Child Orthopedics

Frequently Asked Questions

Our daughter fell and broke her collar bone. The physician's assistant at the emergency department gave her a sling and told her to move it slowly and carefully for a few weeks. That's it. I've had a lot of friends tell me that's outdated and their kids had surgery right away. What's the latest on this problem?

In the past, these injuries were left alone to heal on their own. Patients might have been given a simple sling to wear for a while. They were probably told what motions to avoid during the healing process. But that traditional view is no longer accepted. Now we know that these injuries occur on a continuum. Some patients may need special care. Studies show that complex fractures don't always just heal with good alignment and function. There are many types of clavicular (collar bone) fractures. Some are undisplaced (broken bones do not separate or pull apart). Those respond best to the type of conservative (nonoperative) care that was prescribed for your daughter. Patients with displaced (two ends of bone shift apart), intra-articular (at the joint) or extra-articular (outside the joint) are more likely to need surgery to hold the pieces of bone together while they heal. The same is true for fractures that are angulated, wedge-shaped, or comminuted (multiple fragments). There's enough new evidence to suggest that patients with displaced fractures are at increased risk for a poor outcome. This is especially true for displaced fractures with shortening of the bone. These patients can end up with shoulder weakness and decreased staying power (endurance) for activities requiring shoulder strength. Those are the people who need more than the traditional approach. Surgery may be needed sooner than later. There are many ways the surgeon can approach the problem. A metal plate can be used along the top of the clavicle to hold things together while the bone heals. A newer invention is the site-specific precontoured locking plate. This plate was designed to remain inside the body (no removal required). It is less prominent (sticks up less) and can be used with older adults who have osteoporosis (brittle bones). Sometimes the curved shape of the clavicle doesn't allow the use of plates. The surgeon may have to use a nail or pin that is narrow and flexible enough to pass through the bone lengthwise. At the same time, it has to be strong enough to hold the bone together during healing despite forces placed upon it. This technique is called intramedullary fixation. The nails offer a minimally invasive way to treat patients who have many other injuries in the shoulder and arm. If you have any doubts about the prescribed treatment for your daughter, make a follow-up appointment with an orthopedic surgeon. He or she can evaluate the situation and advise you as to the best treatment plan.

L.A. Kashif Khan, BSc(Hons), MRCSEd, et al. Current Concepts Review: Fracture of the Clavicle. In The Journal of Bone and Joint Surgery. February 2009. Vol. 91. No. 2. Pp. 447-460.

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