Displaced midshaft clavicle fractures in adults - is non-operative management enough?

Adolescent displaced lateral-end clavicle fractures are not comparable to the adult variant. Epidemiology, fracture patterns and outcome of non-operative management

Background

The primary aim of this study was to determine the epidemiology of lateral-end clavicle fractures in adolescents. The secondary aim was to assess the outcome following non-operative management.

Methods

A retrospective review of all adolescent clavicle fractures over a 10-year period was undertaken. Fracture classification, demographics, management, and complications were analysed. Functional outcomes were undertaken with the Quick Disabilities of Arm, Shoulder and Hand and EuroQol five-dimension at mean 8.8 years post-injury.

Results

In total, 677 clavicle fractures were analysed, 8.7% were lateral-end fractures (n = 59/677). The median age was 14.6 (range: 13-17) and 92% were male (n = 54/59). The incidence was 0.17 per 100,000 per year. All displaced physeal fractures (Neer IV n = 14) were managed non-operatively and of the six followed-up, all united with good outcomes. The adult type displaced fracture (Neer II) occurred in fifteen fractures, five underwent operative fixation and ten were managed non-operatively with one subsequent nonunion (n = 1/10). Those patients that underwent non-operative management (response n = 5/10, 50%) reported a median Quick Disabilities of Arm, Shoulder and Hand of 2.3 but approximately 40% reported cosmetic and outcome dissatisfaction at long-term follow-up.

Conclusion

Displaced Neer II lateral-end clavicle fractures are rare in the adolescent population. Although nonunion is rare, some dissatisfaction with cosmesis persists at long-term follow-up despite good functional outcomes with non-operative management.

Less than 1.5cm shortening in clavicle midshaft fracture has long-term functional impact

INTRODUCTION

Mediolateral shortening is a risk in treatment of clavicle shaft fracture, and can lead to scapular dyskinesis and shoulder dysfunction. Many studies advocated surgical treatment if shortening exceeds 15mm.

HYPOTHESIS

Clavicle shaft shortening of less than 15mm has negative impact on shoulder function at more than 1 year's follow-up.

MATERIALS AND METHODS

A retrospective case-control comparative study was performed, with assessment by an independent observer. Clavicle length was measured on frontal radiographs showing both clavicles, and the ratio between the healthy and affected sides was calculated. Functional impact was assessed on Quick-DASH. Scapular dyskinesis was analyzed by global antepulsion on Kibler's classification. In total, 217 files were retrieved for a 6-year period. Clinical assessment was performed for 20 patients managed non-operatively and 20 patients managed by locking plate fixation, at a mean 37.5months' follow-up (range: 12-69months).

RESULTS

Mean Quick-DASH score was significantly higher in the non-operated group: 11.363 [0-50] versus 2.045 [0-11.36] (p=0.0092). Pearson ρ correlation between percentage shortening and Quick-DASH score was -0.3956 [95% CI: -0.6295; -0.0959] (p=0.012). Clavicle length ratio differed significantly between groups: operated group, +2.2% [-5.1%; +17%] for 0.34cm; non-operated group, -8.28% [-17.3%; -0.7%] for 1.38cm (p<0.0001). Shoulder dyskinesis was significantly more frequent non-operated patients: 10 versus 3 (p=0.018). A threshold of 1.3cm shortening was found for functional impact.

CONCLUSION

Restoring scapuloclavicular triangle length is an important aim in management of clavicular fracture. Surgery by locking plate fixation is therefore to be recommended in case of>8% radiological shortening (1.3cm) to avoid medium- and long-term complications in shoulder function.

LEVEL OF EVIDENCE

III; case-control study.

Influence of smoking on the healing of conservatively treated displaced midshaft clavicle fractures

Aims

Tobacco, in addition to being one of the greatest public health threats facing our world, is believed to have deleterious effects on bone metabolism and especially on bone healing. It has been described in the literature that patients who smoke are approximately twice as likely to develop a nonunion following a non-specific bone fracture. For clavicle fractures, this risk is unclear, as is the impact that such a complication might have on the initial management of these fractures.

