1
|
Cavaliere A, Cepparulo V, Pezone G, Schonauer F. Clavicle Fracture Site Surgical Contouring: A Case Report. Arch Plast Surg 2024; 51:67-71. [PMID: 38425849 PMCID: PMC10901599 DOI: 10.1055/s-0043-1775880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 09/01/2023] [Indexed: 03/02/2024] Open
Abstract
Clavicle fractures are frequent injuries accounting for approximately 4% of all fractures in adults with about 35% occurring in the shoulder region among which midshaft fractures are the most common (>66%). Nonsurgical management is the treatment of choice for most clavicle fractures; however, poor functional and aesthetic outcomes may result from nonunion, symptomatic malunion, and aesthetic impairment which are the most common complications. A young woman was referred to our clinic for a "Step Deformity" resulting after primary, nonsurgical treatment of a midshaft clavicle fracture. Residual deformity was corrected with a novel simple and little invasive approach. Midshaft clavicle fractures typically only require conservative nonsurgical treatment, nevertheless suboptimal outcomes may occur. Selective osteotomies and fixation are deemed too invasive when only cosmetic impairment of the clavicle contour is present without any functional or sensitive damage and most patients are discouraged from undergoing surgery. Thus far, no specific focus on this topic, nor exploration of possible correction can be found in the published literature. These residual deformities may be very noticeable sometimes and cause psychological distress and social life impairment. Despite no related functional impairment, this deformity should still be addressed, to improve patients' quality of life.
Collapse
Affiliation(s)
| | | | - Giuseppe Pezone
- Unit of Plastic Surgery, University “Federico II”, Naples, Italy
| | | |
Collapse
|
2
|
deMeireles AJ, Czerwonka N, Levine WN. Clavicle Nonunion and Malunion: Surgical Interventions for Functional Improvement. Clin Sports Med 2023; 42:663-675. [PMID: 37716729 DOI: 10.1016/j.csm.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2023]
Abstract
Clavicle nonunion and malunion are relatively uncommon but, when symptomatic, can result in pain and dysfunction that requires surgical intervention. Various reconstructive and grafting techniques are available to achieve stable fixation and union. In the setting of persistent nonunion, vascularized bone grafting may be necessary. A thorough understanding of the patient's type of nonunion and potential for healing is crucial for achieving satisfactory results because is thoughtful preoperative planning and surgical fixation.
Collapse
Affiliation(s)
- Alirio J deMeireles
- Department of Orthopedic Surgery, Columbia University Irving Medical Center-NewYork Presbyterian Hospital, New York, NY, USA
| | - Natalia Czerwonka
- Department of Orthopedic Surgery, Columbia University Irving Medical Center-NewYork Presbyterian Hospital, New York, NY, USA
| | - William N Levine
- Department of Orthopedic Surgery, Columbia University Irving Medical Center-NewYork Presbyterian Hospital, New York, NY, USA.
| |
Collapse
|
3
|
Ajit Singh V, Ho SC, Abdul Rashid ML, Santharalinggam RD. Functional and radiological outcome of non-operative treated clavicle fractures and its association with acromioclavicular joint arthrosis. J Orthop Surg (Hong Kong) 2023; 31:10225536231208242. [PMID: 37824849 DOI: 10.1177/10225536231208242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Clavicle fractures are traditionally treated non-operatively. This study determines the functional outcome of midshaft clavicle fractures treated non-operatively, the factors influencing it, and the incidence of acromioclavicular joint (ACJ) arthrosis. METHODS Patients with midshaft clavicular fractures treated non-operatively between 16 and 50 years old with no prior AC joint problems were assessed. Demographics, hand dominance, type of occupation, and smoking status were documented. Functional scoring using DASH score, CM score, and radiological evaluation was done with special tests to diagnose AC joint arthrosis. Two or more positive special tests were considered significant for this study. RESULTS 101 patients were recruited, 83 male and 18 female patients. The average age of 34.7 ± 13.93 years. The average follow-up was 32.7 months (range: 24-75; SD ± 9.9 months). 48.5% were blue-collar workers, and 60.4% involved the dominant upper limb. 44.6% were cigarette smokers. There was 20 mm and more shortening in 21.8% of subjects. 40.6% had a significant special test, and 36.6% had radiological changes of AC joint osteoarthritis. Positive two or more special tests were significantly associated with radiological evidence of arthrosis (p = .00). The mean DASH score was 28.28 ± 17.4, and the mean CM score was 27.58 ± 14.34. Most have satisfactory to excellent scores. Hand dominance, smoking, and blue-collar work were significantly associated with poorer CM scores, and hand dominance was significant for Dash scores. CONCLUSION There is an equal distribution poor, satisfactory and excellent functional outcomes in patients with midshaft clavicle fractures treated non-operatively. The poor outcomes may be attributed to ACJ arthrosis. Hand dominance, smoking and blue-collar work affected the functional outcome. Shortening of the clavicle had no bearing on the clinical and radiological findings of osteoarthritis and functional scores. The presence of two or more positive special tests is an accurate predictor of AC joint arthritis.
