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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 8  |  Issue : 1  |  Page : 46-49

Clavicular fracture in a national wrestler: A case report of rapid return to play


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 Publication13-Jun-2016

Correspondence Address:
Erdinc Acar
Department of Orthopedics and Traumatology, Division of Hand and Upper Extremity Surgery, Meram School of Medicine, Konya N.E University, Konya
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-7341.183954

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  Abstract 

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 2019 Nov 14];8:46-9. Available from: http://www.jotr.in/text.asp?2015/8/1/46/183954


  Introduction Top


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.[1],[2],[3],[4],[5],[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.[5],[7] 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.[8],[9],[10] However, recent reports have discussed decreased union rates of displaced midshaft clavicular fractures treated nonoperatively.[11],[12],[13],[14] 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.[10],[14],[15]

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.[16] 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.[17] Plate osteosynthesis has the benefit of offering much more rigid fixation with more rotational control of the fracture.[17] Shen et al.[18] 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%.[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%.[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.[19]

Although nonoperative treatment of midshaft clavicular fractures is still the standard of care, we are seeing positive results from surgical advances.[14] In 2007,[1] 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 Top


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.[20] 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.[20] In addition, plate osteosynthesis results in less displacement at fixed loads and provides a stronger construct, allowing early rehabilitation.[21]

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].
Figure 2: Radiograph showing plate osteosynthesis

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Rehabilitation

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 3: Radiograph showing postoperative 12 weeks

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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 Top


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.[22] Midshaft clavicular fractures account for 69-82% of all clavicular fractures.[6],[7] In the past, nonoperative treatment was the norm, based on the reports of rare nonunion episodes:[4],[23] 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.[23] 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.[24],[25] We present a successful ORIF surgical repair and specific timeline for return to functional, competitive activity.


  Conclusions Top


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,[19],[26],[27] and intramedullary nailing using titanium elastic nails has also evolved.[14],[28] 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.

Acknowledgment

Thanks for the help from Sinan Bilgin MD, Nazım Karalezli MD, Mehmet Armangil MD.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am 2007;89:1-10.  Back to cited text no. 1
    
2.
Craig EV. Fractures of the clavicle. In: Rockwood CA, Matsen FA 3rd, editors. The Shoulder. Vol. 1. Philadelphia, PA: WB Saunders; 1990. p. 367-401.  Back to cited text no. 2
    
3.
Eskola A, Vainionpää S, Myllynen P, Pätiälä H, Rokkanen P. Outcome of clavicular fracture in 89 patients. Arch Orthop Trauma Surg 1986;105:337-8.  Back to cited text no. 3
    
4.
Neer CS 2nd. Nonunion of the clavicle. J Am Med Assoc 1960;172: 1006-11.  Back to cited text no. 4
    
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Nordqvist A, Petersson C. The incidence of fractures of the clavicle. Clin Orthop Relat Res 1994;300:127-32.  Back to cited text no. 5
    
6.
Postacchini F, Gumina S, De Santis P, Albo F. Epidemiology of clavicle fractures. J Shoulder Elbow Surg 2002;11:452-6.  Back to cited text no. 6
    
7.
Smekal V, Oberladstaetter J, Struve P, Krappinger D. Shaft fractures of the clavicle: Current concepts. Arch Orthop Trauma Surg 2009;129:807-15.  Back to cited text no. 7
    
8.
Grassi FA, Tajana MS, D'Angelo F. Management of midclavicular fractures: Comparison between nonoperative treatment and open intramedullary fixation in 80 patients. J Trauma 2001;50:1096-100.  Back to cited text no. 8
    
9.
Post M. Current concepts in the treatment of fractures of the clavicle. Clin Orthop Relat Res 1989;245:89-101.  Back to cited text no. 9
    
10.
Robinson CM, Court-Brown CM, McQueen MM, Wakefield AE. Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. J Bone Joint Surg Am 2004;86:1359-65.  Back to cited text no. 10
    
11.
Chan KY, Jupiter JB, Leffert RD, Marti R. Clavicle malunion. J Shoulder Elbow Surg 1999;8:287-90.  Back to cited text no. 11
    
