Fractured Collar bone.

Boogles,

If I am getting this right, you had a clavicle fracture which was initially treated nonoperative, but then at about 8 weeks, you had some sort of surgical procedure (you do not say whether the fracture was plated or pinned, and whether or not it was bone grafted). Now, you are six months after the injury (or is it six months after the surgery)?

Anyways.

It is not uncommon to get a fracture a trial of life to see if it will heal on its own. With the clavicle, especially the midshaft fractures, there really is no consensus on the best method of treating them.

Conventional teaching say that almost all midshaft clavicle fractures will heal. That the deformity will cause minimal problems and that the body will remodel most of the callus wad. So, there is little need to treat these fractures will more than a sling and some physical therapy.

However, this is seriously being looked at in recent years. The above was in a time when surgery was still a very dangerous undertaking. Not to say that surgery is still not without many risks, especially to the great vessels just under the clavicle.

But, many surgeons are now leaning more to immediately fixing the clavicle, except in cases of minimally or nondisplaced fractures. It has been found that fractures which have significant angulation or are in bayonet apposition, will heal, usually with a abundant amount of callus, but the resulting relative shortening of the clavicle is not as benign as previously thought. Some patients develop either acrominoclavicular joint (ACJ) or sternoclavicular joint (SCJ) dysfunction.

Also, if the patient has a residual large callus formation with a bump, this often causes significant problems with people who have to wear straps over the clavicles, such as with soldiers who have to carry a ruck sack.


So, it is becoming more common to just go ahead and plate a clavicle fracture right off the bat. However, the patient has to understand the great potential risks to the great vessels and lung, just below the clavicle. There is also a nerve that runs across the midclavicle region, that if damaged, can cause numbness or pain in the nipple region.

Also, the plate will, in almost every case, have to be removed, which is another operation. Though hardware used in fractures in other parts of the body, can usually be left it, clavicle hardware almost universally causes problems. There is minimal soft tissues to cover the plate, so it is always proud.


But, it is also not uncommon to give the fracture a trial of life. If it heals, great. It not, then the surgeon can go in and fix the fracture, as needed. But, even fixed fractures may not heal.

It usually helps to place some bone graft around the freshened ends of the fracture. And, while a fresh fracture may be able to be pinned, intramedullary in the clavicle, if a delayed fracture is being treated, it probably should be plated.

There are many pre-bent plates for clavicle fractures on the market. But, sometimes, they can't be used. The plates do not fix every patient. So, the surgeon does have to make the hardware construct fit the situation, whatever it may be.



But, you are now at that magical 6 month mark (from injury), which would make with a nonunion. Some surgeons count from the latest intervention, so if it is from the surgery, then you are just 4 months out and have another 2 until it is classically considered a nonunion. But, if it looks like it is going to be a non-union, then something can be done at anytime.

One, you could try a bone stimulator, to see if the bone would finally get its act together. It is noninvasive and may prevent the need for another surgery.

But, if you do not want to wait, then you would need another surgery to take down the fracture site, remove any fibrous tissue that has formed within the fracture, reduce the fragments to as anatomic of a position as possible, pack in bone graft, and the stabilize the fracture (usually with a plate).

The wait and see what happens.

But, a known complication of any fracture care, is that the bone may not heal, no matter how it is treated.



You need to really sit down with the surgeon of your choice and discuss your options with him/her. It sounds like you are probably looking at another surgery, to get the fracture to heal. But, do remember, that even then, it may be difficult to get this bone to heal. It has already had two chances. Hopefully

I fractured my collar bone on June 5th of this year, which the doctored have called a comminuted fracture, the part closest to my neck was over an inch and a half away from the part near the end of my shoulder; furthermore, there were several small pieces, with one large chunk a good distance away from the actual break.

I visited a doctor on the 6th, which stated I needed surgery, and to go straight to the ER room to have an Orthopedic surgeon fix me up. However, that orthopedic surgeon felt it would heal fine all on its own. After a month, I had no bone growth (which is typically from what I heard); however, the doctor started talking about surgery. This is the point I visited another doctor, which stated if he would have saw me initially, he would have performed the surgery right away and not had me wait. I opted to allow for my fracture to fuse back together because the surgery is quite expensive. At the two month marker, I still showed no signs of flurries (healing).

In August, the second doctor (the Orthopedic surgeon who was on call for the hospital) said I needed surgery and referred me to his partner, who also agreed I needed surgery, and some other doctor in the office who saw my x-rays mentioned surgery was the best route. I saddled up and the surgery was performed, which consisted of a plate and 5 screws and might I add hurt 10x worse than when I fractured my collarbone.

Now a month after the surgery, I still showed very little signs of bone growth (I also use a bone growth stimulator, well I haven't sign my plate broke). Two months after the surgery, I used my arm with my messed up collarbone to gently brush a fly off my chest and my plate snaps.

After going in for my recent visit, I would told it was not my fault the plate snapped, I do not have significant enough bone growth (the x-ray still shows a clean as day gap between my bones) and the tensions snapped my plate.

I just turned 26, I am full time student and my insurance just expired at the end of October. I am being told I need too and it is the best thing for me to do, is to go back under the knife and get a new plate put in, one that is suppose to be stronger.

