Three-Dimensional Deformities of Nonoperative Midshaft Clavicle Fractures: A Surface Matching Analysis

The deformities of acute diaphyseal clavicular fractures: a three-dimensional analysis

BACKGROUND

Although minimally invasive surgeries have gained popularity in many orthopaedic fields, minimally invasive approaches for diaphyseal clavicular fracture have not been widely performed, which is attributed to difficulties in performing a closed reduction of fracture deformities of a curved bone in a three-dimensional space. The goal of this study was to investigate the radiographic parameters of fracture deformities in a three-dimensional space and to identify the risk factors for deformities.

METHODS

The computed tomography images of 100 patients who sustained a clavicle fracture were included. Five parameters were used to analyze the deformities: change in clavicle length, fracture displacement, and fragment rotation around the X, Y, Z axes. The change in length was assessed using the length of the endpoint line. The displacement was assessed using the distance between the fracture midpoints. The rotation deformities were assessed using the Euler angles. The correlation between the parameters was evaluated with the Pearson correlation coefficient. The risk factors were evaluated using univariable analysis and multiple regression analysis.

RESULTS

The average change in length was - 5.3 ± 8.3 mm. The displacement was 11.8 ± 7.1 mm. The Euler angles in the Z-Y-X sequences were -1 ± 8, 1 ± 8, and - 8 ± 13 degrees. The correlation coefficient between the change in length and the displacement was - 0.724 (p < 0.001). The variables found to increase the risk of shortening and displacement were right-sided fracture (p = 0.037), male sex (p = 0.015), and multifragmentary type (p = 0.020). The variables found to increase the risk of rotation deformity were the number of rib fractures (p = 0.001) and scapula fracture (p = 0.025).

CONCLUSIONS

There was a strong correlation between shortening and displacement. The magnitude of anterorotation around the X axis was greater than the magnitude of retraction around the Z axis and depression around the Y axis. The risk factors for shortening and displacement included right-sided fracture, male sex, and multifragmentary type. The risk factor for retraction around the Z axis was the number of rib fractures, and the risk factor for depression around the Y axis was scapula fracture. These results could be useful adjuncts in guiding minimally invasive surgical planning for diaphyseal clavicular fractures.

The accuracy of computed tomography for clavicle non-union evaluation

BACKGROUND

The primary aim of this study is to determine the accuracy of CT scanning when evaluating non-union of the clavicle.

METHODS

A retrospective review was performed of all CT scans undertaken for suspected nonunion of midshaft clavicle fractures over a 10-year period. The influence of scan timing, callus and patient characteristics was evaluated.

RESULTS

One hundred eighty-four CT scans were analysed. No patient was incorrectly diagnosed with union (n = 85). Ninety-nine scans were reported as non-union with inadequate bridging callus, 19 of which were united at operation or on repeat CT imaging and represented delayed unions. Atrophic callus was found in 57 patients and all of which had a confirmed non-union (positive predictive value 100%). A hypertrophic callus was found in 42 patients, all of the delayed unions were found in this group (positive predictive value for non-union 55%, p < 0.001). CT compared to radiographs showed greater inter-observer agreement for union (weighted kappa 0.75 vs. 0.50 respectively). Overall, CT is 100% sensitive and 81.7% specific for non-union diagnosis.

DISCUSSION

CT has excellent accuracy to determine clavicle union but approximately one in five suspected non-unions went onto unite. Hypertrophic callus finding resulted in a delayed union in approximately half of the cases in our study.

Can Upstream Patient Education Improve Fracture Care in a Digital World? Use of a Decision Aid for the Treatment of Displaced Diaphyseal Clavicle Fractures

BACKGROUND

The increasing proportion of telemedicine and virtual care in orthopaedic surgery presents an opportunity for upstream delivery of patient facing tools, such as decision aids. Displaced diaphyseal clavicle fractures (DDCFs) are ideal for a targeted intervention because there is no superior treatment, and decisions are often dependent on patient's preference. A decision aid provided before consultation may educate a patient and minimize decisional conflict similarly to inperson consultation with an orthopaedic traumatologist.

METHODS

Patients with DDCF were enrolled into 2 groups. The usual care group participated in a discussion with a trauma fellowship-trained orthopaedic surgeon. Patients in the intervention group were administered a DDCF decision aid designed with the International Patient Decision Aid Standards. Primary comparisons were made based on a decisional conflict score. Secondary outcomes included treatment choice, pain score, QuickDASH, and opinion toward cosmetic appearance.

RESULTS

A total of 41 patients were enrolled. Decisional conflict scores were similar and low between the 2 groups: 11.8 (usual care) and 11.4 (decision aid). There were no differences in secondary outcomes between usual care and the decision aid.

DISCUSSION

Our decision aid for the management of DDCF produces a similarly low decisional conflict score to consultation with an orthopaedic trauma surgeon. This decision aid could be a useful resource for surgeons who infrequently treat this injury or whose practices are shifting toward telemedicine visits. Providing a decision aid before consultation may help incorporate patient's values and preferences into the decision-making process between surgery and nonoperative management.

LEVEL OF EVIDENCE

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

Midshaft Clavicle Fractures Treated Nonoperatively Using Figure-of-Eight Bandage: Are Fracture Type, Shortening, and Displacement Radiographic Predictors of Failure?

