Management of acute clavicle fractures

Shining light on the Mary Rose: Identifying chemical differences in human aging and handedness in the clavicles of sailors using Raman spectroscopy

The Mary Rose, for many years the flagship of the Tudor king, Henry VIII, sank during the battle of the Solent on the 19th July 1545. 437 years later, the remains of the hull and associated contents were recovered following a four-year excavation, all dated to a precise point in history. The assemblage is a valuable resource, as the environment preserved over 19,000 objects and the remains of a minimum of 179 crew members. This remarkable preservation allows for the crew of the Mary Rose to be studied holistically; their belongings, appearance, and even their health. Using Raman spectroscopy, this study investigated the clavicle bone chemistry of 12 men, aged 13-40, who died on the Mary Rose. Specifically looking at any changes with age or that could be linked to handedness. Results found that bone mineral increased with age and bone protein decreased. The mineral increase was found to be more substantial than the protein decrease. When the left and right side were considered, these findings maintained and were more pronounced in the right clavicle. This suggests that handedness influences clavicle bone chemistry; offering an important modern consideration for fracture risk. These results enhance our understanding of the lives of Tudor sailors, but also contribute to modern scientific investigation in the drive for a clearer understanding of changes in bone chemistry and potential links to aging related skeletal diseases such as osteoarthritis.

Effect of intramedullary fixation and plate fixation on postoperative wound complications in clavicle fractures: A meta-analysis

More and more meta-analyses have been conducted to compare the effects of intramedullary fixation (IF) and plate fixation (PF) on the outcome of midshaft clavicle fractures. It can affect the doctors' treatment decisions. A number of studies have been conducted in order to assist surgeons in selecting optimal operative procedures and to recommend operative treatment of clavicle fractures in accordance with the best available research. Our analysis of the IF and PF of clavicle fractures was done through a search for PubMed, Emabase, Web of Science, and Cochrane Library. Two different researchers analysed the research literature for quality of analysis and data extraction. The analysis of the data was done with RevMan 5.3. The 95% CI and OR models have been computed by means of either fixed-dose or randomize. In addition, RCT in 114 references have been reviewed and added for further analysis. It is concluded that the application of plate and intramedullary fixation in the middle clavicle operation has remarkable influence on the outcome of post-operation. There was a lower risk of postoperative wound infection in IF (OR, 5.92; 95% CI, 2.46, 14.27 p < 0.0001), smaller surgical incisions (MD, 6.57; 95% CI, 4.90, 8.25 p < 0.0001), and shorter operative time (MD, 17.09; 95% CI 10.42, 23.77 p < 0.0001), less blood loss (MD, 63.62; 95% CI, 55.84, 71.39 p < 0.0001) and shorter hospital stay (MD, 1.05; 95% CI, 0.84, 1.25 p < 0.0001). However, there is no statistical significance in the incidence of wound dehiscence. Thus, the effect of IF on the incidence of injury is better than that of the inner plate in the middle of the clavicle.

The fifty most-cited articles regarding midshaft clavicle fractures

Introduction

The clavicle is the most frequently fractured bone in the human body, and up to 80% of clavicle fractures occur in the middle third diaphyseal region of the clavicle (midshaft). We conducted a bibliometric analysis to identify and evaluate the 50 most-cited publications pertaining to midshaft clavicle fractures (MCF).

Materials and methods

Two independent reviewers conducted separate queries on Web of Science in December 2021 for "midshaft clavicle fractures". The publications yielded were organized from highest to lowest number of citations. We included articles, review articles, and editorial materials and excluded other document types. Both reviewers independently reviewed all abstracts until 50 studies pertaining to MCF were included.

Theory

We hypothesized that most articles would be published between 2000 and 2019, pertain to outcomes, and those with a greater (lower numeric) level of evidence would correlate with number of citations.

Results

The most prolific decade was from 2010 to 2019, with 50% (25/50) of articles published. Average citation density was 6.3 ± 5.5 (range, 1.3-33.1), defined as the average number of citations per year since publication. The median level of evidence (LOE) was 3.5 (IQR: 3). One-way ANOVA tests were used to compare the effects of LOE on total citations and citation density. There were statistically significant differences in total citations (F value = 12.07, p = 0.001) and citation density (F value = 21.14, p < 0.001) between LOE groups. The median number of total citations, grouped by LOE of 1 through 5, were as follows: 110, 66, 66, 51, 52.

Conclusions

This review provides an overview of the 50 most cited papers regarding MCF. This should be used as a reference for physicians and other providers who treat patients with MCF for treatment guidance and for those in teaching roles as a student and resident/fellow educational resource.

MINIMALLY INVASIVE OSTEOSYNTHESIS FOR CLAVICULAR FRACTURE WITH LOCKED PLATE

Objective

To evaluate the clinical and radiographic results of the surgical treatment of fractures of the middle third of the clavicle, using the technique of minimally invasive plate osteosynthesis (MIPO) with locking.

Methods

Prospective case series, evaluating displaced fractures of the middle third of the clavicle submitted to MIPO with locking, with procedures performed by a single surgeon. Patients were evaluated at 12 months using the University of Los Angeles (UCLA) scale and anteroposterior radiographs of the clavicles with 45° cranial and caudal inclination, as well as reporting complications.

Results

In total, 15 patients were evaluated. The median of surgical time was 50 minutes (IQR 35). The UCLA scale had a median of 35 (IQR 2) at 12 months. All patients presented fracture healing. Minor complications occurred in three cases (20%), with two (13.3%) evolving with plate prominence and one (6.7%) with local paresthesia, while major complications occurred in only one case (6.7%), with suture dehiscence requiring surgical re-approach.

Conclusion

MIPO with locking is a viable option for the treatment of displaced fractures of the middle third of the clavicle, with excellent results according to the UCLA scale, fracture healing in all cases, and a low rate of complications. Level of Evidence IV, Case Series.

Virtual surgical planning and mirrored, 3-dimensionally printed guides for corrective clavicle osteotomies in clavicle malunions and nonunions

BACKGROUND

The objective of this study was to retrospectively review clinical and radiographic outcomes of patients who underwent corrective osteotomies for clavicle malunion and internal fixation for nonunion using a combination of virtual surgical planning, patient-specific 3-dimensional (3D)-printed clavicles, and 3D-printed cutting guides manufactured at the point of care.

