RELEVENT LINKS:
Shoulder - General Information
Clavical Fracture Rehabilitation

General Considerations:

Mid-shaft clavicle fractures occur most commonly from falls onto the shoulder.  We see the most from bicycling, skiing and snowboarding falls.  Clavicle fractures present a unique challenge to self-healing because the shoulder cannot be placed in a cast during the healing process. The clavicle is directly under the skin with no overlying fat, making fractures cosmetically apparent, and moreover, they hurt.  

Surgical fixation of the clavicle is being recommended more frequently in order to promote healing. Recent studies indicate long-term shoulder weakness and mal-union from fractures with an overlap or a distraction of more than 1 centimeter when left untreated.  A new intramedullary fixation technique has permitted normal alignment and restoration of length of the clavicle with an early return to work and sports. The risks of surgery, including non-union and infection, are still present; however, for athletes who want to return to full sports as early as possible, and for people who are concerned about optimal anatomic alignment and healing, this technique has served these patients well. The indications, surgical technique and rehabilitation program is described here.

Surgical treatment - Indications:

•    Mid-shaft clavicle fractures with overlap or displacement greater than 1 centimeter
•    Tenting of skin by fracture fragments
•    Active patient with desire for early return to work and healing with no loss of length or
     strength



Surgical  treatment - Contraindications:

•    Skin wounds at the incision site
•    Inability to follow the rehabilitation program

Surgical treatment - Pro's

Surgical intervention can allow the patient to:

•    regain length
•    regain stability
•    return to work

 

Furthermore, surgical fixation will promote proper healing by preventing:

•    overlap between the fractured bone
•    development of a fibrous non-union

Surgical treatment - Con's:

•    Higher infection rate estimated at less than 1%
•    Potential hardware complications or failure
•    Skin incisions
•    Non-union risk
•    Surgical regional block risks

Surgical Technique

The patient is seated in the beach-chair position after an interscalene local anesthetic block is placed. The fracture ends are opened with a scalpel and cleaned.  A guide pin is passed into the medial portion of the clavicle under fluoroscopic x-ray control and over-drilled to fit a 6.5 mm or 4.5 mm screw.  The guide pin is then removed and passed into the lateral clavicle fragment and similarly over-drilled.  The pin is directed out the back of the clavicle.  The drill is attached to the exiting end and redirected to pin the full length of the clavicle under x-ray control.  Finally, a cannulated screw and washer is passed from the back down the bore of the clavicle to fix the fracture.  Care is taken to engage, but to not penetrate, the medial end of the cortex of the bone.  The incision is then closed.

The following is an x-ray image of a mid-shaft clavicle fracture:

X-rays demonstrating this reduction of the fractured mid-shaft clavicle in a professional Race Across America cyclist, who cycled within one month of his injury: