Question for Physiotherapists
QUESTION | More of my patients with
clavicle fractures have had surgery lately. When I first began practice, I
don’t remember anyone having surgery on this injury. Is there a new trend
favouring surgery on clavicle fractures?
ANSWER | Collar
bone or clavicle fractures happen commonly in athletes. The most common site
for the bone to break is at the midshaft. Many of these fractures do not shift
very far and are treated with a sling with excellent results. When they shift
or displace a long way the results of sling treatment are less reliable. These
are typically quite high energy injuries such as when a cyclist falls and
impacts their shoulder on the ground or from direct trauma such as a rugby
tackle. Fractures away from the midshaft generally require surgical treatment
and are not the topic of this article.
fractured clavicle is not very displaced it generally heals if the patient
protects their shoulder with a sling for up to 4 weeks. Shoulder range of
motion exercises are commenced as the pain settles, for some patients this is
as little as 1-2 weeks post injury.
During my time
as an Orthopaedic registrar, even displaced midshaft fractures were treated
with a sling and the patient was told that they would be fine. Unfortunately,
there were significant numbers of patients that did not achieve a satisfactory
outcome in terms of pain, function or cosmesis. One of the better studies on
the subject came out of Canada in 2007. This showed better outcomes for
patients treated with surgery. There was a lower non-union rate, less
shortening of the bone and less shoulder fatigue.
We know that
certain groups of patients do not do as well with non-surgical treatment and
these patients are generally offered early surgery. This includes when they
have a scapula fracture (often referred to as a floating shoulder), if the bone
fragments are tenting or putting pressure on the skin and if blood vessels or
nerves are injured.
The studies that
have followed the Canadian study are somewhat varied in their results. The
Canadian study showed up to 15% non-unions 1 year after non-surgical treatment
but a Finnish study in 2012 did not show much difference in functional outcomes
despite a relatively high non-union rate. What has not been well studied is whether a
clavicle that heals in a shortened position affects the shoulder in the long
run. There is concern that patients with a shorter shoulder girdle will suffer
fatigue related pain of their periscapular muscles with overhead activities.
Across all of
the studies the results were good if the fracture healed but the patients
returned to work faster if they had surgery. Re-operation rates were relatively
high in both groups. In the surgical group many patients wanted the plate
removed and in the non-surgical group many patients required surgery for
ongoing symptoms. This outcome has been reproduced in several subsequent
studies with most showing a small but real benefit with surgical treatment.
As with all things in medicine, treatment must be chosen on an individual
patient basis. Careful consideration of the potential harms and benefits are
important, as well as the functional desires and needs of the individual
patient. If it was my shoulder and I had a displaced midshaft clavicle
fracture, I would have the operation.
|Dr Doron Sher
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