METHODS

Between 2015 and 2021, 18 patients underwent corrective osteotomy for a clavicle malunion (7 shoulders) or internal fixation for a clavicle nonunion (11 shoulders). There were 11 male and 7 female individuals with an average patient age of 43.9 (range 19-76) years. All patients underwent computed tomography evaluation of both clavicles. The DICOM files were manually segmented, virtual surgical planning was performed selectively using commercially available software, and a mirrored version of the normal clavicle was 3D printed along with a 3D-printed replica of the affected clavicle. Three-dimensionally printed mirrored clavicles were used in all cases to ensure adequate restoration of the shape and length of the clavicle and to precontour fixation plates. Virtual surgical planning and 3D-printed cutting guides for osteotomy were used in 4 of 18 (22%) patients. Either cancellous or structural intercalary bone grafting was used in 15 of 18 (83%) cases. Patients were contacted postoperatively to determine clinical outcome scores. Preoperative, early postoperative, and late postoperative radiographs were reviewed to assess for union and complications. The average follow-up time was 24.9 months.

RESULTS

Radiographic evaluation at the most recent follow-up demonstrated adequate restoration of length and successful union for all shoulders. There were no complications or reoperations. Postoperative patient-reported outcomes could be obtained in 16 of 18 (88.9%) patients. At the most recent follow-up, the mean visual analog scale for pain was 2.38 points (range, 1-7), the mean shoulder American Shoulder and Elbow Surgeons score was 73.2 points (range, 25-100), and the mean Patient-Reported Outcome Measurement Information System Upper Extremity score was 26 points (range, 7-35). All (100%) the patients were satisfied with their outcome (9 very satisfied, 7 satisfied), and their mean subjective shoulder value was 73% (range, 10%-100%). However, 2 patients complained of hardware-related symptoms, and 1 patient had return of preoperative symptoms after an interim 2 years of pain relief.

CONCLUSION

The use of mirrored 3D-printed clavicles combined with virtual surgical planning and patient-specific 3D guides provides a reliable technique for restoring native anatomy when performing corrective osteotomies for clavicle malunion or internal fixation for clavicle nonunion, with a high rate of satisfactory clinical and radiographic outcomes.

Acute clavicle fixation after blunt chest trauma: effect on pulmonary outcomes and patient disposition

PURPOSE

Clavicle fractures are common in patients who sustain blunt chest trauma (BCT). Recently, surgical fixation of rib fractures in patients with BCT has been shown to improve pulmonary and clinical outcomes. Therefore, the purpose of this study is to assess the role of early clavicle fixation (ECF) versus non-operative (NO) treatment for midshaft clavicle fractures in this same population.

METHODS

A retrospective chart review was performed in patients with midshaft clavicle fractures and BCT at a Level I Trauma Center between 2007 and 2017. Patients with pre-existing pulmonary conditions and head injuries necessitating mechanical ventilation were excluded. Demographic data, injury mechanisms, and Thoracic Trauma Severity Scores (TTS) were analyzed. Inpatient pulmonary outcomes were assessed with serial vital capacity (VC) measurements, intubation, mechanical ventilation, and pulmonary complications data. In addition, intensive care unit (ICU) and hospital length of stay (LOS), mortality, discharge location, and incidence of postoperative complications in the ECF group were also measured.

RESULTS

Thirty-six patients underwent ECF, and 24 underwent NO treatment. The ECF cohort was statistically younger and had a greater incidence of clavicle fracture shortening than the NO group. There was no difference in pulmonary outcomes, ICU or hospital LOS, or mortality between groups. There were no complications associated with ECF. Patients who underwent ECF were more likely to discharge to home. There were no postoperative complications associated with ECF.

CONCLUSION

ECF of midshaft clavicle fractures does not improve pulmonary outcomes in patients with BCT. However, despite the lack of pulmonary benefit, there appears to be no added risk of harm. Therefore, ECF is a reasonable consideration in this patient population who otherwise meet clavicle fracture operative indications.

Comparative Study of Postoperative Outcomes of Clavicle Midshaft Fracture Treated by Nailing vs. Plating

Background

A midshaft clavicle fracture is a prevalent form of injury of the upper extremity that affects one's quality of life. Several treatment modalities facilitate fixation of the displaced midshaft clavicle to decrease nonunion and malunion of the clavicle fracture. Still, numerous factors influence choosing an optimal surgical intervention. Thus, this study investigates the functional outcome of two standard fixation techniques, titanium elastic nails (TENs) and locking plates, as a prospective comparative study for surgical management of displaced midshaft clavicle fractures.

Methods

We performed closed/open reduction and internal fixation in 62 patients (40 male and 22 female) with TENs and locking plates, respectively, which were followed up at regular intervals following the surgery (at two, six, 12, 24, and 48 weeks). The surgical outcome was assessed both from functional and radiological standpoints. The influence of surgical fixation on functional outcome was evaluated based on the Constant-Murley score and the fracture recuperation based on union times.

Results

When compared to plate fixation, TENs had lesser union times. Still, there was no statistical difference in union time between the two groups. The functional assessment graded by Constant-Murley score had a similar distribution of scores between the two groups.With a follow-up of twelve months, the Constant-Murley scores between the groups were not statistically different. While the average score for plate fixation was slightly higher than that of TENs, the nonunion rate was found to be similar in both groups.

Conclusion

Surgical interventions using both TENs and plate fixation are suitable for managing clavicle midshaft fractures as they have a similar functional outcome. However, considering early recovery with minimal surgical complications, TENs can be a preferred treatment choice for managing displaced midshaft clavicle fractures.

Imaging Review of Alpine Ski Injuries

Skiing is a continuously evolving winter sport, responsible for a considerable number of musculoskeletal injuries. Specific injury patterns and mechanisms in the upper and lower extremities, head, and spine are influenced by skier expertise and skill, position during injury, and environmental conditions. Predilection for certain joints and injury patterns have changed over time, largely due to technological advancements in equipment, increased awareness campaigns, and preventive protocols. Knowledge and understanding of these trends and developments can aid the radiologist to reach a timely and accurate diagnosis, thereby guiding clinical management and potentially reducing the overall incidence of debilitation and death.

Examining the novel use of continuous compression implants in clavicle reconstruction: A biomechanical study

BACKGROUND

Current implants for clavicle fractures are known to cause poor cosmesis and irritation, which may require implant removal. Low-profile shape-memory staples provide an attractive alternative, but their biomechanical utility in clavicle reconstruction is unknown. We hypothesized that shape-memory reconstructions would be more compliant compared to traditional constructs but would also outperform conventional plates during cyclic loading to failure.

METHODS

This study was performed with 36 synthetic clavicles and 12 matched pairs of cadaveric specimens. The synthetic study tested four reconstructions: a single superiorly placed staple (n = 6), a single anteroinferiorly-placed staple (n = 6), a 3.5 mm reconstruction plate (n = 12), and two orthogonally placed staples (n = 12). The cadaveric study tested three constructs: reconstruction plate (n = 8), two orthogonal staples (n = 8), and a 2.7 mm reconstruction plate combined with a superior staple (n = 8). Non-destructive 4-point bending, compression, and torsion assays were performed prior to destructive cantilever bending and cyclic torsion tests.

