Clavicle Fractures In Hockey

Q: My 13-year-old son was on the wrong end of an open-ice hit and suffered a broken collarbone. What is the usual treatment for this injury, and how long is he going to be off the ice?
– Deanna J. (Minneapolis, Minn.)

 

A: Fractures of the clavicle are incredibly common injuries in ice hockey, occurring in players from the 8-and-Under to the professional level and beyond. Over the past five to 10 years, increased media attention has been given to this injury as several superstars, including Patrick Kane, Connor McDavid, and T.J. Oshie all suffered clavicle fractures while playing in NHL games.

The clavicles, sometimes referred to as collarbones, are horizontal, flat bones that are found in the upper chest and connect the breastbone (sternum) to the shoulders on either side. Clavicle fractures commonly result from direct trauma to the area during a collision. Players may collide with another player, like your son did, the boards, or the ice. 

The ideal treatment for clavicle fractures is variable and depends upon several important fracture characteristics. First, it is essential to know which part of the bone is fractured. Most clavicle fractures occur in the weakest part of the bone, the middle third, and those can often be treated successfully without surgery. Another important consideration in ice hockey players is shoulder dominance, which determines stick grip. A right-handed player places the left hand on top of the stick for support, but most of the motion associated with shooting the puck occurs with the right shoulder. Therefore, a right-handed player recovering from a left clavicle fracture may recover a little faster and have considerably less trouble getting back on the ice than if they had sustained a fracture of their right clavicle. 

The amount of displacement, meaning how far apart the fracture fragments are from one another, is a critical piece of information to consider when evaluating for surgery. If the parts of the bone on either side of the fracture are very far apart from each other, operative treatment with plates and screws may be necessary to properly bring the bone fragments together. Other indications for surgery include the presence of multiple fracture fragments, open wounds overlying the injury, and/or skin tenting, which occurs when bone fragments are placing significant pressure onto the skin from the inside. 

If the goal is returning to play as soon as possible, surgery may also be considered. The surgical procedure immediately re-aligns the fracture fragments and secures them into place with metal plates and screws. Once the bone is back in its proper position, healing occurs much more quickly. 

A recent study in NHL players with clavicle fractures revealed that those players who underwent surgery returned to play one month sooner than those players treated without surgery (65 days versus 97). While research continues to evolve, the most up-to-date evidence has demonstrated a benefit in terms of successful healing and restoration of natural anatomy. However, as with any surgery, there is always a risk of postoperative complications. In some cases, additional surgeries may be required to treat those complications.

Nonoperative options typically involve treating the player with a sling for 4-6 weeks. After this time, repeat X-rays will be obtained and a repeat examination performed by the physician. If X-rays demonstrate adequate healing of the fracture, and if the injured clavicle is no longer tender on examination, physical therapy can safely begin at that point. 

Return to skating and introduction of contact can usually commence around eight to 12 weeks following the injury. It is important to note that with nonoperative treatment of any clavicle fracture, there is often some degree of residual deformity after the bone heals; however, in most cases, pain is no longer present, and there are no limitations in shoulder function. As compared to clavicle fractures treated by surgery, those treated only by placing the arm in a sling have up to a 15% chance of not healing properly. Therefore, a discussion with your treating doctor about the risks and benefits of surgery as compared to the risks of incomplete healing without surgical intervention is warranted. P

 

Charles A. Popkin, MD is a team physician for USA Hockey and is a member of the Safety and Protective Equipment Committee. He is an Associate Professor of Orthopedic Surgery at the Center for Shoulder, Elbow and Sports Medicine at Columbia University in New York City. 

Issue: 
2023-07

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