How is a collarbone fracture treated?
The clavicle fracture can be treated conservatively or surgically. The decision is made on the basis of the X-ray image. Most clavicle fractures can be treated conservatively.
These include the non-displaced clavicle fracture, where there is only an axial kink in the area of the clavicle, and the slightly displaced (slightly dislocated) clavicle fracture, when there is no significant shortening of the clavicle length. More severely displaced clavicle fractures can theoretically be treated conservatively, but this often results in false joint formation (pseudarthrosis) and/or excessive bone callus formation. A remaining false joint formation leads to remaining pain in the fracture area, an excessive callus formation can compress the vascular nerve tract running under the clavicle and lead, for example, to circulatory and sensory disorders of the arm.
In the conservative therapy of a collarbone fracture, a special bandage is applied, which wraps around both shoulders like a rucksack (“backpack bandage”). On the patient’s back the bandage is pulled taut and fastened so that the shoulders are pulled backwards. By pulling the shoulders back, the collarbone fracture is set up (reduced) and held.
Immobilisation in the fracture area reduces pain and accelerates healing of the fracture. Under no circumstances should the rucksack bandage be applied so tightly that a venous congestion develops in the arms or that this leads to sensory and movement disorders of the arm. Adults wear the rucksack bandage for at least 3-4 weeks depending on the type of fracture, children up to 6 years of age for 2-3 weeks.
The length of time the bandage is worn is ultimately determined individually on the basis of the X-ray follow-ups. With the help of the X-ray image, fracture healing (fracture consolidation) and fragment position can be monitored. In the event of an increasing fragment displacement of the clavicle fracture (secondary dislocation) despite a backpack bandage, the fracture may still need to be surgically stabilized.
A problem in the X-ray assessment of the clavicle fracture is a fracture gap that is sometimes visible for months despite clinically stable bony fracture development. For this reason, the clinical examination findings should be taken into account when deciding on the wearing period of the rucksack bandage. Weigel and Nerlich (2004) recommend the following procedure: If the patient moves the shoulder painlessly and there is no longer pain from pressure in the fracture area, it can be assumed that the fracture is stable during exercise (not load-stable!
), even if this is not consistent with the radiological findings. Problems with the backpack bandage are frequent: all these problems have a negative effect on the patient’s cooperation (compliance) and can endanger the result of conservative therapy. Further treatment initially involves daily retightening of the rucksack bandage in the first week.
A first X-ray check should be performed after about 1 week, then depending on the type of fracture and the risk of a possible fracture displacement. At the latest when the backpack bandage is removed, a new X-ray check should be carried out. After 6-8 weeks, the collarbone fracture should have healed in a load-stable manner.
- Too loose or too tight fit
- Too little padding
- Low wearing comfort
- Handling unclear to the patient
The indication for surgical therapy of a clavicle fracture should be cautious, because the results are usually good with properly performed conservative therapy and the risks (see below) of conservative therapy can be avoided. The indication for surgical therapy of a clavicle fracture is still valid: Plate osteosynthesis: Bridging fracture plating (clavicle fracture) is the standard procedure for surgical stabilization of clavicle fractures. The fracture is reached by a skin incision running longitudinally over the clavicle or vertically over the fracture zone (“sabre cut”).
The fracture zone is prepared in a way that is gentle on the bone and soft tissue and bridged with a metal plate. At least 3 screws should be inserted above and below the plate to stabilize the fracture sufficiently. The operation is concluded with a final X-ray check, insertion of a wound tube (Redon drainage) and layered wound closure.
- Open collarbone fractures (rare)
- Accompanying vascular and nerve injuries
- Heavily displaced fractures
- Threatening fragment piercing of the skin
- Failure of conservative therapy
- Lateral fracture (fracture at the outer end of the clavicle, as the healing potential of the bone is very limited and permanent functional limitations can be expected)
- (Cosmetic reasons)
Prevot nailing is a relatively new procedure for surgical stabilization of clavicle fractures. The bone cavity (medullary canal) of the clavicle is opened through an incision near the breast bone and a nail is inserted through the closed or open fracture zone to the lateral end of the clavicle. The nail acts as an internal fracture splint.
Good results with this surgical method have been reported in the literature. Since various manufacturers now offer these nails, the name TEN (titanic elastic nail) is also used synonymously. With both surgical procedures, early functional physiotherapy (physiotherapy) can be followed up.
A backpack bandage is not necessary. The arm must not be loaded (supported, lifted, etc.) for 6-8 weeks, depending on the X-ray follow-up. The inserted osteosynthesis material (plate, screws or nail) can be removed after approx. 18-24 months (plate) or 8-12 months (nail).
