|Year : 2015 | Volume
| Issue : 1 | Page : 46-49
Clavicular fracture in a national wrestler: A case report of rapid return to play
Erdinc Acar, Serdar Toker
Department of Orthopedics and Traumatology, Division of Hand and Upper Extremity Surgery, Meram School of Medicine, Konya N.E University, Konya, Turkey
|Date of Web Publication||13-Jun-2016|
Department of Orthopedics and Traumatology, Division of Hand and Upper Extremity Surgery, Meram School of Medicine, Konya N.E University, Konya
Source of Support: None, Conflict of Interest: None
The objective of the present study was to present the case of surgical treatment and rehabilitation of a midshaft clavicular fracture in a national wrestler. This is a case report of a 20-year-old female national wrestler who met a motorcycle accident (July 9, 2014). Postinjury radiographs revealed a midshaft clavicular fracture. She came a month after the accident. She had got a pain. Differential diagnosis revealed spiral oblique midshaft clavicular fracture. The sports medicine staff discussed surgical and nonsurgical options. A surgical procedure of internal fixation with an 8-hole anatomic clavicula plate was performed. In August 2014, she had surgery at Emirdag/Afyon County Hospital. Surgical treatment for clavicular fractures is becoming increasingly common. We suggest that new rehabilitation protocols for clavicular repairs should be investigated now that surgical treatment is being pursued more frequently. More aggressive treatment procedures and rehabilitation protocols for clavicular fractures have evolved in recent years. With these medical advancements, athletes are able to return to play much more quickly without compromising their health and safety.
Keywords: Accelerated rehabilitation, athletic injuries, upper extremity injuries
|How to cite this article:|
Acar E, Toker S. Clavicular fracture in a national wrestler: A case report of rapid return to play. J Orthop Traumatol Rehabil 2015;8:46-9
|How to cite this URL:|
Acar E, Toker S. Clavicular fracture in a national wrestler: A case report of rapid return to play. J Orthop Traumatol Rehabil [serial online] 2015 [cited 2020 May 28];8:46-9. Available from: http://www.jotr.in/text.asp?2015/8/1/46/183954
| Introduction|| |
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.,,,,, Based on the anatomy of the clavicle, the midshaft region is the most susceptible to fracture, accounting for more than 70% of clavicular fractures., In the past, clavicle fractures have traditionally been treated nonoperatively. The traditional conservative protocol provides positive results in more than 90% of athletes treated with a figure-8 sling.,, However, recent reports have discussed decreased union rates of displaced midshaft clavicular fractures treated nonoperatively.,,, 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.,,
Operative management of clavicular fractures includes external fixation, intramedullary fixation, and osteosynthesis with a plate and screws. External fixation has been effective in open fractures and nonunions. Intramedullary fixation has been described as the simplest of the three procedures, limiting the exposure involved. However, intramedullary fixation should not be used if a plate would better maintain clavicular length. Plate osteosynthesis has the benefit of offering much more rigid fixation with more rotational control of the fracture. Shen et al. reported a union rate of 97% in 232 athletes who underwent plate osteosynthesis, with only one deep infection and four superficial infections. No deformities or deficits in the strength or range of motion were noted, and the satisfaction rate was 94%. 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%. 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.
Although nonoperative treatment of midshaft clavicular fractures is still the standard of care, we are seeing positive results from surgical advances. In 2007, the Canadian Orthopaedic Trauma Society reported that early plate fixation for displaced clavicular fractures resulted in improved outcomes, early return to function, and decreased rates of nonunion and malunion. Thus, our purpose is to present the case of a national wrestler who sustained a midshaft clavicular fracture and underwent advanced surgical repair and rehabilitation. Combining the surgical repair and rehabilitation protocol allowed the athlete to return to wrestle for competition 12 weeks postinjury.
| Case Report|| |
In July 2014, a 20-year-old female national wrestler fractured her right clavicle during a motorcycle accident. She came a month after the accident at Emirdag/Afyon County Hospital. She had got a pain. In August 2014, she had surgery at Emirdag/Afyon County Hospital.
