nonoperative with positive functional outcomes. However, as functional assessment has become more understood, surgical intervention has become more popular. Both operative and non-operative treatments have reported beneficial and positive functional outcomes. The following review will highlight the treatment options available and the literature supporting those treatments. Inevitably, there is not a general standard treatment. The best treatment depends on the individual patient’s goal. Key words: Clavicle - Fractures, bone - Shoulder fractures.
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lavicular fractures are quite common, accounting for as low as 2% and as high as 12% of all fractures sustained and as high as 44% of all shoulder injuries.1-6 It has been estimated the incidence of clavicle fractures in adults is 29.14 fractures per 100,000 per year with most occurring in males under the age of 30 and typically as a result of contact from sporting activity.7 The main goals after a clavicle fracture are to unionize the fracture completely and restore the clavicle to its proper length.8 Previously, the
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SPORTS MEDICINE
Corresponding author: G. Oliver, PhD, FACSM, ATC, 39 Rob Street, Farmington, AR 72730, USA. E-mail:
[email protected]
Vol. 63 - No. 4
University of Arkansas, Fayetteville, AR, USA
trend in clavicle fracture management has been non-operative with positive functional outcomes.9 However, as functional assessment is becoming more understood, surgical intervention is becoming popular. This paper will discuss the benefits of non-operative and operative treatments of mid-shaft clavicular fractures. Athletes or individuals with increased overhead activity during their daily lives should evaluate the benefits and risks of surgical intervention in order to regain full functional motion.10 However, for the sedentary person or non-active overhead individual, non-operative treatment may be of benefit to avoid surgical risks. This paper will provide an overview of clavicular functional anatomy, clavicular fracture classification, non-operative and operative options, as well as athlete specific clavicle repair. Functional anatomy The clavicle is the first bone in the human body to ossify in the fifth week of gestation and last to fuse at 21-25 years of age.11 The sternal end (medial) is convex anteriorly, while the acromial end (lateral) is concave anteriorly. The bone is flat at both the ster-
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er, all genders tend to display a longer left clavicle. The depth and radius of the medial curvature are significantly larger than the curvature of the lateral third.8 Compared to females, males have displayed distinctly stronger curvature of both the medial and lateral portions of the clavicle.8 The medial curvature radius has been shown to be similar between genders, while the lateral curvature radius appears smaller in men than compared to women. Additionally, it is also smaller on the left side compared to the right in both genders. When analyzing calcium bone density, the medial or sternal end presents the greatest density while there is a distinct decrease in bone density from the middle-third to the lateral end. The cortical thickness of the bone is greatest at the middle third and significantly lower at both the medial and lateral ends.8 With clavicular fractures being so prevalent, it is important to understand the functional anatomy when deciding the appropriate treatment option. Base on the Adnermahr et al.8 study, it is evident that the bony make up of the clavicle is different between genders as well as side-specific. Thus, when deciding the optimal treatment option, one should consider the individual and realize that no one method may be the best for everyone.