12.
McKee MD, Pedersen EM, Jones C, Stephen DJ, Kreder HJ, Schemitsch EH, et al. Deficits following nonoperative treatment of displaced midshaft clavicular fractures. J Bone Joint Surg Am 2006;88:35-40.  Back to cited text no. 12
    
13.
McKee MD, Wild LM, Schemitsch EH. Midshaft malunions of the clavicle. J Bone Joint Surg Am 2003;85:790-7.  Back to cited text no. 13
    
14.
Smekal V, Irenberger A, Struve P, Wambacher M, Krappinger D, Kralinger FS. Elastic stable intramedullary nailing versus nonoperative treatment of displaced midshaft clavicular fractures: A randomized, controlled, clinical trial. J Orthop Trauma 2009;23: 106-12.  Back to cited text no. 14
    
15.
Hill JM, McGuire MH, Crosby LA. Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg Br 1997;79:537-9.  Back to cited text no. 15
    
16.
Schuind F, Pay-Pay E, Andrianne Y, Donkerwolcke M, Rasquin C, Burny F. External fixation of the clavicle for fracture or non-union in adults. J Bone Joint Surg Am 1988;70:692-5.  Back to cited text no. 16
    
17.
Preston CF, Egol KA. Midshaft clavicle fractures in adults. Bull NYU Hosp Jt Dis 2009;67:52-7.  Back to cited text no. 17
    
18.
Shen WJ, Liu TJ, Shen YS. Plate fixation of fresh displaced midshaft clavicle fractures. Injury 1999;30:497-500.  Back to cited text no. 18
    
19.
Zlowodzki M, Zelle BA, Cole PA, Jeray K, McKee MD; Evidence-Based Orthopaedic Trauma Working Group. Treatment of acute midshaft clavicle fractures: Systematic review of 2144 fractures: On behalf of the Evidence-Based Orthopaedic Trauma Working Group. J Orthop Trauma 2005;19:504-7.  Back to cited text no. 19
    
20.
Moonot P, Ashwood N. Clavicle fractures. Trauma 2009;11:123-32.  Back to cited text no. 20
    
21.
Golish SR, Oliviero JA, Francke EI, Miller MD. A biomechanical study of plate versus intramedullary devices for midshaft clavicle fixation. J Orthop Surg Res 2008;3:28.  Back to cited text no. 21
    
22.
Swanson KE, Swanson BL. A minimally invasive surgical technique to treat distal clavicle fractures. Orthopedics 2009;32:509.  Back to cited text no. 22
    
23.
Wick M, Müller EJ, Kollig E, Muhr G. Midshaft fractures of the clavicle with a shortening of more than 2 cm predispose to nonunion. Arch Orthop Trauma Surg 2001;121:207-11.  Back to cited text no. 23
    
24.
Mizue F, Shirai Y, Ito H. Surgical treatment of comminuted fractures of the distal clavicle using Wolter clavicular plates. J Nippon Med Sch 2000;67:32-4.  Back to cited text no. 24
    
25.
Mueller M, Burger C, Florczyk A, Striepens N, Rangger C. Elastic stable intramedullary nailing of midclavicular fractures in adults: 32 patients followed for 1-5 years. Acta Orthop 2007;78:421-3.  Back to cited text no. 25
    
26.
McKee MD, Seiler JG, Jupiter JB. The application of the limited contact dynamic compression plate in the upper extremity: An analysis of 114 consecutive cases. Injury 1995;26:661-6.  Back to cited text no. 26
    
27.
Poigenfürst J, Rappold G, Fischer W. Plating of fresh clavicular fractures: Results of 122 operations. Injury 1992;23:237-41.  Back to cited text no. 27
    
28.
Frigg A, Rillmann P, Perren T, Gerber M, Ryf C. Intramedullary nailing of clavicular midshaft fractures with the titanium elastic nail: Problems and complications. Am J Sports Med 2009;37:352-9.  Back to cited text no. 28
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1]


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