FINDINGS

The single staple and double staple groups demonstrated significantly decreased resistance to bending (p < 0.001) and torsion (p ≤ 0.027) when compared to reconstruction plate groups. The double staple group sustained significantly fewer cycles to failure than the reconstruction plate group in cyclic torsional tests (p = 0.012). The synthetic models produced higher stiffness and failure mechanisms that were completely different from cadaveric specimens.

INTERPRETATION

Shape memory alloy implants provided inadequate stiffness for clavicle fixation but may have utility in other orthopaedic applications when used as a supplementary compression device in conjunction with traditional plated constructs. Synthetic bones have limited capacity for modeling fragility fractures.

Reliability of the radiographic views in supine position for evaluation of displaced midshaft clavicle fracture length

PURPOSE

To analyze the agreement of the displaced midshaft clavicle fracture length measurement between each of the supine radiographic position (chest anteroposterior (AP), both clavicle AP, and 20° cephalic tilt clavicle AP view) and computed tomography (CT) scan of the clavicle. Furthermore, the inter- and intraobserver reliability of each radiographic position was analyzed.

METHODS

Prospective cross-sectional study was performed with patients diagnosed with displaced midshaft clavicle fracture treated conservatively. Three views of radiographs and CT scan of clavicle were obtained in supine position after informed consent. The measurement of fractured clavicle length was done by three observers at the time and after 4 weeks interval.

RESULTS

Thirty-three patients (25 males and 8 females), with a mean age of 45, were recruited. The agreement between each of the radiographic measurement and CT scan was good. The interobserver reliability was moderate to good for radiographic measurement. The highest intraclass correlation coefficient (ICC) of 0.80-0.81 was shown between the 20° cephalic tilt and the CT scan, followed by the both clavicle AP (0.75-0.77) and the chest AP (0.69-0.75), respectively. There was an excellent intraobserver reliability for all of the radiographic measurement with the ICC 0.92-0.99.

CONCLUSION

The supine radiographs could be a useful option to measure the displaced midshaft clavicle fracture length. The recommended view was the 20° cephalic tilt clavicle AP view in supine position to best evaluate the fractured clavicle length.

Utilization of regional anesthesia for open reduction and internal fixation of clavicular fractures is associated with increased same-day discharge and not readmissions

Background

Regional anesthesia is becoming increasingly used for analgesia in clavicular surgery. The purpose of the study is to examine same-day discharge and readmissions in patients with clavicular fractures receiving open reduction and internal fixation, comparing those who received regional anesthesia to those that did not.

Methods

The National Surgical Quality Improvement Program registry was used to build a retrospective cohort with the primary and secondary outcomes of same-day discharge and readmission rates, respectively. The independent variable was type of anesthesia (ie, regional vs general). Unadjusted univariable followed by multivariable logistic regression analysis for the association of each covariate with the primary and secondary outcome was performed. A p<0.05 was considered statistically significant.

Results

A total of 2300 patients were included, in which 346 (15.0%) of received a nerve block. The only factor associated with same-day discharge on crude analysis was the use of a nerve block (OR 1.70, 95% CI 1.21 to 2.40, p<0.01). Factors not associated with same-day discharge included geriatric age (OR 0.39, 95% CI 0.26 to 0.57, p<0.01), diabetes mellitus (OR 0.54, 95% CI 0.33 to 0.89, p=0.01), dependent functional status (OR 0.27, 95% CI 0.11 to 0.69, p<0.01), hypertension (OR 0.39, 95% CI 0.29 to 0.52, p<0.01), bleeding disorder (OR 0.24, 95% CI 0.10 to 0.59, p<0.01) and an American Society of Anesthesiologists Physical Status score ≥3 (OR 0.33, 95% CI 0.25 to 0.45, p<0.01). On adjusted analysis, regional anesthesia was associated with increased odds of same-day discharge (OR 1.67, 95% CI 1.18 to 2.37, p<0.01), but not 30-day readmission (OR 0.57, 95% CI 0.13 to 2.52, p=0.46).

Conclusion

Regional anesthesia use in patients with clavicular fractures is associated with higher odds for same-day discharge. There is no significant difference in the rates of hospital readmission within a 30-day period.

Level of Evidence

IV, retrospective case series.

Clavicle Fracture Malunion Treated with an Osteotomy Guided by a Three-Dimensional-Printed Model: A Case Report

CASE

This case report describes the management of a chronic and symptomatic clavicle malunion with use of a 3-dimensional (3D)-printed model during the preoperative surgical planning.

CONCLUSION

The use of 3D printing has many applications in the medical field. Constant improvement in the quality of 3D printing has contributed to its increased use in a variety of surgeries. In our patient, 3D printing was used to generate a surface model of the clavicle fracture malunion and the "mirrored" contralateral healthy clavicle to plan an intraoperative osteotomy, which optimized the relative position of the osteotomy segments and hardware fixation.

Biomechanical comparison between solid and cannulated intramedullary devices for midshaft clavicle fixation

Background

A method of closed reduction and internal fixation with cannulated screws was proposed as a surgical treatment of midshaft clavicle fractures. However, there are no mechanical studies about the cannulated screw used in the fixation of midshaft clavicle fracture. We conducted this study to compare the construct bending stiffness of a fixation midshaft clavicle fracture with a Knowles pin, cannulated screw and reconstruction plate. In addition, purchase lengths of both intramedullary devices were measured.

Methods

After transverse osteotomy over the midpoint for fracture simulation, eighteen synthetic clavicles were assigned to 3 groups and fixed with reconstruction plate, Knowles pin or cannulated screw. Purchase length was defined as the engaged length of the intramedullary portion of the two intramedullary devices Stiffness, yield load and maximum load of the cantilever bending test were calculated of each tested synthetic bones.

Results

The Knowles pin group had a significantly longer average intramedullary purchase length compared with that of the cannulated screw group. The construct stiffness in the reconstruction plate group (5.6 ± 0.9 N/mm) was higher than that of the intramedullary devices; the Knowles pin group (3.1 ± 0.6 N/mm) provided a greater construct stiffness than did the cannulated screw group (1.7 ± 0.4 N/mm) (p = 0.007). The cannulated screw group had the lowest yield and maximum load compared with the reconstruction plate and Knowles pin groups. Both the reconstruction plate and Knowles pin failed at the implant-bone interface. However, the cannulated screw group failed at the osteotomy site with broken implants.

Conclusion

This study suggests that fixation of midshaft clavicle fractures with cannulated screws may lead to early failure due to inadequate mechanical strength. Ideal intramedullary clavicle devices should supply adequate intramedullary purchase lengths and mechanical strength.