Methods

A systematic review and meta-analysis were performed for conservatively treated displaced midshaft clavicle fractures. Embase, PubMed, and Cochrane Central Register of Controlled Trials (via Cochrane Library) were searched from inception to 12 May 2022, with supplementary searches in Open Grey, ClinicalTrials.gov, ProQuest Dissertations & Theses, and Google Scholar. The searches were performed without limits for publication date or languages.

Results

The meta-analysis included eight studies, 2,285 observations, and 304 events (nonunion). The random effects model predicted a pooled risk ratio (RR) of 3.68 (95% confidence interval 1.87 to 7.23), which can be considered significant (p = 0.003). It indicates that smoking more than triples the risk of nonunion when a fracture is treated conservatively.

Conclusion

Smoking confers a RR of 3.68 for developing a nonunion in patients with a displaced middle third clavicle fracture treated conservatively. We know that most patients with pseudarthrosis will have pain and a poor functional outcome. Therefore, patients should be informed of the significantly higher risks of nonunion and offered smoking cessation efforts and counselling. Moreover, surgery should be considered for any patient who smokes with this type of fracture.

[Combined intrapulmonary/intramediastinal K-wire position after K-wire osteosynthesis of the clavicle : A case report]

BACKGROUND

Lateral clavicle fractures can be treated both conservatively and surgically depending on the fracture classification. Different surgical techniques have been described for the operative treatment. The selection of the appropriate technique is decisive for the functional outcome and healing process without complications.

CASE

We report on a patient with a secondary dislocation of two Kirschner wires after Kirschner wire osteosynthesis. The secondary dislocation caused one of the wires to migrate into the mediastinum and pulmonary tissue, directly under the aortic arch. To prevent further migration with potential damage to surrounding structures, a uniportal video-assisted thoracoscopy was performed to retrieve the wire.

CONCLUSION

The treatment of lateral clavicle fractures should be performed with bent Kirschner wires as they can otherwise lead to severe complications including the occurrence of pseudarthrosis or secondary migration of the material. Safe and stable surgical techniques (plate osteosynthesis, hybrid treatment) should be preferred if they are available.

An Institutional Standardised Protocol for the Treatment of Acute Displaced Midshaft Clavicle Fractures (ADMCFs): Conservative or Surgical Management for Active Patients?

BACKGROUND AND OBJECTIVES

The treatment of acute displaced midshaft clavicle fractures (ADMCFs) is still under debate. The aim of this study was to verify the effectiveness of our institutional protocol by comparing the clinical and radiographic outcomes of two groups of patients with ADMCFs treated operatively and non-operatively.

MATERIALS AND METHODS

active patients with a traumatic, isolated non-pathological ADMCF with at least 1-year clinical and radiographic follow up were included. Surgical treatment was performed in the cases where the residual displacement was higher than 140% after the application of a figure-of-eight bandage (F8-B). All other cases were treated conservatively with a F8-B. A total of 134 patients were enrolled and divided into two groups: surgical and conservative groups, with 59 and 75 patients, respectively. Radiological and clinical parameters were evaluated.

RESULTS

Good clinical (Constant-Murley Score, the Quick Disability of the Arm, Shoulder and Hand score, and VAS satisfaction) and radiographic outcomes (initial and residual shortening, initial and residual displacement) were obtained for ADMCFs in both groups. Multivariate analysis showed that patients treated conservatively had better clinical outcomes compared to surgically treated patients (p < 0.001). Return to sports was longer in those treated with surgery. Initial shortening was found to impact clinical outcomes as well as initial displacement. None of the patients showed signs of non-union in both groups.

CONCLUSIONS

Very good mid-term clinical results can be obtained in adult patients with ADMCFs, conservatively or operatively managed, by applying our institutional treatment protocol based on objective radiographic parameters evaluated in the ER.

