Background: Removing a segment of the clavicle allows an obvious inward movement of the shoulders with the loss of its bone length. Because it is the collarbone such reduction osteotomies are often thought of as fractures…a well known traumatic bone injury of the clavicle. But understanding how a clavicle osteotomy is different than a fracture explains many aspects of the intraoperative surgical technique and the postoperative recovery of clavicle reduction osteotomies.
A clavicle fracture is rarely a completely transverse line like that done in osteotomy cut. They are often at least oblique in orientation and not uncommonly spiral or even comminuted. As a result they usually have a larger surface area for the bone to heal. This often requires fixation devices that are much longer than those used in clavicle reduction osteotomies….often well over 1/2 the length of the clavicle with an associated longer incision to apply these devices. An important conceptual difference is that surgery in clavicle fractures is designed to bring the bone back out to length in a shoulder that is often injured as well.
Conversely a clavicle osteotomy is a very discrete cross-sectional cut in the bone. This is a smaller area of bone to heal and the plate fixation applied to hold it together has a much shorter length due to the use of a smaller access incision. It is also surgery that is designed to reduce the length of the clavicle on an otherwise normal functioning shoulder.
Case Study: This patient desired to a more feminine shoulder shape with a bideltoid distance of 49cms. There was not much clavicle show indicating that the softy tissues were fairly thick over the clavicles. There was some asymmetry with the left clavicle being longer with a higher left shoulder.
Under general anesthesia and through 3.5cm incisions in the supraclavicular fossa segments of the clavicle were removed with 2.5cms on the right and 2.75cms on the left. Double plate fixation was applied with a 6 hole 3.5cm plate on top and a 2.5mm plate on the anterior surface of the repposed bone.
When seen the next day after surgery the changes in her shoulder shape were apparent.
Her postoperative x-ray showed good alignment of the segments with bicortical screw placements.
One of the major postoperative differences between clavicle reduction osteotomies and clavicle fracture repair is in the recovery. While both have similar endpoints (6 weeks for full arm range of motion) how they get there is on dissimilar recovery processes. In clavicle fractures with an injured shoulder joint and more than adequate bone fixation early physical therapy is begun to lessen the risk of scarring and shoulder fibrosis. Conversely in clavicle reduction osteotomies with normal shoulder function and more limited bone fixation early restricted arm motion is encouraged with progressive increases up to the six week postoperative period.
Case Highlights:
1) Segmental clavicle resection is an effective shoulder reduction procedure.
2) The key to a successful shoulder reduction is stable fixation of the reapposed medial and lateral bone segments across a narrow osteotomy site.
3) Clavicle reduction plate fixation can not be very long in length to keep the incision small, thus the need for double plating.
Dr. Barry Eppley
World-Renowned Plastic Surgeon