Clavicle fractures hurt. The collarbone sticks up under the skin and moves around. It’s scary. In the past, most fractures of this type were left alone to heal on their own. Today, many are being repaired. So what changed?
First, some basic anatomy: The collarbone (clavicle) is a curved, twisted, partially flat bone that acts as a strut — or outrigger — stabilizing the shoulder. It is most commonly broken in the middle after falls off of bicycles, motorcycles, horses or other moving objects.
In children, the bone ends heal quickly and erase any deformity. In adults, it’s different. The old belief was that most collarbones heal well without surgery. But newer data shows that if the bone is displaced more than 1.5 centimeters, or angled more than 45 degrees, the healing is compromised. Either the clavicle doesn’t heal at all, or it mends with a deformity that produces long-term weakness and intermittent pain. This data, combined with better repair techniques, has changed the approach to clavicle fractures.
Clavicle surgery, when it was previously performed, involved thick plates and screws. Since the bone is not flat along its entire length — in fact, it twists — such plates artificially affected the pattern of the clavicle as it healed. The surgery often involved cutting through a sensory nerve that crosses the clavicle, and most often, the plates had to be removed after healing since the skin overlying the collarbone is thin.
Even when the plates could remain, they were not always secure — so most athletes were prevented from returning to sports until healing occurred. This combination of negatives led many surgeons and patients to ignore most clavicle fractures.
Two technical advances have changed our strategy. First, today’s plates — when they are used — now come pre-curved to match most clavicle shapes. Additionally, newly designed threads in the screw holes of the plate allow the screws to lock the plate in securely. This produces a much stronger construct than the older screws, which simply held the bone against the plate. Lastly, the materials used have changed to higher quality steel or titanium, permitting thinner, lower-profile plates.
Most attractive for many patients is the improved technique called “intramedullary pinning.” In this procedure, a screw is placed through the bore of the clavicle, eliminating the need for the plate altogether. While tricky to perform and not applicable to all fractures, pinning is performed as outpatient surgery through a mini incision. Patients can quickly to return to sports (one of our patients rode his bike in the “Race Across America” two weeks after surgery), though they’re advised not to fall if possible.
The outcomes of surgically repaired clavicle fractures are now proving to be better and less deforming than those of fractures left alone. The shoulder is better stabilized, the power increased, and the cosmetic appearance improved.
So, the next time you crash and break your collarbone, have confidence that your season may not be over. On the other hand: Staying vertical has a much better outcome.
Dr. Kevin R. Stone is an orthopedic surgeon at The Stone Clinic and chairman of the Stone Research Foundation in San Francisco.
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