In her medical history, the wrestler had reported that point tenderness and gross deformity along the medial shaft of the clavicle and crepitus and swelling over the fracture site were apparent. 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. Neurologic examination was within normal limits for both motor and sensory nerves. The patient was then referred to the team's orthopedic physician for further evaluation. Radiographic examination revealed a closed midshaft, comminuted fracture of the right clavicle [Figure 1] with shortening of 3 cm. Operative and nonoperative options were carefully discussed, and surgery was elected.
|Figure 1: Anterior-posterior radiograph showing midshaft clavicular fracture|
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Internal fixation of the right clavicle with plate osteosynthesis was performed. Plate osteosynthesis was chosen over intramedullary pins due to the plate's ability to resist greater torsion and no risk of pin migration. In addition, plate osteosynthesis results in less displacement at fixed loads and provides a stronger construct, allowing early rehabilitation.
At the time of surgery, a large butterfly fragment of approximately 2 cm off the anterior aspect of the midclavicle and a spiral oblique fracture were noted. The butterfly fragment was fixed with a 3.5 mm interfragmentary screw, reducing the fracture to two parts. The fracture was reduced and secured with the superior plate. Given the length of the fracture, the superior plate was used to maximize the strength and stability [Figure 2].
The rehabilitation process began immediately postsurgery under the direction of the medical and athletic training staff. Two days after surgery, the patient was performing range-of-motion pendulum exercises and strengthening through bicep curls and triceps extensions as shown in [Table 1]. As is routinely the case, our focus was the entire kinetic chain throughout the entire rehabilitation period. Repetitions and sets were increased as tolerated. Range of motion progressed from active assistive to full active exercises with the patient performing all motions independently. By postoperative day 4, the patient had achieved 170°-173° of shoulder flexion and abduction and 19°-22° of shoulder extension and adduction.
|Table 1: Accelerated rehabilitation program for clavicle fracture (exercises by week)|
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Weekly radiographs were taken to ensure that no complications were occurring during the healing process. Two weeks after surgery, shoulder extension and adduction had improved slightly >30° and muscle strength was 80%. She was allowed to discontinue the use of her sling and begin jogging. At week 3-10, the patient began push-up progressions off a table, dynamic stabilization and advanced scapular exercises, strengthening exercises, and participation in noncontact practices. By week 11, full strength and range of motion were achieved, and the wrestler was released to full contact during practice. By week 12, the wrestler was released to return to full competition [Figure 3]. She won a silver medal at Turkey Wrestling Championships in January 2015 [Figure 4].
|Figure 4: U 23 Women Turkey Wrestling Championships 31 January — 1 February 2015, in the province of Eskisehir, were made between the dates. Saziye Nur Madah 60 pounds Turkey second|
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| Discussion|| |
The fracture sustained in this case was a Type I, middle third of the clavicle, which is considered the most common site for clavicular fractures. Midshaft clavicular fractures account for 69-82% of all clavicular fractures., In the past, nonoperative treatment was the norm, based on the reports of rare nonunion episodes:, The recommendation for Type I clavicular fractures with shortening was a conservative approach for 6 weeks and then, if no callus had formed, surgery was indicated. However, the treatment of clavicular fractures has changed drastically in recent years. Due to the current trend of nonunion rates in nonsurgical management, open reduction and internal fixation (ORIF) has become readily accepted in clavicular fracture management.
The ORIF was performed immediately, and the athlete returned to full, competitive contact within 12 weeks. Previous timelines for regaining full range of motion and function after surgery were unclear., We present a successful ORIF surgical repair and specific timeline for return to functional, competitive activity.
| Conclusions|| |
Traditionally, an athlete undergoing traditional treatment of a clavicular fracture would have been immobilized for 3-6 weeks before any range-of-motion exercises were started. However, in the past few years, more aggressive treatment protocols for clavicular fractures have become popular. Success rates of 94-100% with low rates of infections and complications have been reported with plate fixations of acute midshaft clavicular fractures,,, and intramedullary nailing using titanium elastic nails has also evolved., With surgical treatment and appropriate rehabilitation, our athlete was able to return to competition at 12 weeks without compromising her health or safety.
The rehabilitation protocol implemented in this case was advanced, yet evidence on validated accelerated rehabilitation protocols for clavicular fractures is currently lacking. As surgical repair for clavicular fractures becomes more frequent, we need to investigate new rehabilitation protocols.
Thanks for the help from Sinan Bilgin MD, Nazım Karalezli MD, Mehmet Armangil MD.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]