Intramedullary nail fixation of non-traditional fractures: Clavicle, forearm, fibula

Locked intramedullary fixation is a well-established technique for managing long-bone fractures. While intramedullary nail fixation of diaphyseal fractures in the femur, tibia, and humerus is well established, the same is not true for other fractures. Surgical fixations of clavicle, forearm and ankle are traditionally treated with plate and screw fixation. In some cases, fixation with an intramedullary device is possible, and may be advantageous. However, there is however a concern regarding a lack of rotational stability and fracture shortening. While new generation of locked intramedullary devices for fractures of clavicle, forearm and fibula are recently available, the outcomes are not as reliable as fixation with plates and screws. Further research in this area is warranted with high quality comparative studies, to investigate the outcomes and indication of these fractures treated with intramedullary nail devices compared to intramedullary nail fixation.

Biomechanical Comparison of Superior Versus Anterior Plate Position for Fixation of Distal Clavicular Fractures: A New Model

OBJECTIVES

Although most clavicular fractures are amenable to nonoperative management, metadiaphyseal fractures are considerably more complex, with rates of suboptimal healing as high as 75% when treated nonoperatively. The poor results are ascribed to the deforming forces on the distal clavicle from the surrounding muscles and the weight of the arm. It recently has been noted that some operative fixations of these fractures are also failing when a standard superiorly placed plate is used. We hypothesized that anterior plating, when compared with superior plating, improves the strength and durability of the construct by redirecting the axis of the major deforming force across rather than in line with the screws of the construct.

METHODS

Six pairs of fresh-frozen human cadaveric clavicles with the scapula attached by the coracoclavicular ligaments were osteotomized just medial to the ligaments and plated with a standard 3.5-mm limited-contact dynamic compression plate. Specimens were potted and mounted on a materials testing system machine, preserving the anatomic relationship of the clavicle and scapula. They were then loaded through the coracoclavicular ligaments to mimic the weight of the arm pulling inferiorly. Each specimen was loaded with 375 N at 1 Hz for 2000 cycles. Sequential loading was then applied at 25-N intervals until failure. Statistical analysis was performed using a Wilcoxon signed-rank test.

RESULTS

The superiorly plated specimens failed after fewer cycles and with lower force than the anteriorly plated specimens. The median number of cycles to failure was 2082 for anterior plated specimens and 50 for superiorly plated (P = 0.028). The median load to failure was 587.5 N in the anterior group and 375 N in the superior group (P = 0.035). The median stiffness was 46.13 N/mm for anterior and 40.45 N/mm for superior (P = 0.375) plates.

CONCLUSIONS

Anteriorly plated distal third clavicular fractures have superior strength and durability compared with fractures plated superiorly when using a physician-contoured, 3.5-mm, limited-contact, dynamic compression plate in this cadaver model.

The biomechanical effect of clavicular shortening on shoulder muscle function, a simulation study

BACKGROUND

Malunion of the clavicle with shortening after mid shaft fractures can give rise to long-term residual complaints. The cause of these complaints is as yet unclear.

METHODS

In this study we analysed data of an earlier experimental cadaveric study on changes of shoulder biomechanics with progressive shortening of the clavicle. The data was used in a musculoskeletal computer model to examine the effect of clavicle shortening on muscle function, expressed as maximal muscle moments for abduction and internal rotation.

FINDINGS

Clavicle shortening results in changes of maximal muscle moments around the shoulder girdle. The mean values at 3.6cm of shortening of maximal muscle moment changes are 16% decreased around the sterno-clavicular joint decreased for both ab- and adduction, 37% increased around the acromion-clavicular joint for adduction and 32% decrease for internal rotation around the gleno-humeral joint in resting position.

INTERPRETATION

Shortening of the clavicle affects muscle function in the shoulder in a computer model. This may explain for the residual complaints after short malunion with shortening.

LEVEL OF EVIDENCE

Basic Science Study. Biomechanics. Cadaveric data and computer model.

Patient factors influencing return to work and cumulative financial claims after clavicle fractures in workers' compensation cases

BACKGROUND

This study analyzed workers' compensation patients after surgical or nonoperative treatment of clavicle fractures to identify factors that influence the time for return to work and total health care reimbursement claims. We hypothesized that return to work for operative patients would be faster.

METHODS

The International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes and Current Procedural Terminology codes were used to retrospectively query the Workers' Compensation national database. The outcomes of interest were the number of days for return to full work after surgery and total reimbursement for health care-related claims. The primary independent variable was treatment modality.

RESULTS

There were 169 claims for clavicle fractures within the database (surgical, n = 34; nonoperative, n = 135). The average health care claims reimbursed were $29,136 ± $26,998 for surgical management compared with $8366 ± $14,758 for nonoperative management (P < .001). We did not find a statistically significant difference between surgical (196 ± 287 days) and nonoperative (69 ± 94 days) treatment groups in their time to return to work (P = .06); however, there was high variability in both groups. Litigation was an independent predictor of prolonged return to work (P = .007) and higher health care costs (P = .003).

CONCLUSION

Workers' compensation patients treated for clavicle fractures return to work at roughly the same time whether they are treated surgically or nonoperatively, with surgery being roughly 3 times more expensive. There was a substantial amount of variability in return to work timing by subjects in both groups. Litigation was a predictor of longer return to work timing and higher health care costs.

A hybrid approach to mid-shaft clavicle fixation

BACKGROUND

The purpose of this study was to demonstrate the strength characteristics of a hybrid uni-cortical construct for clavicle fixation. The technique reported aims to combine benefits of uni-cortical fixation with stability comparable to traditional bi-cortical fixation. The approach utilises long, oblique uni-cortical screws at the distal ends of the plate acting as surrogate bi-cortical screws. Locked uni-cortical screws positioned centrally provide bending and torsion strength to the construct. This alternative hybrid uni-cortical technique does not require far cortex screw or drill penetration required in bi-cortical fixation techniques, thus avoiding potentially catastrophic vascular and or neurologic injury. The purpose of this study was to compare the mechanical behaviour of the hybrid uni-cortical construct to standard bi-cortical fixations under both torsion and bending loads.

METHOD

Thirty osteotomized human cadaveric clavicles were randomly allocated to three surgical fixation techniques: bi-cortical locked screw fixation, bi-cortical non-locked screw fixation and hybrid uni-cortical screw fixation. Each clavicle construct was tested non-destructively under torsional loading, and then under cantilever bending to failure. Construct bending and torsional stiffness, as well as ultimate failure strength, were measured.

RESULTS

There were no significant differences between uni-cortical or bi-cortical fixation constructs in either bending stiffness or ultimate bending moment (p>0.05); however, there was a trend towards greater bending stiffness in the hybrid construct. The uni-cortical hybrid fixation technique displayed a significantly lower mean torsional stiffness value when compared with the bi-cortical locked screw fixation (mean difference: 134.4 Nmm/degrees, 95% confidence interval [32.3, 236.4], p=0.007).