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nal (medial) and acromial (lateral) ends. The bony anatomy of the clavicle makes it a unique, yet injury susceptible structure. The uniqueness of the clavicle is its S-shape. The curved S-shape allows the clavicle to serve as a connection between the sternum and scapula. The medial portion that connects to the sternum is more circular, while the lateral end that connects with the scapula is flat. The middle one-third of the clavicle, where the shape transitions from circular or tubular to flat, is thought to be the weakest. Therefore, the middle one-third of the clavicle is at greatest risk of injury.12 It has been reported that 70-80% of all clavicle fractures occur at the middle one-third.8 The acromioclavicular (AC) joint is formed from the distal end of the clavicle and the acromion of the scapula. The acromioclavicular joint consists of cartilage that varies in size for individuals. There is a thin capsule stabilized by posterior, anterior, inferior, and superior ligaments. The strongest ligament is located superiorly and is supported by the attachment of the deltoid and trapezius muscles.13 The anteroposterior stability is provided by acromioclavicular ligaments and provides little vertical support. The ligament between the conoid and the trapezoid (coracoclavicular ligament) passes from the interior surface of the clavicle to the base of the coracoid process of the scapula and provides the vertical stability of the acromioclaviular joint. The coracoclavicular ligament provides the primary support of the scapula. In the sagittal plane, the clavicle functions as a strut to stabilize the glenohumeral joint. In the frontal plane, it performs a suspension function allowing the shoulder girdle to be suspended from the clavicle by the coracoclavicular ligament. Proximally, the clavicle is part of the sternoclavicular joint. The joint is comprised of the lateral end of the clavicle, the upper and lateral part of the manubrium sterni, and the cartilage of the first rib. Clavicular dimensions are unique to each individual. Males average 15.6+1 cm, while females average 14.6+1 cm. Males have a significantly larger bone diameter than females. Howev-
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Classification of fractures
Clavicle fractures are classified by their anatomical location/region. Allman has classified clavicle fractures into three groups based on three anatomical regions of the clavicle.14 The most frequent fracture is classified as group I. A group I fracture occurs in the middle one-third or the midshaft of the clavicle. Group II fractures are localized to the distal third or acromial end of the clavicle, and group III fractures are of the proximal third or sternal end.14 Incidence of injury has deemed group I as the most frequently occurring.15 Based on the anatomy of the clavicle the group I fractures are to the most vulnerable area of the bone where it transitions from
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tra-articular (type 1B). Type II fractures are subdivided based on the presence of bony angulation of either exhibiting residual bony contact (type 2A) or no contact (type 2B) between the major fragments with varying degrees of shortening. Type 2B has further dividing into wedge comminuted (type 2B1) and segmentally comminuted (type 2B2) fractures. Type 3A and 3B fractures were also subdivided based on their articular involvement. Type 3B exhibits posterior displacement of the shaft fragment with a simple oblique configuration or an avulsion of an inferior bone fragment.7 Clavicle fracture classifications can be confusing. Allman 14 includes only those that involve the lateral coracoclavicular ligament, Neer,16 along with Craig 17 include fractures medial to the ligaments. While the Edinburg system offers a more pragmatic assessment focusing on the positional displacement and identifies at risk of delayed or non-union.7
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tubular in form to flat. Groups II and III have a much lower incidence with group III least frequent. In 2002, group I fractures accounted for 81.3% of all clavicular fractures, while 16.6% were group II, and 2.1% were group III.5 Fractures to the acromial end of the clavicle or group II fractures can be furthered classified. Neer 16 was the first to classify the distal fracture of the clavicle into two types. Neer classified the distal third fracture or group II fracture based on bone displacement, type I has no displacement and type II has displacement. Further Neer explained type IIA as a fracture where the coracoclavicular ligaments remain intact, while type IIB there is ligamentous disruption. Craig further modified Neer’s classification to include five types of lateral clavicular (group II) fractures.17 Type I is a fracture lateral to the coracoclavicular ligament and typically is non-displaced. Type II is a fracture medial to the coracoclavicular ligament and the proximal segment is usually displaced relative to the distal end. Type III fractures extend into the AC joint and can lead to AC joint degenerative changes. Type IV is a proximal fragment displacement out of the periosteal tube and occurs in children. Type V is a comminuted fracture where the coracoclavicular ligaments remain attached to an inferior bone fragment, but not attached to the proximal or distal fragment. The Edinburg classification that was based on an analysis of 1000 clavicle fractures was the first to subclassify shaft fractures according to their degree and displacement.7 The classification system identified three different areas of fracture. Type 1 includes the fifth of the bone lying medial to a vertical line drawn upwards from the center of the first rib; type 2 consists of the intermediate three-fifths of the diaphysis; and type 3 is the fifth of the bone lateral to a vertical line drawn upwards from the center of the base of the coracoid process. Further classification subdivided each type based on radiological view of the anatomical site as well as the extent of displacement, comminution and articular extension. Type I fractures are further defined as extra- (type 1A) or in-
