The patient was then referred to the team orthopaedic physician for further evaluation. 20 Neurologic examination was within normal limits for both motor and sensory nerves. The clavicle was elevated medially due to sternocleidomastoid muscle spasm and depressed laterally as a result of the pull of gravity on the glenohumeral joint as well as pectoralis muscle spasm. Point tenderness and gross deformity along the medial shaft of the clavicle and crepitus and swelling over the fracture site were apparent. Unable to support himself, the athlete was escorted off the field by the sports medicine staff for injury evaluation.įield evaluation by the athletic trainer ruled out a shoulder dislocation, which the athlete had reported in his medical history. The athlete was completing a pass route when he went airborne and fully extended his body and shoulder in attempt to catch the pass he landed on the tip of his shoulder, sustaining a direct blow. In September 2009, a 23-year-old male collegiate football athlete fractured his right clavicle during preseason football practice. Combining the surgical repair and rehabilitation protocol allowed the athlete to return to the starting lineup for competition 6 weeks postinjury. 10 Thus, our purpose is to present the case of a National Collegiate Athletic Association Division I football player who sustained a midshaft clavicular fracture and underwent advanced surgical repair and rehabilitation. 14 However, in a retrospective study of 80 patients (40 nonoperative, 40 operative), return to sport activity was quicker for the patients treated nonoperatively: 2.6 months versus 3.2 months, respectively. When nonoperative protocols were compared with operative measures such as elastic stable intramedullary nailing, the operative groups had faster return to daily activities and better overall functional outcomes. 14 In 2007, the Canadian Orthopaedic Trauma Society 6 reported that early plate fixation for displaced clavicular fractures resulted in improved outcomes, early return to function, and decreased rates of nonunion and malunion. 19Īlthough nonoperative treatment of midshaft clavicular fractures is still the standard of care, we are seeing positive results from surgical advances. 19 With respect to displaced fractures, plating of 460 resulted in a nonunion rate of 2.2% compared with a nonunion rate of 15.1% in 159 patients treated nonoperatively. 18 In reviewing nonrandomized, noncomparative data of 635 plated fractures versus nonoperative treatment, the plated fractures had a nonunion rate of 2.5% and nonoperative treatment had a nonunion rate of 5.9%. No deformities or deficits in strength or range of motion were noted, and the satisfaction rate was 94%. 17 Shen et al 18 reported a union rate of 97% in 232 athletes who underwent plate osteosynthesis, with only 1 deep infection and 4 superficial infections. 17 Plate osteosynthesis has the benefit of offering much more rigid fixation with more rotational control of the fracture. However, intramedullary fixation should not be used if a plate would better maintain clavicular length. 16 Intramedullary fixation has been described as the simplest of the 3 procedures, limiting the exposure involved. External fixation has been effective in open fractures and nonunions. Operative management of clavicular fractures includes external fixation, intramedullary fixation, and osteosynthesis with a plate and screws. Closed treatment may lead to significant deficits, whereas surgical management results in an earlier and more reliable return to full function with a low complication rate. 8 –, 10 However, recent reports 11 –, 14 have discussed decreased union rates of displaced midshaft clavicular fractures treated nonoperatively. 7 The traditional conservative protocol provides positive results in more than 90% of athletes treated with a figure-8 sling. 4, 7 In the past, clavicle fractures have traditionally been treated nonoperatively due to concerns about infection, hardware prominence, and a potential increase in the risk of nonunion. 1 –, 6 Based on the anatomy of the clavicle, the midshaft region is the most susceptible to fracture, accounting for more than 70% of clavicular fractures. Fractures of the clavicle are very common, accounting for between 2% and 12% of all fractures sustained and as many as 44% of all shoulder injuries.
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