CONCLUSION

A hybrid uni-cortical approach to clavicle plate fixation that may improve screw purchase and reduce risk of intra-operative vascular damage demonstrates comparable bending strength to current bi-cortical approaches.

Plating versus intramedullary fixation for mid-shaft clavicle fractures: a systemic review and meta-analysis

Background. Plate fixation and intramedullary fixation are the most commonly used surgical treatment options for mid-shaft clavicle fractures; the latter method has demonstrated better performance in some studies.

Objectives. Our aim was to critically review and summarize the literature comparing the outcomes of mid-shaft clavicle fracture treatment with plate fixation or intramedullary fixation to identify the better approach.

Search Methods. Potential academic articles were identified from the Cochrane Library, MEDLINE (1966-2015.5), PubMed (1966-2015.5), EMBASE (1980-2015.5) and ScienceDirect (1966-2015.5). Gray studies were identified from the references of the included literature.

Selection Criteria. Randomized controlled trials (RCTs) and non-RCTs comparing plate fixation and intramedullary fixation for mid-shaft clavicle fracture were included.

Data Collection and Analysis. Two reviewers performed independent data abstraction. The I² statistic was used to assess heterogeneity. A fixed- or random-effects model was used for the meta-analysis.

Results. Six RCTs and nine non-RCTs were retrieved, including 513 patients in the intramedullary fixation group and 521 patients in the plating group. No significant differences in terms of the union rate and shoulder function were found between the groups. Patients in the intramedullary fixation group had a shorter operative time, less blood loss, smaller wound size, and shorter union time than those in the plating group. With respect to complications, significant differences were identified for all complications and major complications (wound infection, nonunion, implant failures, transient brachial plexopathy, and pain after 6 months). Similar secondary complications (symptomatic hardware, hardware irritation, prominence, numbness, hypertrophic callus) were observed in both groups.

Conclusions. Intramedullary fixation may be superior to plate fixation in the treatment of mid-shaft clavicle fractures, with similar performance in terms of the union rate and shoulder function, better operative parameters and fewer complications.

Biomechanical properties of titanium elastic nail applied to a cadaveric clavicle model

BACKGROUND

The goal of this study was to examine biomechanical properties of titanium elastic nail fixation method that was applied to cadaveric clavicles with different thicknesses and lengths.

METHODS

To test stiffness and failure load of clavicle with titanium elastic nail fixation, 12 pairs of clavicles were obtained. A short oblique fracture line (AO/OTA classification: 15-B1.2) was created at midpoint of the cadaveric bones. They were divided into four groups according to the nails with different thickness and length/diameter ratios. The fixated bones were situated on a jig that allows 3-point bending to measure stiffness and load failure.

RESULTS

The stiffness was measured to be mean 3.49 ± 1.49 N/mm in group 1. The stiffness for group 2 was mean 10.41 ± 2.18 N/mm, and for groups 3 and 4, the stiffness was mean 11.89 ± 2.99 N/mm and mean 24.44 ± 4.86 N/mm, respectively. When analyzed with statistics, group 1 had significant differences from groups 2 (P < 0.006), 3 (P < 0.001), and 4 (P < 0.000), and group 4 also had statistical significances from rest of the groups (P < 0.000).

CONCLUSIONS

For 2.5 mm titanium elastic nail, it is necessary to make fixation with a titanium elastic nail that is longer than 3 diameter lengths, and length that is longer than and equal to 3 diameter length titanium elastic nail was required for 3.5 mm titanium elastic nail to provide appropriate stiffness for firm fixation. Also, variances in both thickness and length have shown a similar effect.

STUDY DESIGN

Cadaveric study.

Functional outcomes of operative fixation of clavicle fractures in patients with floating shoulder girdle injuries

BACKGROUND

Double disruptions of the superior suspensory shoulder complex, commonly referred to as 'floating shoulder' injuries, are ipsilateral midshaft clavicular and scapular neck/body fractures with a loss of bony attachment of the glenoid. The treatment of 'floating shoulder' injuries has been debated controversially for many years. The purpose of this study was to demonstrate the clinical and functional outcomes of patients with 'floating shoulder' injuries who underwent operative fixation of the clavicle fracture only.

MATERIALS AND METHODS

Between 2002 and 2010, 32 consecutive floating shoulder injuries were identified in skeletally mature patients at a level I trauma center and followed in a single private practice. Thirteen patients met the inclusion and exclusion criteria for this retrospective study with a minimum 12-month follow-up. Clavicle and scapular fractures were identified by Current Procedural Technology codes and classified based on Orthopaedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen criteria. 'Floating shoulder' injuries were surgically managed with only clavicular reduction and fixation utilizing modern plating techniques. Nonunion, malunion, implant removal, range of motion, need for secondary surgery, pain according to the visual analog scale (VAS), and return to work were measured.

RESULTS

All injuries were the result of high-energy mechanisms. Fracture union of the clavicle was seen after initial surgical fixation in the majority of patients (12; 92.3 %). Final pain was reported as minimal (11 cases; 1-3 VAS), moderate (1 case; 4-6 VAS), and high (1 case; 7-10 VAS) at last follow-up. Excellent range of motion (180° forward flexion and abduction) was observed in the majority of patients (8; 61.5 %). The Herscovici score was 12.9 (range 10-15) at 3 months. Unplanned surgeries included two clavicular implant removals and one nonunion revision. None of the patients required reconstruction for scapula malunion after nonoperative management. Twelve patients returned to previous work without restrictions.

CONCLUSIONS

'Floating shoulder' injuries with only clavicular fixation return to function despite persistent scapular deformity and some residual pain.

LEVEL OF EVIDENCE

Level IV.

The long-term outcome of displaced mid-third clavicle fractures on scapular and shoulder function: variations between immediate surgery, delayed surgery, and nonsurgical management

BACKGROUND

Conservative management for uncomplicated displaced clavicle fractures is common practice. Delay of surgical fixation may result in less favorable outcomes.

METHODS

A retrospective cohort study was conducted of 60 patients with a closed mid-third clavicle fracture that did not meet current operative or nonoperative guidelines; 20 primary (plate fixation <6 weeks), 20 delayed (plate fixation >6 weeks), and 20 matched conservative patients were included. Each patient completed 2 questionnaires, the Disabilities of the Arm, Shoulder, and Hand and the American Shoulder and Elbow Surgeons, as well as visual analog scales for pain, cosmetic satisfaction, and overall satisfaction. In addition, 10 patients from each group underwent clinical review of scapular rotation by the lateral scapular slide test, clinical impingement, range of motion assessment, and radiologic review of clavicle union and length.

