Clavicle Fracture Complications: Plate Penetration and Surgical Solutions

Clavicle fracture with plate penetration through the skin?

Hello Doctor, I was in a car accident on March 17, 2015, which resulted in a mid-shaft fracture of my left clavicle, causing the bone to break into two displaced segments.
In early April, I underwent surgery to place a plate for stabilization, with six screws used for fixation.
By early May, I started rehabilitation for my left arm, which was going smoothly.
However, after the stitches were removed in mid-April, I noticed a purplish discoloration about 1 cm around the surgical site.
On June 27, 2015, the plate pierced through the skin.
I underwent debridement and suturing on July 13, 2015, but after the stitches were removed on August 4, I found that the skin was still too thin.
On August 17, the plate began to break through the skin again.
I have now decided to have surgery on August 31, 2015, to remove the plate early and replace it with a flexible titanium alloy screw that will be inserted horizontally through the middle of the clavicle.
However, I had a previous surgery on the distal end of my left clavicle due to a fracture, and there is already a fixation device in place, so the doctor mentioned that it may not be possible to successfully pass this new screw through.
Additionally, the doctor indicated that there might be a small protrusion at the proximal end (near the neck) where the screw bends.

I would like to ask:
1.
Is this method of fixation considered minimally invasive surgery? If so, is it normal for there to be a small protrusion with this type of surgery, and is there still a concern for skin penetration? When the screw needs to be removed later, will it be sufficient to make approximately 1 cm incisions at both ends to extract it?
2.
Given that I have had the plate in place for 5 months, is the clavicle not healed enough? Is it necessary to use this screw for fixation? The X-rays show that the clavicle is healing, but the doctor is concerned that it may be brittle and prone to re-fracture.

3.
If the plate is removed and the screw fixation is unsuccessful, should I avoid sleeping flat on my back?
I apologize for the complexity of my questions, and I appreciate your patience in answering them.
Thank you.

gary, 20~29 year old female. Ask Date: 2015/08/26

Dr. Shi Guozheng reply Orthopedics

The fixation method you mentioned may involve the use of intramedullary nails.
This is not a minimally invasive surgery, but the incision can be smaller.
After healing, in some cases, a small incision can be made from the lateral side to remove the bone screws.
Whether a second surgery is necessary must be thoroughly discussed with your attending physician.
After the removal of the plate, if there is no bone union, pain may persist.
However, lying flat is still possible.

Reply Date: 2015/08/26

More Info

Clavicle fractures, particularly those that require surgical intervention, can lead to various complications, including plate penetration, which you've experienced. Your situation involves a series of surgeries and adjustments to your treatment plan, which is not uncommon in complex cases like yours. Let’s address your questions one by one.

1. Is this type of fixation considered minimally invasive surgery?
The procedure you are undergoing with the titanium alloy screw can be classified as a minimally invasive technique, especially if it involves smaller incisions compared to traditional open surgery. However, the term "minimally invasive" can vary based on the specific techniques and instruments used. The presence of a small protrusion from the screw is not unusual, especially if the screw is positioned close to the skin. While it may not pose an immediate risk of skin penetration, it is essential to monitor it closely. If the protrusion causes discomfort or skin irritation, further evaluation may be necessary. When it comes to removing the screw, typically, the surgeon would make small incisions at both ends of the screw to extract it, which should minimize scarring.

2. Is the clavicle sufficiently healed after five months of plate fixation?
Clavicle fractures generally take about 6 to 12 weeks to heal, but complete healing can take longer, especially if there were complications or if the fracture was particularly severe. The fact that your X-rays show signs of healing is a positive indication. However, your doctor’s concern about the bone being "brittle" suggests that while there may be some healing, the structural integrity of the bone may still be compromised. This is not uncommon in cases where there has been significant displacement or multiple surgeries. The decision to keep the screw in place is likely a precautionary measure to provide additional support until the bone has fully regained its strength.

3. If the plate is removed and the screw fixation fails, should I avoid sleeping on my back?
After the removal of the plate and depending on the success of the screw fixation, your sleeping position may need to be adjusted. If the screw does not provide adequate stability, you might be advised to avoid certain positions that could put stress on the clavicle, especially if you experience pain or discomfort. It’s crucial to follow your surgeon's recommendations regarding activity restrictions and sleeping positions post-surgery. They may suggest using pillows for support or sleeping in a position that minimizes pressure on the affected area.

In addition to these specific concerns, it’s essential to maintain open communication with your healthcare team. They can provide tailored advice based on your healing progress and any symptoms you may experience. Regular follow-ups and imaging studies will help assess the healing process and determine the best course of action moving forward.

Lastly, it’s worth noting that rehabilitation plays a critical role in recovery after clavicle surgery. Engaging in physical therapy can help restore strength and mobility, which is vital for your overall recovery. If you have concerns about your rehabilitation process or the exercises you are doing, don’t hesitate to discuss them with your physical therapist or orthopedic surgeon.

In summary, your case involves careful monitoring and management due to the complexities of your fracture and the surgical interventions you've undergone. While there are risks associated with any surgical procedure, following your doctor's advice and maintaining a proactive approach to your recovery can significantly enhance your healing process.

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