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Clavicular fractures
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Treatment
As with most injuries, treatment protocols are either conservative (non-operative) or aggressive (operative). Previously, operative treatments were only indicated for clavicular fractures that were: 1) unstable with neurovascular compromise; 2) an open fracture; 3) skin tenting on a displaced fracture; or 4) concomitant scapular neck fracture.18 All other clavicle fractures were not considered an operative emergency. Management focus is achievement of bony union, functional movement, and reduction of non-union and malunion incidence. Non-union is evident when there is lack of bony development after six to eight months while malunion presents greater complications, such as possible shortening. Conventionally, the treatment of choice for clavicle fractures has been non-operatively due to the risk of infection and risk of non-union.19 Clinical evidence has shown positive results in 90% of athletes who have elected for non-operative treatment with a figure-of-eight bandage.20, 21 Though recent
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reports have revealed a decrease in union rates in non-operative treatment of displaced midshaft fractures,22-24 surgical management has become common.21, 25 When treating athletes, early mobility and functionality with rapid return to play is paramount. Recently, 10-30% of non-operative treatments have reported unsatisfactory results of non-union as well as decreased function.25
compared to the 16.7 days experienced by the non-operative group. In addition, return to sport activity was delayed in the operative group compared to the non-operative group (3.2 months and 2.6 months, respectively). Grassi et al. concluded non-operative treatment appears to be more beneficial than open intramedullary fixation.29 Therefore, depending on the outcome goals, data have revealed that both operative and nonoperative treatments for clavicular fractures allow for positive outcomes.
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Operative versus non-operative
In 2007 6 a report on 132 clavicle fractures compared treatments of plate osteosynthesis to a non-operative sling. Constant shoulder scores resulted in 96 for operative and 90 for non-operative, while DASH scores were 5 and 15, respectively. Mean time to union was only 16 weeks for operative treatment but 28 weeks for non-operative treatment.6 Comparing non-operative sling treatment to Hagie pins, single-assessment numeric evaluations revealed 97 to 94 (out of 100); respectively at the one-year postoperative visit.26 Union rates were 26 of 27 in the operative group, and 22 of 23 in the non-operative group. While in an additional study, Kulshrestha et al.27 examined non-operative sling versus plate fixation and at 6 months post operative there was 100% union in the operative group and 20 of 28 in the nonoperative. When comparing elastic stable intramedullary nailing to a sling in 120 clavicle fractures after a two-year follow-up, average union was 12 weeks in surgical group and 17 weeks non-operative group.28 Clavicular shortening was reported in 4% of the surgical and 5% in the non-operative group, with the operative group obtaining union sooner. Grassi et al.29 retrospectively examined 80 patients, 40 open reduction internal fixation with intramedullary pins and 40 who were treated with a figure-of-eight bandage. The internal fixation group sustained many complications: eight superficial infections, three refractures, two delayed unions with pin breakage, and two non-unions. The internal fixation group returned to activities of daily living an average of 40.7 days
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Non-operative treatment
Historically, non-operative treatment of midshaft clavicle fractures has been the normative treatment in both youth and adults. The majority of clavicle fractures (80-90%) are successfully treated non-operatively.30 Non-operative treatment is warranted for fractures in children, simple fractures with minimal displacement, and fractures in patients with low compliance without indication for surgical treatment.19 Non-operative treatment is focused on pain management and either a sling or figure-of-eight bandage. The figure-of-eight bandage allows for extension by pulling the shoulders back in attempt to prevent clavicular shortening and malunion. For the figure-of-eight bandage to work appropriately, it must maintain its tension and often needs to be tightened daily. The use of a sling has also shown to be beneficial and is often more comfortable for the patient than the figure-of-eight bandage.31 The sling assists in immobilization of the affected arm as well as allows for comfort by supporting the weight of the arm. Adults who sustain a midshaft clavicle fracture do heal non-operatively. When treating non-operative, the initial treatment is immobilization (sling or figure-of-eight bandage) until pain is resolved, usually 2 to 4 weeks. At the time of pain resolution, patients are allowed to work on range of motion and then light resistance to be added at six weeks. Athletic return to play after non-operative treatment is on the average three months. Non-operative treatments reported by
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performed a nonrandom study with 40 patients in each group. Each patient had a follow up visit 64 months after intramedullary pin fixation. Results found eight superficial infections; two pin breaks; three refracture after pin removal; and one secondary plate fixation. The non-operative group had zero non-unions and no secondary surgery. Data revealed that non-operative treatment has proven successful with stable union and is recommended for undisplaced fractures with low incidence of non-union.26, 29 Of the non-operative treatment both sling and figure-of-eight bandages have both been successful with sling being the treatment of choice solely based on comfort. There appears to be no consensus on the optimal duration of immobilization, which ranges from two weeks to six weeks.
