Clavicle fractures. Intro. Orthopaedic Textbooks 1995: Displaced Clavicle Fractures 2/2/2016. Who am I?... Outcome.generally good.
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1 Clavicle fractures John Theodoropoulos MD MSc FRCSC Mount Sinai Hospital University of Toronto Intro Who am I?... Academic urban practice University of Toronto GTA; 4 million catchment Team orthopaedic surgeon (Leafs, Marlies, Blue Jays) Orthopaedic Textbooks 1995: Displaced Clavicle Fractures Outcome.generally good. Displaced fractures of the clavicle generally do well with non-operative treatment Nonunion rate <1% (Neer 3 / 2239 cases) Malunionsof the clavicle require no treatment 1
2 2005 Clavicle Fractures We know closed treatment has a significant failure rate (nonunion, symptomatic malunion) We know ORIF has a high success rate and low complication rate That doesn t necessarily mean that we should fix all clavicle fractures 2
3 Clavicle Fractures Nonunion = 14% in non-op vs 1.6% in operative Time to union = 28 wks in non-op vs 16 wks in operative Symptomatic malunion = 18% in non-op vs 0% in operative Hardware removal = 8% in operative group July 4, 2014 Clavicle Fractures July 4,
4 Clavicle Fractures Hardware removal = 18% in operative group Reoperation rate = 25% July 4, 2014 CASE 1: 17 y.o. OHL forward Fall directly into boards chasing puck Painful deformity shoulder N/v intact Skin intact No previous injury Displaced midshaft clavicle fracture 4
5 Healthy Considerations moderately displaced fracture Draft year Good player Mid to late season ORIF pre-contoured plate At 6 weeks 5
6 At 6 weeks Who would let him practice? Who would let him play? How can we assess return to play and does surgery make this easier? Feb 24, 2015 Feb 26, 2015: Player has surgery on fractured clavicle 6
7 April 12, 2015 November 3, 2015: Player fractures clavicle, surgery the following day November 27, 2015: Player will be back in January 7
8 January 8, 2015: Player not expected to return until 3 months after surgery Timing in season Key Questions Risks versus benefits of early return CT Scan, Biodex testing CT Scan 8
9 CT Scan Biodex Testing CASE 1: 22 y.o. CHL forward Isolated clavicle injury Painful deformity shoulder Skin tenting 9
10 CASE 1: 22 y.o. CHL forward July 4, 2014 Case 1 July 4,
11 Look at the Patient.not just the xrays July 4, 2014 Time Line/Rehab Initial Dx3-4 months Wk1: Rest and immobilization Local Rx: ice, microcurrent; soft tissue treatments Work the hand and elbow Infection Physician follow up Rehab Wk2: Lower body ex. ie. Bike Continue with local Rx Discontinue immob. AROM/PROM to 90 deg. Supine proprio ex No strengthening!! 11
12 Rehab Wk 3: AROM/PROM/Proprio ex. Ball tosses Skate on own. No shooting/stick handling Rehab Wk 4: Intro shoulder strengthening Pushups Skating with SC Begin stickhandling End of 4 th wkbegin limited shooting X-ray Physician F/U Rehab Wk 5: Cont. strengthening On and off-ice conditioning Shoulder shrugs *** Increase shooting on ice and dry land 12
13 Rehab Wk6: Skate with team No contact!! Physician F/U Rehab Wk 7: Cleared for full participation Contact in practice Wk8: X-ray; Surgeon F/U RTP End Result 13
14 Do I operate on all clavicle fractures in hockey? Do I operate on all clavicle fractures in hockey? Do I operate on all clavicle fractures in hockey? 14
15 Acute clavicle fractures in the NHL Incidence Since 2004 Acute clavicle fractures in the NHL Incidence SINCE 2004 Acute clavicle fractures in the NHL Incidence SINCE
16 Acute clavicle fractures in the NHL Incidence SINCE 2004 l l Acute clavicle fractures in the NHL Incidence 17 clavicle fractures in the NHL since 2004 (out of a total 994 fractures) Man Games Lost 22 MGL/injury Acute clavicle fractures in the NFL* Incidence l 19 mid-third clavicle fractures in the NFL over the last 5 years l Minimally / non-displaced 6 (32%) l Displaced / comminuted 13 (68%) * Connor et al., Carolina panthers 16
17 Acute clavicle fractures in the NFL* Displaced / comminuted fractures (13) Acute ORIF NON op Number of fractures 6 7 Average healing time Nonunions or refracture 0 4 RTP same season 3 1 Missed time NEXT season 0 3 * Connor et al., Carolina panthers Cost Cost to the hospital (OR time, plate, etc) Cost to society - QALY s - $49,000 Cost to the patient i.e. self-employed Cost time is money professional athlete 17
18 Displaced clavicle fractures in professional contact sport athlete LIKELY reasonable to consider early operative fixation recognizing the risks thereof Predictable clinical course May significantly shorten RTP THANK YOU! 18
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