When is early return too early? Clavicle plate fixation in Australian Rules football athletes: A retrospective review of cases

Background: We retrospectively reviewed return to sport times and results for a series of professional Australian Rules football (AFL) players after clavicle fracture management using a precurved Titanium (Acumed) plate and screws. We allowed very early use and aimed to assess if this construct is strong enough to withstand collision sport activities before radiological union is confirmed. Methods: We reviewed 14 consecutive senior listed AFL players who underwent plate fixation by the senior author over a 10 year period. Outcome measures were taken between 12 and 36 months post operatively and included time to return to play, Nottingham Clavicle Score (NCS) and the Oxford Shoulder Score.  Results: The median time for return to training was 3.5 weeks and 6 weeks for return to full competition.  All fractures eventually united. Three of the players that returned before 6 weeks post-operatively suffered significant impacts that caused a bend in the titanium plates. One of these required revision fixation surgically due to perceived weakness in the bent plate construct and cosmetic deformity. The mean Nottingham Clavicle Score and Oxford Shoulder Score were 87.9 and 45.1 points respectively. Survival analysis showed that more than half of the players returned to training at 4 weeks and over 80% at 12 weeks. Discussion: The decision to operate early on AFL players who suffered a clavicle fracture in competition play resulted in excellent longterm results. However, the decision to return some players earlier than accepted times for bony union resulted in bending of plates in a significant number, and the risk of further injury must be weighed up in a collision sport.  The early return to play time had no adverse effects on performance and participant satisfaction was high, as reflected by the Nottingham Clavicle score and the Oxford shoulder score.