Collapse
Affiliation(s)
- Vivek Ajit Singh
- National Orthopaedic Centre of Excellence in Research & Learning (NOCERAL), Department of Orthopaedic Surgery, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Shu Chien Ho
- National Orthopaedic Centre of Excellence in Research & Learning (NOCERAL), Department of Orthopaedic Surgery, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Muhammad Lutfi Abdul Rashid
- National Orthopaedic Centre of Excellence in Research & Learning (NOCERAL), Department of Orthopaedic Surgery, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Rupini Devi Santharalinggam
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| |
Collapse
|
4
|
Kraal T, Struijs PAA, Langenberg LC, van Bergen CJA. Fractures around the shoulder in the skeletally immature: A scoping review. World J Orthop 2023; 14:604-611. [PMID: 37662664 PMCID: PMC10473910 DOI: 10.5312/wjo.v14.i8.604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/23/2023] [Accepted: 07/10/2023] [Indexed: 08/17/2023] Open
Abstract
Fractures around the shoulder girdle in children are mainly caused by sports accidents. The clavicle and the proximal humerus are most commonly involved. Both the clavicle and the proximal humerus have a remarkable potential for remodeling, which is why most of these fractures in children can be treated conservatively. However, the key is to understand when a child benefits from surgical management. Clear indications for surgery of these fractures are lacking. This review focuses on the available evidence on the management of clavicle and proximal humerus fractures in children. The only strict indications for surgery for diaphyseal clavicle fractures in children are open fractures, tenting of the skin with necrosis, associated neurovascular injury, or a floating shoulder. There is no evidence to argue for surgery of displaced clavicle fractures to prevent malunion since most malunions are asymptomatic. In the rare case of a symptomatic malunion of the clavicle in children, corrective osteosynthesis is a viable treatment option. For proximal humerus fractures in children, treatment is dictated by the patient's age (and thus remodeling potential) and the amount of fracture displacement. Under ten years of age, even severely displaced fractures can be treated conservatively. From the age of 13 and onwards, surgery has better outcomes for severely displaced (Neer types III and IV) fractures. Between 10 and 13 years of age, the indications for surgical treatment are less clear, with varying cut-off values of angulation (30-60 degrees) or displacement (1/3 - 2/3 shaft width) in the current literature.