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Neer 32 in 1960 revealed that of 2235 clavicle fractures, only 0.13% were non-union. Then, in 1968 Rowe 33 examined 566 fractures and non-union rate was only 0.8%. However, it is important to note this study included children and was conducted at a time when functional assessment was not a focal point of results. By 1997, Hill discovered a non-union rate of 15% in his study of displaced clavicle fractures. Hill et al.25 reported a 30% dissatisfaction rate in 52 clavicular fractures with 37% having difficulty in overhead movements. The majority of non-unions were seen in fractures with greater than 2 cm displacement. Nevertheless, the literature remains consistent with evidence of adults healing from clavicle injuries by means of a figure-of-eight bandage or sling. Immobilization is necessary for a minimum of 2-4 weeks. After six weeks, a patient recovering from a broken clavicle can begin light activity. Standard return to contact sport is allowed at three months. Anderson et al. prospectively examined the effectiveness of non-operative treatment of a sling and figure-of-eight bandage for middle-third clavicle fractures.31 Sixty-one patients were evaluated. Duration of immobilization was eight weeks for the figure-ofeight bandage and four weeks for the sling. It was concluded that functionally and cosmetically the two methods of non-operative treatment are similar, however many patients prefer the sling.31 In an exanimation of 566 fractures, it was reported a non-union rate of 0.8%.33 Later it was reported in 1145 fractures there was a non-union rate of 5.9%.34 More recently the Canadian Orthopedic Trauma Society 6 examined operative fixation and non-operative treatments and found that one-year following the fracture; the operative patients had greater functional outcomes as well as decreased rates of malunion than compared to the non-operative treatments. Judd et al.26 randomized 57 midshaft clavicle fractures to be treated non-operatively or with pin fixation. The pin fixation group had one non-union and two refractures. The nonsurgical group had zero nonunions and one refracture. Grassi et al.29
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Clavicular fractures
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Plate fixation
Operative measures of external fixation have included dynamic compression plates, tubular plates, or reconstruction plates. Plate fixation is commonly used to surgically treat displaced midshaft clavicle fractures.35 Plate fixation has been a procedure of choice since it allows for immediate stability and rapid postoperative mobilization.32, 36 There have been many reports of successful plate implants, however, complications have also been reported.35 Plate fixation is also associated with higher neurovascular risks.9 Due to the local anatomical structures it is recommended portions of the plate be removed because of undue pain or discomfort. Plate fixation complications have included implant failure, nonunion, infection, and refracture after plate removal, hypertrophic or dysesthetic scars, implant loosening, intraoperative vascular injury.9, 37-39 Reconstruction plates are prone to leading to deformation at the site of the fracture, decreasing the chance of union.9 Upon further investigation through a systematic review, it was found non-union rates were no higher than 10% and infections were below 10%.35 Plating of 635 fractures of varying degree had a non-union rate of 2.5%
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non-union reported and no infections or refractures.46 Of the 55 treated with intramedullary fixations, it was concluded the procedure was minimally invasive with excellent functional and cosmetic results. It has been suggested intramedullary fixation should not be the treatment of choice if plate fixation will maintain the clavicular length.47 In addition, complications include implant shortening, implant breakage, temporary brachial plexus palsy, and skin break down where the hardware is inserted.9 Historically, intramedullary fixation has resulted in excellent healing rates.48-50 In a study of 364 fractures the non-union rate for intramedullary fractures was 1.6% and the non-union rate for non-operative treatment reached 5.9%.9 However, besides the great response in healing rates, intramedullary fixation has been associated with complications. The majority of reported complications have been superficial infections, however delayed union, non-union and refractures have also been reported.47 Biomechanically, intramedullary bracing using elastic titanium nails allows the optimal position of the implant to maintain tension adequate position under a loaded stress.51 It is minimally invasive and provides pain relief.51 