Closed midshaft clavicle fractures

Aims

The management of mid-shaft clavicle fractures (MSCFs) has evolved over the last three decades. Controversy exists over which specific fracture patterns to treat and when. This review aims to synthesize the literature in order to formulate an appropriate management algorithm for these injuries in both adolescents and adults.

Methods

This is a systematic review of clinical studies comparing the outcomes of operative and nonoperative treatments for MSCFs in the past 15 years. The literature was searched using, PubMed, Google scholar, OVID Medline, and Embase. All databases were searched with identical search terms: mid-shaft clavicle fractures (± fixation) (± nonoperative).

Results

Using the search criteria identified, 247 studies were deemed eligible. Following initial screening, 220 studies were excluded on the basis that they were duplicates and/or irrelevant to the research question being posed. A total of 27 full-text articles remained and were included in the final review. The majority of the meta-analyses draw the same conclusions, which are that operatively treated fractures have lower nonunion and malunion rates but that, in those fractures which unite (either operative or nonoperative), the functional outcomes are the same at six months.

Conclusion

With regard to the adolescent population, the existing body of evidence is insufficient to support the use of routine operative management. Regarding adult fractures, the key to identifying patients who benefit from operative management lies in the identification of risk factors for nonunion. We present an algorithm that can be used to guide both the patient and the surgeon in a joint decision-making process, in order to optimize patient satisfaction and outcomes. Cite this article: Bone Jt Open 2022;3(11):850–858.

Management of Displaced Midshaft Clavicle Fractures with Figure-of-Eight Bandage: The Impact of Residual Shortening on Shoulder Function

The treatment of displaced midshaft clavicle fractures (MCFs) is still controversial. The aims of our study were to evaluate clinical and radiological outcomes and complications of patients with displaced MCFs managed nonoperatively and to identify potential predictive factors of worse clinical outcomes. Seventy-five patients with displaced MCFs were enrolled and treated nonoperatively with a figure-of-eight bandage (F8-B). Initial shortening (IS) and displacement (ID) of fragments were radiographically evaluated at the time of diagnosis and immediately after F8-B application by residual shortening (RS) and displacement (RD). The clavicle shortening ratio was evaluated clinically at last follow-up. Functional outcomes were assessed using Constant (CS), q-DASH, DASH work and DASH sport scores. Cosmetic outcomes and rate of complications were evaluated. Good to very good mid-term clinical results were achieved by using the institutional treatment protocol. Multiple regression identified RS as an independent predictor of shoulder function, while RD affects fracture healing. These findings support the efficacy of our institutional protocol and thus could be useful for orthopedic surgeons during the decision-making process.

The emergency medicine management of clavicle fractures

BACKGROUND

Clavicle fractures are common. An emergency physician needs to understand the diagnostic classifications of clavicle fractures, have a plan for immobilization, identify associated injuries, understand the difference between treating pediatric and adult patients, and have an approach to multimodal pain control. It is also important to understand when expert orthopedic consultation or referral is indicated.

OBJECTIVE OF THE REVIEW

To provide an evidence-based review of clavicle fracture management in the emergency department.

DISCUSSION

Clavicle fractures account for up to 4% of all fractures evaluated in the emergency department. They can be separated into midshaft, distal, and proximal fractures. They are also classified in terms of their degree of displacement, comminution and shortening. Emergent referral is indicated for open fractures, posteriorly displaced proximal fractures, and those with emergent associated injuries. Urgent referral is warranted for fractures with greater than 100% displacement, fractures with >2 cm of shortening, comminuted fractures, unstable distal fractures, and floating shoulder. Nondisplaced or minimally displaced fractures with no instability or associated neurovascular injury are managed non-operatively with a sling. Pediatric fractures are generally managed conservatively, with adolescents older than 9 years-old for girls and 12 years-old for boys being treated using algorithms that are similar to adults.

CONCLUSIONS

When encountering a patient with a clavicle fracture in the emergency department the fracture pattern will help determine whether emergent consultation or urgent referral is indicated. Most patients can be discharged safely with sling immobilization and appropriate outpatient follow-up.