RESULTS

The American Shoulder and Elbow Surgeons patient self-reported questionnaire demonstrated a median score of 5.5 for the delayed group, 2 for the primary group, and 1 for the conservative group (P = .032). The median Disabilities of the Arm, Shoulder, and Hand score was 7.92 for the delayed group, 3.32 for the primary group, and 1.67 for the conservative group (P = .212). Six patients in the delayed group had scapular malrotation compared with 2 in the primary group and none in the conservative group (P = .008). Flexion and external rotation in 90° abduction were decreased in the conservative group (P = .049 and .041, respectively).

CONCLUSION

We support the conservative management of uncomplicated displaced clavicle fractures but recognize that a lower threshold for early surgery should be considered where optimal shoulder function is required.

Is intramedullary nailing more effective than non-operative treatment in adults with displaced middle-third clavicle fractures?

BACKGROUND

Clavicle fractures are common, accounting for 5-12 % of all fractures. Traditionally, displaced middle-third clavicle fractures have been managed non-operatively but the associated displacement often leads to mal-union with shortening, cosmetic deformity and occasionally non-union, with clinicians looking towards alternative operative methods such as intramedullary nailing (IMN). However, such methods have their own complications. In order to ascertain the effectiveness of IMN in the management of middle-third clavicle fractures compared with non-operative treatment, analysis of recent evidence is required and this review aims to achieve that, focusing on relevant, contemporary randomised-control trials.

MATERIALS AND METHODS

Essential search-terms identified from the research question were used to formulate a search strategy. A systematic search of multiple databases was then performed from 1966 until present and appropriate papers for appraisal identified.

RESULTS

Thirteen papers were identified, with 10 excluded using appropriate eligibility criteria. The remaining papers were then critically appraised. With regards shoulder function, all papers demonstrated an association between IMN and a significantly (P < 0.05) superior shoulder function score, but no consensus with regards to complication rates. However, all have identified limitations; therefore, their overall findings must be considered conservatively.

CONCLUSIONS

Further, high-quality research, ideally in the form of well-designed, multi-centre RCTs is required to allow acceptable implementation of IMN of middle-third clavicle fractures into widespread practice. However, early results demonstrate that in young patients with displaced middle-third clavicle fractures, who are motivated to return to work, IMN provides superior functional results and should be considered. However, the importance of considering each patient individually as to their suitability for each management option, before coming to an informed decision with the patient rather than having a blanket approach to MTCF is essential.

LEVEL OF EVIDENCE

Level 1.

Does plate type influence the clinical outcomes and implant removal in midclavicular fractures fixed with 2.7-mm anteroinferior plates? A retrospective cohort study

BACKGROUND

The purpose of this study was to evaluate surgical healing rates, implant failure, implant removal, and the need for surgical revision with regards to plate type in midshaft clavicle fractures fixed with 2.7-mm anteroinferior plates utilizing modern plating techniques.

METHODS

This retrospective exploratory cohort review took place at a level I teaching trauma center and a single large private practice office. A total of 155 skeletally mature individuals with 156 midshaft clavicle fractures between March 2002 and March 2012 were included in the final results. Fractures were identified by mechanism of injury and classified based on OTA/AO criteria. All fractures were fixed with 2.7-mm anteroinferior plates. Primary outcome measurements included implant failure, malunion, nonunion, and implant removal. Secondary outcome measurements included pain with the visual analog scale and range of motion. Statistically significant testing was set at 0.05, and testing was performed using chi-square, Fisher's exact, Mann-Whitney U, and Kruskall-Wallis.

RESULTS

Implant failure occurred more often in reconstruction plates as compared to dynamic compression plates (p = 0.029). Malunions and nonunions occurred more often in fractures fixed with reconstruction plates as compared to dynamic compression plates, but it was not statistically significant. Implant removal attributed to irritation or implant prominence was observed in 14 patients. Statistically significant levels of pain were seen in patients requiring implant removal (p = 0.001) but were not associated with the plate type.

CONCLUSIONS

Anteroinferior clavicular fracture fixation with 2.7-mm dynamic compression plates results in excellent healing rates with low removal rates in accordance with the published literature. Given higher rates of failure, 2.7-mm reconstruction plates should be discouraged in comparison to stiffer and more reliable 2.7-mm dynamic compression plates.

Return to athletic activity after plate fixation of displaced midshaft clavicle fractures

BACKGROUND

Recent data support primary plate fixation of displaced midshaft clavicle fractures. The safety and efficacy of this practice have not been well documented in athletes.

HYPOTHESIS

Plate fixation of clavicle fractures in athletes is a safe and effective procedure, resulting in a reliable and timely return to play.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 29 patients with displaced midshaft clavicle fractures from athletic activity were treated with plate fixation between January 1, 2003 and December 31, 2008, including 1 patient treated for each clavicle for separate injuries. All 29 patients were contacted for follow-up. At a mean follow-up of 21 months, patients completed a questionnaire focused on the time to return to athletics and treatment course. Patients also completed the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire. Radiographs were reviewed to identify fracture comminution, displacement, shortening, and angulation; radiographic union time; and malunion.

RESULTS

All of the patients (30/30 cases) returned to sports after open reduction internal fixation of their fracture. The mean time to return to play was 83 days with a range of 13 to 277 days. Seven (23%) of the cases returned to athletics at ≤6 weeks after surgery, and a total of 20 patients (67%) returned at ≤12 weeks after surgery. All patients (100%) were satisfied with their treatment. The QuickDASH scores revealed almost perfect recovery (mean score, 0.8 of 100). Four minor complications were identified. No patient had a refracture, plate fracture, loss of fixation, nonunion, malunion, or deep wound infection.

CONCLUSION

Plate fixation of displaced clavicle fractures in athletes is a safe procedure, resulting in a high satisfaction rating and minimal disability to the upper extremity. An early return (<6 weeks) to sports is possible after this treatment; however, the time to return is highly variable.

Anatomical study of the clavicle: endomedullary morphology

BACKGROUND

The treatment of clavicle fractures remains controversial. The objective of this study was to investigate the possibility of clavicular intramedullary fixation by nailing through an anatomic study combined with CT scan studies.

METHODS

For the anatomic study, 20 clavicles of donated bodies to science (10 men, 10 women, 10 right, 10 left) were used. We measured the length of the clavicle, lateral epiphysis diameter, mean diaphysis diameter, medial epiphysis diameter, lateral width, lateral radius of curvature, medial width and medial radius of curvature. Intramedullary cavity diameter (anteroposterior and superoinferior) and calibration were measured by CT scan study on 20 clavicles.

RESULTS

Average length was 152 mm for men and 140 mm for women. The anteroposterior curvature was most pronounced. The medullary canal had a gradually decreasing size from the distal portion to the middle segment, but never disappeared.