Collapse
Affiliation(s)
- Tim Kraal
- Department of Orthopedic Surgery and Sports Medicine, Amsterdam University Medical Centers, Amsterdam 1105 AZ, Netherlands
| | - Peter AA Struijs
- Department of Orthopedic Surgery and Sports Medicine, Amsterdam University Medical Centers, Amsterdam 1105 AZ, Netherlands
| | - Lisette C Langenberg
- Department of Orthopedic Surgery, NoordWest Ziekenhuisgroep, Alkmaar 1815 JD, Netherlands
- Department of Orthopedic Surgery and Sports Medicine, Erasmus University Medical Center – Sophia Children’s Hospital, Rotterdam 3015 GD, Netherlands
| | - Christiaan JA van Bergen
- Department of Orthopedic Surgery and Sports Medicine, Erasmus University Medical Center – Sophia Children’s Hospital, Rotterdam 3015 GD, Netherlands
- Department of Orthopedic Surgery, Amphia, Breda 4818 CK, Netherlands
| |
Collapse
|
5
|
Heyworth BE, Pennock AT, Li Y, Liotta ES, Dragonetti B, Williams D, Ellis HB, Nepple JJ, Spence D, Willimon SC, Perkins CA, Pandya NK, Kocher MS, Edmonds EW, Wilson PL, Busch MT, Sabatini CS, Farley F, Bae DS. Two-Year Functional Outcomes of Operative vs Nonoperative Treatment of Completely Displaced Midshaft Clavicle Fractures in Adolescents: Results From the Prospective Multicenter FACTS Study Group. Am J Sports Med 2022; 50:3045-3055. [PMID: 35984091 DOI: 10.1177/03635465221114420] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The optimal treatment of midshaft clavicle fractures is controversial. Few previous comparative functional outcome studies have investigated these fractures in adolescents, the most commonly affected epidemiologic subpopulation. PURPOSE/HYPOTHESIS The purpose was to prospectively compare the outcomes of operative versus nonoperative treatment in adolescents with completely displaced midshaft clavicle fractures. The study hypothesis was that surgery would yield superior outcomes. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS Patients aged 10 to 18 years treated for a midshaft clavicle fracture over a 5-year period at 1 of 8 pediatric centers were prospectively screened, with independent treatment decisions determined by individual musculoskeletal professionals. Demographics, radiographic clinical features, complications, and patient-reported outcomes (PROs) were prospectively recorded for 2 years. Regression and matching techniques were utilized to adjust for potential age- and fracture severity-based confounders for creation of comparable subgroups for analysis. RESULTS Of 416 adolescents with completely displaced midshaft clavicle fractures, 282 (68) provided 2-year PRO data. Operative patients (n = 88; 31%) demonstrated no difference in sex (78% male) or athletic participation but were older (mean age, 15.2 vs 13.5 years; P < .001), had more comminuted fractures (49.4% vs 26.3%; P < .001), and had greater fracture shortening (25.5 vs 20.7 mm; P < .001) than nonoperative patients (n = 194; 69%). There was no difference in mean PRO scores or rates of "suboptimal" scores (based on threshold values established a priori) between the operative and nonoperative treatment groups (American Shoulder and Elbow Surgeons, 96.8 vs 98.4; shortened version of the Disabilities of the Arm, Shoulder and Hand, 3.0 vs 1.6; EuroQol [EQ] visual analog scale, 93.0 vs 93.9; EQ-5 Dimensions index, 0.96 vs 0.98), even after regression and matching techniques adjusted for confounders. Operative patients had more unexpected subsequent surgery (10.4% vs 1.4%; P = .004) and clinically significant complications (20.8% vs 5.2%; P = .001). Overall, nonunion (0.4%), delayed union (1.9%), symptomatic malunion (0.4%), and refracture (2.6%) were exceedingly rare, with no difference between treatment groups. CONCLUSION Surgery demonstrated no benefit in patient-reported quality of life, satisfaction, shoulder-specific function, or prevention of complications after completely displaced clavicle shaft fractures in adolescents at 2 years after injury. REGISTRATION NCT04250415 (ClinicalTrials.gov identifier).
