The treatment of clavicle fractures is still controversial and debated. Non-operative treatments are the common choice in non-displaced fractures, whereas operative treatments using plates and screws fixation are the current gold standard in displaced and comminuted fractures. The implants that are mostly used can be divided into two groups: intramedullary devices (nails) and extramedullary devices (plates). Plates can be subdivided into reconstruction plates and small fragment locking compression plates. As in any other operative intervention, postoperative complications have been reported. Wijdicks
et al. published a large systematic review of the complications of plate fixation of clavicle fractures and reported low non-union and malunion rates (< 10%) [
12]. Furthermore, they noted that the vast majority of complications seemed to be implant-related, with irritation or failure of the plate consistently reported in almost every study ranging from 9 to 64% of the cases [
12]. Failure of the implants is seen in 1 to 4% of the cases [
13] and can be related to either a mechanical or a biological mode. Biological reasons include poor bone quality, age, and fracture location. Mechanical reasons include bending stress leading to plate failure usually at the screw–plate junction, screw loosening, and plate breakage [
7,
13,
14]. In the former, the mechanism of failure is expressed as a gradual loosening of fixation, leading to pull out of the hardware construct. In the latter, a formal breakage of the hardware occurs, while the screws remain well fixed to the bone without loosening [
7]. Some risk factors for plate breakage have been suggested. Among them are high energy injuries, Robinson 2B2 fracture type, using a plate to bridge a fracture, and lifting a heavy weight within 1 month after surgery against rehabilitation program since the plates may not be strong enough to support shoulder motion before bony union [
7,
15].
There are different types of bones in the skeleton; the clavicle is classified as a modified long bone whose biomechanical behaviour is unlike a vertical long bone. In vertical long bones gravity applies compression forces along the bone; however, in the clavicle, gravity is perpendicular to the bone due to its horizontal position. In a laboratory environment on 12 fresh cadaveric clavicles, Harnroongroj
et al. found that the compression load along the axis of the clavicle produced a middle one-third clavicular fracture as in clinical observation [
16]. Clavicle anatomy and biomechanics may explain why a bridging plate is a risk factor for plate breakage. Questions about ways to optimize the surgical technique and rehabilitation protocol following clavicle fracture, while considering the characteristics and orientation of the clavicle relative to gravity, should be raised and examined.
In the current case report, our patient was exposed to some of the risk factors for implant failure including the use of a bridging plate and postoperative functional restrictions. Another important aspect, which is less common but is gaining attention, especially among policymakers and health reforms, is patient expectations [
17]. We present a scenario where the chain of decisions was in accordance to the patient’s goal (regain function as soon as possible) while considering other factors such as age, level of physical activity, and fracture pattern, yet the outcome was not satisfying. We believe that in our case the risk factor of our patient’s personality, along with the type of fracture, bridging plate, and the nature of forces and stresses acting on the clavicle, led to plate failure and poor surgical outcome. Identifying a patient’s personality (highly motivated to regain functionality) in advance and educating the patient thoroughly on the treatment process including the possible risks and complications that might occur due to poor compliance with the rehabilitation instructions, might have helped in avoiding plate failure.