CONCLUSION

Evaluation of morphological data can clarify the specifications of an intramedullary nail: flexibility of the nail to match clavicle curvature and a locking system to ensure primary stability. Intramedullary fixation by nailing in displaced fractures of the middle portion of the clavicle is a minimally invasive surgical technique, with excellent functional and cosmetic results.

Clinical and financial comparison of operative and nonoperative treatment of displaced clavicle fractures

HYPOTHESIS

Surgical stabilization of displaced clavicle fractures was once considered to have rare indications. Our purpose was to present the clinical and economic effects of surgical management using data collected from operative and nonoperative patients.

METHODS

Our fracture database was queried from January 1, 2005, to January 1, 2010, identifying 204 patients with displaced midclavicular fractures. Radiographs and charts were reviewed, and questionnaires were distributed.

RESULTS

Operative patients had less chronic pain (6.1% vs 25.3%), less cosmetic deformity (18.2% vs 32.5%), less weakness (10.6% vs 33.7%), less loss of motion (15.2% vs 31.3%), and fewer nonunions (0% vs 4.8%). Operative patients missed fewer days of work (8.4 days vs 35.2 days) and required less assistance (3 days vs 7 days) for care at home. Mean income lost was $321.69 versus $10,506.25. Operative patients had a mean emergency department bill of $2,060.51 versus $1,871.92 and had a mean hospital bill of $8,520.30 versus $3,692.65, and anesthesia charges averaged $946.11. Operative patients required less physical therapy, and the mean physical therapy cost was $971.76 versus $1,820. Nonoperative patients required more pain medication ($43.22 vs $45.98). Overall, the cost was $12,976.94 for operative patients and $18,068.27 for nonoperative patients.

CONCLUSIONS

Patients with displaced clavicle fractures benefit clinically and financially from stabilization. They have less chronic pain, less deformity, less weakness, and better range of motion. They return to work sooner, take less pain medication, and require less physical therapy. Their initial hospital bill is higher because of surgical charges but is balanced by less income loss, resulting in a cost savings of $5,091.33 in operative patients.

Results of anterior-inferior 2.7-mm dynamic compression plate fixation of midshaft clavicular fractures

OBJECTIVES

To evaluate the outcome of operatively treated unstable displaced diaphyseal clavicle fractures with anterior-inferior 2.7-mm dynamic compression plate (DCP) fixation.

DESIGN

Retrospective review of clavicle fractures.

SETTING

Level-1 trauma teaching center.

PATIENTS/PARTICIPANTS

One hundred twenty-nine clavicle fractures.

INTERVENTION

An anterior-inferior approach to clavicle fractures was used with the application of a 2.7-mm DCPs.

MAIN OUTCOME MEASUREMENT

Radiographic assessment of healing and complication rates.

RESULTS

One hundred twenty-five fractures healed (97%). Postoperative complications included 1 superficial wound problem, 3 deep wound problems, 5 nonunions, and 4 prominent implants requiring removal in 3.

CONCLUSIONS

Anterior-inferior placement of 2.7-mm DCPs seems safe and is associated with minimal complications.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Risk factors for nonunion in 337 displaced midshaft clavicular fractures treated with Knowles pin fixation

BACKGROUND

Clavicular fractures account for nearly 10 % of all fractures, and the majority of those fractures involve the midshaft. Historically, these fractures were treated nonoperatively; however, recent data suggest an increased risk of nonunion and symptomatic malunion for displaced, comminuted midshaft clavicular fractures treated conservatively. Surgical intervention via plate osteosynthesis or intramedullary fixation with pins, nails, or screws has been shown to reduce, but not eliminate, this risk. Identification of risk factors predictive of nonunion would improve the overall management of displaced, comminuted midshaft clavicular fractures.

METHODS

The medical records of 337 consecutive patients who underwent Knowles pin fixation and supplemental cerclage for the treatment of displaced, comminuted midshaft clavicular fractures between April 2007 and March 2009 were retrospectively reviewed. The records of the mechanism of injury, side of injury, Robinson fracture classification, presence of associated injuries, cerclage material, and patient-related variables, including diabetes mellitus, hypertension and smoking, were analyzed. Variables were assessed by univariate and multivariate analysis to identify those factors significantly associated with the development of fracture nonunion.

RESULTS

A total of 19 nonunions occurred. Increasing age and use of wire for supplemental cerclage fixation were significantly associated with an increased risk for fracture nonunion (p < 0.001). Although suggested as predictors of nonunion in other studies, female gender and fracture severity were not significantly associated with nonunion.

CONCLUSIONS

Nonunion remains a significant complication in the treatment of displaced, comminuted midshaft clavicular fractures even with intramedullary fixation. Use of absorbable suture in place of wire for cerclage fixation and careful selection of treatment strategy in the elderly may reduce the risk for nonunion.

Risk factors for postoperative complications of displaced clavicular midshaft fractures

BACKGROUND

This study evaluated the risk factors of the complications following operative treatment of an acute displaced clavicular midshaft fracture using a reconstruction plate.

METHODS

One hundred twenty-five patients with an acute displaced clavicular midshaft fracture underwent open reduction and plate fixation using a reconstruction plate. Cerclage wires or interfragmentary screws were used for additional comminuted fragment fixation. Clinical outcomes and radiologic evaluation were assessed. Risk factors for postoperative complications requiring reoperation were analyzed by univariate analysis.

RESULTS

Bony union was achieved in 110 patients without any complications within 10.6 weeks postoperatively. Fifteen patients (12%) had a complication requiring reoperation. Implant-related complications occurred in 10 patients (plate breakage in 6 and plate loosening in 4). Deep infection and intractable adhesive capsulitis occurred in one and two patients, respectively. Refracture of the same clavicle after plate removal occurred in two patients. All patients with plate breakage demonstrated nonunion at the time of second operation. Unlike plate breakage, plate loosening was found to be associated with technical errors. Preoperative fracture pattern (p = 0.012) and usage of cerclage wires for additional fragment fixation were found to be significantly related to implant failure (p = 0.009).

CONCLUSIONS

Open reduction and internal fixation using a reconstruction plate for acute displaced clavicular midshaft fractures demonstrated satisfactory clinical outcomes and favorable bony union rates. However, hardware-related complications because of fracture pattern, nonunion, and inadequate surgical techniques require detailed consideration. Furthermore, when additional fixation is needed for comminuted fracture fragments, interfragmentary screw fixation is recommended before cerclage wiring.