Collapse
Affiliation(s)
- Benton E Heyworth
- Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Andrew T Pennock
- Department of Orthopedics, Rady Children's Hospital, San Diego, California, USA
| | - Ying Li
- Department of Orthopaedic Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Brittany Dragonetti
- Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - David Williams
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Henry B Ellis
- Sports Medicine Center, Texas Scottish Rite Hospital, Dallas, Texas, USA
| | - Jeffrey J Nepple
- Department of Orthopedic Surgery, School of Medicine, Washington University, St Louis, Missouri, USA
| | - David Spence
- Department of Orthopaedic Surgery, Campbell Clinic Orthopaedics, Memphis, Tennessee, USA
| | | | - Crystal A Perkins
- Department of Orthopedic Surgery, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Nirav K Pandya
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Mininder S Kocher
- Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Eric W Edmonds
- Department of Orthopedics, Rady Children's Hospital, San Diego, California, USA
| | - Philip L Wilson
- Sports Medicine Center, Texas Scottish Rite Hospital, Dallas, Texas, USA
| | - Michael T Busch
- Department of Orthopedic Surgery, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Coleen S Sabatini
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Frances Farley
- Department of Orthopaedic Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - Donald S Bae
- Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
6
|
van Essen T, Hillen RJ. A simple surgical technique for correcting malunion after midshaft clavicle fracture. Shoulder Elbow 2021; 13:459-463. [PMID: 34394744 PMCID: PMC8355657 DOI: 10.1177/1758573220933247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 05/20/2020] [Indexed: 11/16/2022]
Abstract
Clavicle malunion occurs in two-thirds of all clavicle fractures treated conservatively. It can lead to pain, shoulder dysfunction and cosmetic complaints. Surgical treatment of all midshaft fractures will lead to overtreatment, as not all malunions are symptomatic. In the past, several treatment modalities for correcting malunion of the clavicle have been described, and all have been successful but none have shown superiority. This article describes a new surgical technique with excising a wedge to realign the clavicle malunion.
Collapse
Affiliation(s)
- Tom van Essen
- Tom van Essen, MD, Department of Orthopedic Surgery,
Dijklander Ziekenhuis, Waterlandlaan 250, 1441 RN Purmerend, The Netherlands.
| | | |
Collapse
|
7
|
Strong DH, Strong MW, Hermans D, Duckworth D. Operative management of clavicular malunion in midshaft clavicular fractures: a report of 59 cases. J Shoulder Elbow Surg 2019; 28:2343-2349. [PMID: 31351904 DOI: 10.1016/j.jse.2019.04.058] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 04/15/2019] [Accepted: 04/24/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Nonoperative management has long been the preferred treatment for clavicular fractures; however, good outcomes, particularly with a shortened and malunited clavicle, are not universal. We report on radiographic and patient-based outcomes of a patient cohort with symptomatic clavicular malunions managed with corrective osteotomy, plate fixation, and local bone graft. We hypothesized that local bone graft would be sufficient for achieving union and length of malunion time would not affect the outcome. METHOD Over a 10-year period, 59 cases underwent operative management of symptomatic clavicular malunion. The surgical technique included osteotomy of the malunion, restoration of length, fixation with a plate, and local bone graft. The average length of time between fracture and surgery was 193.42 weeks (range, 8 weeks to 30 years). All patients were followed up postoperatively until radiographic union was achieved. Disabilities of the Arm, Shoulder and Hand scores were obtained and patients completed questionnaires to assess patient-based outcomes postoperatively. RESULTS All 59 cases achieved union with an average time of 9.25 weeks (range, 6-38 weeks) and only required local bone graft. All patients improved postoperatively with a mean Disabilities of the Arm, Shoulder and Hand score of 1.81 (range, 0-20.68) at 12 months. In 2 patients, infection developed, requiring revision of fixation, and union was subsequently achieved. Two patients had fractures adjacent to their hardware after union was achieved. CONCLUSIONS Corrective osteotomy with restoration of length and alignment, soft-tissue preservation, local bone graft, and plate fixation is a reliable treatment option for midshaft clavicular malunion. Union can be achieved, with good clinical outcomes independent of malunion time.
Collapse
Affiliation(s)
- David H Strong
- Orthopaedic Department, Sydney Adventist Hospital Wahroonga, Sydney, NSW, Australia.
| | - Michael W Strong
- Orthopaedic Department, Sydney Adventist Hospital Wahroonga, Sydney, NSW, Australia
| | - Deborah Hermans
- Orthopaedic Department, Sydney Adventist Hospital Wahroonga, Sydney, NSW, Australia
| | - David Duckworth
- Orthopaedic Department, Sydney Adventist Hospital Wahroonga, Sydney, NSW, Australia
| |
Collapse
|