Intramedullary nailing allows for a stable fixation for early function and restitution of clavicle symmetry. The disadvantages are cost of the implant and the need for implant removal after union. In addition, intramedullary osteosynthesis was examined in 136-fractured clavicles.51 Seventy-eight fractures had successful closed reduction. Visual analogue scale revealed average pain on day of operation as 72.4 (with 100 being most painful). On day three postoperative, pain was reported an average of 18.9. In addition to the decrease in reported pain, there was an increase in range of motion from abduction preoperatively of 42° to 121° of abduction. All hardware was removed once union was complete on average of 7.6 months postoperative. Additionally, Constant Murley scores one year following implant removal were on the average 97.1 (out of 100).51 Jubel et al.46 examined the effectiveness
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compared to the 5.9% of nonsurgical. Plating of 460 displaced fractures resulted in 2.2% non-union rate compared to the 15.1% seen in the nonoperative treatment group.34 Smith et al. examined 100 completely displaced midshaft fractures and reported a non-union rate of 24% (12/50) and 0% (0/50) non-union rate with plating treatment.34 This same study examined neurological complaints after treatment. Thirty percent of the nonoperative group developed upper extremity neurological complaints with overhead use of arm compared to 6% in the operative group. Additionally, 44% complained of the appearance of the healed bone. Nevertheless, 30% of the patients in the operative group requested removal of the plate.35 A majority of the infections reported from plate fixations were found to be wound infections that were treated successfully with oral antibiotics.35 Refractures reported averaged 9-64%,6, 40-43 thus based on the systematic review 35 it was concluded that plate debridement, removal or revision resulted in major complications 64% of the time. Intramedullary fixation
Intramedullary fixation is often preferred over plate fixation because it is a simpler procedure. Intramedullary fixation has a smaller surgical incision, less invasive, complete hardware removal, and shorter hospital stay.44 Various devices can be used with this surgical option including Knowles pins, Hagie pins, Rockwood pins, and minimally invasive titanium nails.9 Devices need to be very flexible, the implant needs to be very stable, and it must be small enough to pass through the medullary space at its most narrow point in the midclavicle.8 Additionally, the implant must be stable enough to neutralize the potential disruptive forces. Though intramedullary fixation is often preferred, it does not allow for as much rotational stability as plate fixation.45 In addition, pin migration has also been reported as a concern. In a review of 55 intramedullary fixations, it was reported hardware was removed at an average of eight weeks, one
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vide cortical compression and greater rotational control of the fracture. It has shown to be more beneficial in maintaining a rigid fixation with rotational control as compared to the intramedullary fixation.34 Plate osteosynthesis has become the standard of care for operative treatment of clavicular fractures.19 The goal of plate osteosynthesis is to regain clavicle length and shoulder alignment. Plate fixation can only be used if the distal fragment can hold at least two biocortical screws.9 Forty-four patients age 18-66 with Neer type II fractures were treated with hook plate via open reduction and internal fixation.55 All hardware was removed after consolidation at an average of 8.4 months postoperatively. All patients were able to have immediate function however impingement was noted. Follow up was performed at 27 months and average Constant Murley score was 92.4 out of 100. Thirty-two percent of the patients were asymptomatic, with 68% reporting discomfort from the implant. Of the 68% who had discomfort, all discomfort was resolved with hardware removal. Hardware was removed an average of 8.4 months postoperative and after radiographs revealed bony union. It was concluded the hook plate allowed for immediate function post operatively, however there was a high degree of impingement so the authors advised to remove the hardware as soon as union occurs. Golish et al.56 examined plate versus intramedullary fixation in cyclically loaded clavicles. Eight matched pair clavicles were compared on their biomechanical properties. It was concluded that the plate fixation might provide for a stronger construct allowing for early rehabilitation. Thyagarajan 44 recommends intramedullary pin fixation over plating when deciding between types of operative treatment.
