It is difficult to reduce and maintain the reduction of
clavicle fractures as there will be deforming forces in the midshaft area of
the clavicle. The clavicle will heal regardless as to if a sling or figure 8
strap is used. Despite the presence of a bump, fracture displacement, and
deformity, healing of the fracture still occurs rapidly. Healing occurs in
about 85% of cases, however, the clavicle will not look aligned due to the
difficulty in reducing the fracture. It is hard to achieve a reduction of these
fracture without surgery. Without surgical reduction, the fracture may end with
some degree of malunion and possible shortening of the clavicle. The fragments
will not line up with the distal fragment appearing to be downward and
anteriorly rotated. Shortening is clinically significant because it alters the
dynamics of the muscles around the shoulder. It also narrows the
costoclavicular space. The patient may complain of decreased shoulder strength
and endurance if the patient had a displaced midshaft clavicle fracture that
healed with more than 2 cm of shortening.
What are the symptoms of clavicle malunion?
Pain, easy fatigability, cosmetic problems (especially in
females), neurological dysfunction (possible involvement of the brachial plexus—especially
the ulnar nerve), and the patient may have thoracic outlet syndrome.
X-rays should be done of both shoulders. Bilateral panoramic
views are beneficial in order to measure the shortening. The physician will
also want to check the amount of overlap at the ends of the clavicle. Treatment
Surgical treatment of the malunion may be successful in
restoring the function and relieving the pain. A clavicle osteotomy is done in
the plane of the healed fracture. The fracture is recreated with correction of
the deformity and the length of the clavicle is restored. A local or iliac
crest bone graft can be used if needed.
If an osteotomy is done with reduction of the clavicle to
its preinjury position and leaves a significant bone defect, the physician will
need a tricortical piece of bone at the osteotomy area. It is probably better
to use a precontoured clavicle plate in the superior position with six
cortices, three placed on each side of the osteotomy.