Role of autologous bone graft in the surgical treatment of atrophic nonunion of midshaft clavicular fractures

A retrospective study was conducted to evaluate the role of autologous bone graft in treating atrophic nonunion of midshaft clavicle fracture with a limited-contact dynamic compression plate (LC-DCP). Between 1995 and 2008, sixty cases of atrophic nonunion of midshaft clavicle fractures were managed with open reduction and internal fixation with an LC-DCP. The cases were separated into 2 groups to evaluate the effect of autologous bone graft in the enhancement of bone union. In group 1 (n=24), autologous bone graft was not used; in group 2 (n=36), autologous bone graft was used. Pre- and postoperative management were the same in both groups. Radiographic results and functional outcomes according to the Quick Disability of Arm, Shoulder, and Hand score were evaluated. Average follow-up was 25.2 months (range, 24-48 months).No statistically significant difference was found between the 2 groups regarding demography and preoperative functional scores (P>.05). Operative time and hospital stay were statistically significant longer in group 2 (P<.001), and donor site pain was apparent in group 2. All 60 patients had uneventful union. No statistically significant differences were found between the 2 groups regarding union time (average, 9.8 weeks in group 1 and 9.2 weeks in group 2) and postoperative functional scores (P>.05). Limited-contact dynamic compression plate fixation is an effective method for treating atrophic nonunion of midshaft clavicle fractures. Autologous bone graft was not needed.

An assessment of patient satisfaction with nonoperative management of clavicular fractures using the disabilities of the arm, shoulder and hand outcome measure

BACKGROUND

Clavicle fractures historically have been managed without internal fixation. Current literature is raising questions regarding this management as opposed to offering operative fixation in some instances. This study addresses the use of the Disabilities of the Arm, Shoulder and Hand (DASH) outcomes measure to identify those that have the least satisfaction with nonoperative care of the clavicle fracture based upon clavicular deformity and variation in fracture location based upon Allman Classification.

METHODS

Patients having suffered clavicle fractures were mailed the DASH Outcomes Questionnaire to be completed and returned. A total of 113 surveys were returned completed with 92 being of value for evaluation. Patient chest or clavicle radiographs were evaluated, and measurements were made of the clavicle fractures for amount of separation or shortening and grade according to Allman Classification. Statistical evaluation compared DASH Scores (patient satisfaction as outcome measure) to the Allman Classification and the degree of separation or shortening. Comparison of categorical variables was performed using Fisher's exact test. Comparison of continuous variables was preformed using Student's t test. Statistical significance was demonstrated by a p value of less than 0.05.

RESULTS

Patients with clavicular shortening of greater than 2 cm were found to have the highest DASH score indicating dissatisfaction and disability with their outcome postinjury (p = 0.0001). Separation or lengthening seemed to be associated with lower DASH Scores. Patients with Allmen Classification I (midshaft clavicle) fractures had higher DASH score than other fracture locations (p = 0.0001).

CONCLUSIONS

Patients with midshaft clavicle fractures with shortening of greater than 2 cm may be good candidates for operative repair given the degree of dissatisfaction with nonoperative management of these fractures as assessed by long-term outcome measures of disability.

Plate fixation versus intramedullary fixation for displaced mid-shaft clavicle fractures: a systematic review

Purpose

The optimal surgical approach for displaced midshaft clavicle fracture remains controversial. The objective of this systematic review is to compare functional outcome and complications after plate fixation and intramedullary fixation for displaced midshaft clavicle fractures.

Methods

A computer aided search of PUBMED and Embase was carried out on January 11th 2011. Every study that was published in the English, German, French or Dutch language was considered for inclusion. A total of four studies could be included of which two compared intramedullary fixation versus plate fixation, and two compared intramedullary fixation and plate fixation versus conservative treatment for displaced midshaft clavicle fractures. Studies that compared plate fixation with intramedullary fixation in patients with fresh unilateral displaced midshaft clavicle fractures were included. Dislocation or displacement had to be mentioned in the inclusion criteria of the study for inclusion in this review. The modified version of the Cochrane Bone, Joint and Muscle Trauma Group’s former quality assessment tool was used. Furthermore, the studies included were scored according to the GRADE approach to assess the quality. The chosen studies were summarised in a data-extraction form. Because of the different study designs and characteristics data were summarised separately for each study.

Conclusions

High quality evidence from one study and low quality evidence from three studies showed no difference in functional outcome or complications after plate fixation or intramedullary fixation for displaced midshaft clavicle fractures.

Evolving management of middle-third clavicle fractures in the National Football League

BACKGROUND

Clavicle fractures have historically been managed nonoperatively. Recent literature suggests a subset of clavicle fractures may be best treated with primary surgical treatment.

PURPOSE

To review the National Football League (NFL) experience in the management of middle-third clavicle fractures over a 5-year period.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective review of clavicle fractures that occurred during a 5-season period was obtained from the NFL Injury Surveillance System. A detailed questionnaire was also sent to the medical staff of all 32 NFL teams.

RESULTS

Nineteen players sustained a middle-third clavicle fracture over the 5-year period. Six fractures were nondisplaced or minimally displaced. All 6 healed at an average time of 7.3 weeks. Thirteen fractures were 100% displaced. Six of the 13 underwent acute surgical fixation that resulted in fracture healing without complication at an average of 8.8 weeks. The remaining 7 players with a completely displaced fracture were initially treated nonoperatively. Three of these 7 healed clinically without sequela at an average of 13.3 weeks after injury; however, 4 players sustained a refracture within 1 year of the initial injury.

CONCLUSION

Over the past 5 years, nearly 50% of NFL players with a completely displaced middle-third clavicle fracture were treated successfully with acute surgical fixation without sequela and healed at an average of 8.8 weeks. Three of these players were able to return to play during the same season. In addition, 4 of 7 players initially treated nonoperatively for a completely displaced middle-third clavicle fracture refractured their clavicle within a 1-year period from their initial injury. The 4 players missed an average of 1.5 seasons because of their clavicle injury and subsequent clinical course. Based on this review, it may be reasonable to consider acute surgical treatment of this injury in the NFL player to enable a successful clinical outcome in a predictable time frame.

Malunion after midshaft clavicle fractures in adults

This is an overview of the current literature on malunion after midshaft clavicle fracture. Anatomy, trauma mechanism, classification, incidence, symptoms, prevention, and treatment options are all discussed. The conclusion is that clavicle malunion is a distinct clinical entity that can be treated successfully.

Difficulty in diagnosing the pathological nature of an acute fracture of the clavicle: a case report

Fractures of the clavicle comprise between 5% to10% of all fractures. Medial clavicular fractures are uncommon and are normally caused by high-energy trauma. A low impact mechanism of injury should raise suspicion of a pathological fracture, but this case report highlights the difficulty in diagnosing the pathological nature of an acute fracture of the clavicle. We describe a patient who presented with a medial clavicular fracture after a simple fall but the fracture was diagnosed as pathological in retrospect four months after the initial presentation. We would also like to emphasise that the medial clavicle is the most frequent site of pathological fractures of the clavicle, and the possibility of an underlying pathological condition should be considered whenever a patient with a medial clavicular fracture is encountered.