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of intramedullary fixation on mid-clavicular fractures in athletes. Twelve athletes with mid-clavicle fractures presented preoperatively with shoulder abduction range of motion an average of 36.3° and postoperatively 154.2°. Pain preoperative was reported as an average of 71.7 (100 being the most pain) and three day postoperative, 19.2. Hardware was removed after full union an average of 7.2 months post operative. One year after hardware removal Constant Murly scores averaged 96.2 (out of 100). It was concluded that elastic intramedullary fixation allows for the chance of early return to play.46 Wang and Wong 52 examined Knowles pin fixation to treat unstable clavicle fractures. This method uses the acromion, the proximal clavicle, and the coracoid process for stable fixation. Twenty-five patients had transacrominal extra-articular Knowles pin fixation for their mid-clavicle fracture. It was revealed that 92% had union at 8 and 12 weeks post-operatively. Three of the 25 patients had heterotrophic ossification in the coracoclavicular space without any symptoms. Every patient had a radiolucent zone around the pin before pin removal with the mean radius size between 1.5 mm ± 0.8 mm. There was no medial pin migration for any patient due to the posterior hub of the Knowles pin. Eight patients had lateral pin migration, yet only two of the 25 patients were symptomatic. All patients had pins removed between 5-21 months after surgery. The method provided a high rate of bone union, good functional results and minimal complications. However, good bone quality is essential for this treatment technique. If the bones are weak a second surgery will be necessary. Historically, Knowles pins have shown positive outcomes. Neviaser et al.53 in 1975 reported a 100% healing rate utilizing Knowles pins. Again in 1981 a 100% healing rate was reported on a variety of intramedullary fixation cases.54
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Clavicular fractures
Plate osteosynthesis Plate osteosynthesis has the benefits of a rigid fixation as well as the ability to pro-
Vol. 63 - No. 4
Treatment for athletes Clavicular fractures are considered one of the most common injuries in sport that have traditionally been treated non-operatively
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age amount of playing time missed for all patients was 1.5 NFL seasons. Three of the players were able to return to play in the same season. Three of these four athletes were treated with surgical fixation and were able to return to play eight weeks later. Of the four who returned to play fastest, the one not treated surgically returned to play for 10 weeks before refracturing the clavicle. Four of the seven athletes, over 50%, originally treated non-operatively refractured within one year. This study found surgical fixation to provide the best chances of returning to play within the same season of fracture and avoiding injury reserve status for an entire year. Therefore, surgery is important to consider when dealing with completely displaced or comminuted middle-third clavicle fractures in athletes. Verborgt 57 also examined complications that occurred due to the surgical procedure in 39 semi-professional athletes. Of the 39 patients, 90% showed union on plain film radiographs at 12 weeks postoperatively. A refracture was sustained in 5% of the patients. Of those patients who sustained the refracture, all were after new trauma to the area and all had the low-contact dynamic compression plate. Seven patients developed a wound infection where four were resolved with antibiotics while 3 required surgical debridement and IV antibiotics. Three patients developed transient, mild neurological system that eventually resolved at six weeks. In an additional study 13 patients were followed after midshaft clavicular fracture that were treated operatively with intramedullary nailing 58 resulted in restoration of clavicle length and allowed for early mobilization and return to play in an average of seven weeks with excellent functional results. In another study examining athletes, it was reported out of 232 athletes with plate osteosynthesis, union rate was 97% and the satisfactory rate was 94%.59 Rabe and Oliver 60 presented a unique case of a 23-year old male collegiate football player. The break of the clavicle included a butterfly fragment 2 cm off the anterior aspect of the mid-clavicle and a spiral