My thing is, that's some almost $50,000 for the surgery and I am uninsured.

My thinking is, if the surgical route will not help my bone growth, because it being done so long after the incident, should I bother going through with it.

However, this also leads me to my next stress is, my surgeon said if I allow the bone to stay the way it is now, not only was the original surgery a lose, but my collarbone has the possibility of shifting.

I have lost a major amount of mobility and strength in my arm, I am starting to realize I may not be 100% again even after a surgery. But I am also worried to see if the mobility I have no is what I will end up with if it is not treated and does not fuse back together.

In addition, it is my dominate arm. I am ambidextrous, but the majority of what I do when I have the choice of which arm, is with my left.

Boogles,

If you live close to a city which has a medical school, you might contact their orthopedic department. Many times, the schools will provide care free of charge to patients who do not have insurance to cover care that is necessary.

You can also contact the your local board of health, to see if there are any programs that you may qualify for, to pay for the bills. Some private practices will also do pro-bono care to the patients who have a problem that really needs an operation.


Unfortunately, when bones are treated with internal fixation, it is a race as to what happen first: the bone healing or the fixation failing. No hardware can withstand repetitive stress, it is just like a paper clip which a bent one too many times. It will ultimately fail.


In fracture care, there are few cases where you can get the majority of orthopedic surgeons to agree on the best way to approach the fracture.

In comminuted fractures, it is often very difficult to determine the best approach. Sometimes it is almost impossible to put all the little pieces back together, and it is better to let mother nature have a go at fixing it. If surgery is done, and there are a lot of small pieces, which to not have any soft tissue attachment, what do you do with them? Take them out, leave them and hope they get incorporated, use them as bone graft, it can be a real dilemma for the surgeon.

Contrary to what most patients believe about modern medicine, it does not have all the answers. And, just because a surgery can be attempted, is it always the best thing to do? Often, one of the hardest things to do, is to teach orthopedic residents when not to operate.

Extremely comminuted fractures (sometimes called a bag of bones fracture) are often best left alone. The amount of bleeding set up by the injury often stimulates the body to lay down an abundant amount of callus and thus heal the fracture.


It seems that the odds have just not been in your favor throughout this whole predicament. You do probably need to have another attempt at fixing this injury. The clavicle is the only bony attachment of the upper extremity to the axial skeleton. So, there is always stress being applied across the bone.


You have a real problem here. The chance of the bone healing on its own is small, but that is not to say that it is zero. But...with continued stress across the nonunion will most likely go on to what is called a pseudoarthrosis.


You should contact your surgeon and see if there is anything that he/she can recommend. Try all avenues. Again, some of the larger systems (Mayo Clinic, Cleveland Clinic, Campbell Clinic, etc) will do pro-bono work, but you will have to travel to make use of them.


Good luck. Hope you do find a solution to your problem. Sorry about your situation. Again, good luck.

Dear all,

I had an injury to the collarbone. The image is shown here:

http://tinyurl.com/bnstwze

Please tell me if surgery is the only option.
Thanks.

shomikc,

The best treatment for midshaft clavicle fractures is still not known. There is a lot of controversy about whether or not they should be operated upon.

There is one camp that feels that all clavicle fractures should have ORIF (open reduction and internal fixation) with a contoured clavicle plate. Supposedly, this brings the clavicle out to length and restores the overall biomechanics of the bone. This group of orthopedic surgeons feels that, since the clavicle is the only bony attachment of the upper extremity to the axial skeleton (the spine), that it is very important to restore the length and mechanics.

However, surgery on the clavicle carries some pretty significant risks. The great vessels are just under the collar bone, and are at risk with any surgery in that area. Of course, injury to the aorta, pulmonary vessels, etc could lead to catastrophic bleeding. Also, the plates used to fix the clavicle are usually very proud and cause the patient problems. So, almost always, the plate has to be removed once the bone is healed, which is another surgical procedure.


But, the other camp on this subject feels that the majority of clavicle fractures do not need surgery and that operating on the majority of clavicle fracture is unnecessary surgery.

They feel that the clavicle almost universally heals with abundant callus. They feel that the bump of callus formation almost never bothers patients, and that since the shoulder has such mobility, that it is not necessary for the clavicle to be brought exactly back out to length. That the small change in length does not affect the biomechanics enough to warrant risky surgery.


So, again, the treatment of midshaft clavicle fractures is controversial.


Thus, each fracture and patient has to be taken on a case by case basis. If the ends of the bone are tenting the skin, there is a great amount of angulation at the fracture site, or there is soft tissue interposed in between the ends of the bones, then surgery is usually recommended.

If the patient is in an occupation where he/she will need to wear load bearing equipement or ruck sacs (military, fire fighter, etc), then surgery may be the best way to go.

Of course, the patient has to understand the risks surrounding surgery.


But, if the patient does not have a lot of physical demands, then just letting the fracture heal on its own is the most common method of treatment. The patient may end up with a lump at the fracture site, but, it usually does not cause any problems.


So, you need to discuss your case with your surgeon. You have to look at your situation, and then pick the best treatment option for you.

Good luck.