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with external fixation by sling or figureof-eight bandage. Operative measures are elected when the fracture is open or there is neurovascular compromise. However, often athletes choose the operative route in attempt to get regain early mobilization and return to play. In a retrospective study from 1995-2003, 39 semi-professional athletes were treated surgically with plate fixation for a displaced midshaft clavicle fracture.57 All patients were surgically repaired within one week of the initial injury with rigid plate fixation using either a reconstruction plate or a lowcontact dynamic compression plate. Results revealed excellent outcomes resulting in early pain resolution, early return to sports activity, and high patient satisfaction. Postoperatively patients were immobilized with a sling but were instructed to begin passive and active range of motion as pain tolerated. Patients reported one-week, six weeks, and 12 weeks postoperatively. Clinical assessment included Constant Murley scores, visual analogue pain scores (0=no pain, 10=severe pain), return to play status, and patient’s satisfaction. At six weeks, results revealed the patients had a mean average of an 88 (max of 100 points) Constant Murley score. Pain measures revealed a score of 3 out of 10. Average time to return to sport activity was 45 days. While patient satisfactions rates were 75% very satisfied, 20% satisfied, and 5% unsatisfied, 95% stated that they would have the same surgery again. An additional retrospective study examining 19 National Football League players who sustained middle-third clavicle fractures over the period of five years. Of the 19 fractures, 13 were 100% displaced. Six of the 13 had surgical fixation with healing in 8.8 weeks. Three patients had plate fixation and another three had intramedullary fixation. Once the fractured healed, two of the three intramedullary implants were removed while all other hardware stayed in place.10 The six fractures which were not displaced or minimally displaced had an average healing time of 7.3 weeks. Of the players with completely displaced fractures, 50% were treated successfully. The aver-
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fratture della spalla. Gli obiettivi principali dopo una frattura della clavicola sono quelli di mantenere un’unione completa e di ripristinare la normale lunghezza della clavicola. In passato, la principale tendenza nella gestione della frattura della clavicola ha favorito il trattamento non chirurgico, con esiti funzionali positivi. Tuttavia, con una maggiore comprensione della valutazione funzionale, l’intervento chirurgico si è diffuso maggiormente. Sia i trattamenti chirurgici sia quelli non chirurgici hanno dimostrato effetti benefici ed esiti funzionali positivi. La seguente review evidenzierà le opzioni terapeutiche disponibili e la letteratura a sostegno di tali trattamenti. Inevitabilmente, manca un trattamento standard generale, poiché il miglior trattamento dipende dalle circostanze di ogni paziente individuale. Parole chiave: Clavicola - Fratture, ossa - Spalla, fratture.
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oblique fracture. Plate osteosynthesis was chosen over intramedullary pins in order to resist tensile forces and limit pin migration. The patient was able to begin aggressive rehabilitation directly following surgery. Four days post operative, the patient had 170-173° of shoulder flexion and 19-22° of abduction. Two weeks after surgery muscle strength was at 80% and shoulder extension and adduction showed signs of improvement reaching 30°. By four weeks the patient was performing dynamic stabilizations and advanced scapular exercises and participating in non-contact football practice. The patient was released for full contact at week five. It was concluded that this patient’s case had successful return to competition due to both the surgical intervention and the strong aggressive rehabilitation program. Conclusions
The incidence of clavicle fractures continues to be one of the highest injury rates to the shoulder. We have presented the literature that supports the utilization of non-operative as well as operative treatments. Many methods have been proposed for non-operative treatment with the conclusion that both the sling and figure-of-8 bandage allow for functional and cosmetic results. Operative treatment options have had controversial reviews based on patient-based outcome measures. Nonoperative treatment seems to be the trend when there is minimal displacement. However, a subset of patients such as athletes may lean toward operative measures in the attempt to regain function and return to play in significantly less time. Treatment decisions should be made on a case by case bases for every individual to determine what method is best.
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Clavicular fractures
Riassunto Fratture della clavicola: una review della letteratura Le fratture della clavicola sono responsabili del 5-10% di tutte le fratture e di oltre il 30% delle
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fractures of the clavicle in the semi-professional athlete. Acta Orthop Belg. 2005;71:17-21. 58. Meier C, Grueniner P, Platz A. Elastic stable intramedullary nailing for midclavicular fractures in athletes: Indications, technical pitfalls and early results. Acta Orthop Belg 2006;72:269-75. 59. Shen WJ, Liu TJ, Shen YS. Plate fixation of fresh displaced midshaft clavicle fractures. Injury 1999;30:497500. 60. Rabe SB, Oliver GD. Clavicular fracture in collegiate football player: A case report of rapid return to play. J Athl Train 2011;46:107-11.
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