As there are no clear and unique radiographic predictors of healing disturbances for acute midshaft clavicle fractures, their treatment is still controversial. The aim of the study was to evaluate in midshaft clavicle fractures treated nonoperatively if fracture type (FT), shortening, and displacement, assessed before and after figure-of-eight bandage (F8-B) application, could be considered prognostic factors of delayed union and nonunion. One hundred twenty-two adult patients presenting a closed displaced midshaft clavicle fracture, managed nonoperatively with an F8-B, were enrolled. FT, initial shortening (IS), and initial displacement (ID) were radiographically evaluated at diagnosis, and both residual shortening (RS) and displacement (RD) were measured after F8-B application. The patients were followed up 1, 3, 6, and 12 months post-injury. Multivariate statistical analysis was performed. RD should be considered as radiological predictor of sequelae. Further, an RD equal to 104% of clavicle width was identified as an optimal cut-off point to distinguish between healed and unhealed fractures, and 140% between delayed union and nonunion. Our data pointed out the effectiveness of the F8-B in reducing fracture fragments and restoring clavicular length. In midshaft clavicle fractures of adults, fracture comminution and clavicular shortening did not influence bone healing. On the contrary, RD has been shown as the most likely predictor of both delayed union and nonunion.

Dual mini-fragment plate fixation for Neer type-II and -V distal clavicle fractures

Contemporary methods for open reduction and internal fixation of displaced distal clavicle fractures have excellent rates of union and high rates of reoperation for symptomatic implant removal. The authors describe their preferred surgical technique and case series of patients with Neer Type-II and -V distal clavicle fractures treated with lower profile dual mini-fragment plates using interdigitating screws placed into the distal segment to enhance fixation.

Three-Dimensional Analysis of the First Metatarsal Bone in Minimally Invasive Distal Linear Metatarsal Osteotomy for Hallux Valgus

BACKGROUND

Modified Bösch osteotomy (distal linear metatarsal osteotomy [DLMO]) is one of the minimally invasive correctional surgeries for hallux valgus. The 3-dimensional correctional angles and distances of the first metatarsal bone in DLMO have not been clarified. The purpose of this study was to analyze the 3-dimensional postoperative morphological changes of the first metatarsal bone in DLMO.

METHODS

Twenty patients (30 feet) who underwent DLMO were enrolled. Preoperative plain radiographs and computed tomography (CT) scans of the feet were examined. Postoperative radiographs and CT scans were also obtained after bone union. The surface data of the pre- and postoperative first metatarsals were reconstructed from the CT data. The positions of the distal ends of the first metatarsals described with respect to the proximal ends were calculated using CT surface-matching technique.

RESULTS

The distal end of the first metatarsal after DLMO was significantly supinated (10.2 ± 6.0 degrees, P < .001), adducted (6.0 ± 11.8 degrees, P = .004), dorsiflexed (11.1 ± 10.9, P < .001), shortened (7.4 ± 2.5 mm, P < .001), elevated (2.3 ± 3.1 mm, P = .001), and laterally shifted (8.2 ± 3.0 mm, P < .001) compared to the preoperative metatarsal distal end. Supination correction demonstrated a significant correlation with adduction correction (r = 0.659, P < .001) on correlation analyses between these parameters.

CONCLUSION

The 3-dimensional corrections of the first metatarsal bone after DLMO were evaluated. Pronation and abduction were successfully corrected. Furthermore, adduction correction might be an important factor affecting correction of pronation.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Three-dimensional clavicle displacement analysis and its effect on scapular position in acute clavicle midshaft fracture

BACKGROUND

The purpose of this study was to measure the distance of the clavicle in 3 dimensions (3D) and each direction (anterior to posterior, medial to lateral, and superior to inferior) and to analyze the correlation of the angular orientation of the scapula according to each directional distance of the clavicle.

METHODS

Sixty-seven patients with Robinson 2B1 and 2B2 clavicle midshaft fracture (46.0 ± 17.4 years, men = 50, women = 17) were selected as final subjects. Patients' computed tomography was reconstructed using an image processing program (3D Slicer 4.3 software). Anteroposterior (AP) distance, medial-to-lateral distance, superior-to-inferior distance, and 3D distance of both clavicles were measured. The plane connecting the 3 points (superior pole, inferior pole, and center of glenoid) of the scapula was used to calculate differences in the angular orientation between both scapulae.

RESULTS

Among each directional distance of the clavicle, only the AP distance showed negative correlation with scapular angular orientation with anterior tilting, internal rotation, and upward rotation of the scapula (Pearson's correlation coefficient: -0.68, -0.24, and -0.28; P < .001, P = .048, and P = .021).

CONCLUSION

The shortening of the AP distance of the clavicle was related to the angular orientation of the scapula in acute clavicle fracture. AP shortening should be considered when determining the treatment of clavicle fracture.

Glenohumeral translation during active external rotation with the shoulder abducted in cases with glenohumeral instability: a 4-dimensional computed tomography analysis

BACKGROUND

Although glenohumeral instability is common, the mechanism of instability remains unclear. The purpose of this study was to quantitatively evaluate humeral head translation during active external rotation with abduction in patients with glenohumeral instability by use of 4-dimensional computed tomography scans.

METHODS

Ten patients with unilateral glenohumeral instability with a positive fulcrum test were prospectively included in this study. Sequential computed tomography of bilateral shoulders during active external rotation at 90° of shoulder abduction was performed for 6 seconds at 5 frames per second. The 3-dimensional positions of the humeral head center in the anteroposterior, superoinferior, and mediolateral directions were calculated at 0°, 20°, 40°, 60°, and maximum shoulder abduction-external rotation from the starting position. Translation of the humeral head center from the starting position was evaluated using Dunnett multiple-comparison tests, and the differences between the affected and intact shoulders were assessed using Wilcoxon signed rank tests.

RESULTS

The humeral head center translated posteriorly, inferiorly, and medially during glenohumeral external rotation with the shoulder in the abducted position on the intact side. However, the affected humeral head showed significantly less posterior translation (P = .028), greater inferior translation (P = .047), and less medial translation (P = .037) than the contralateral side.

CONCLUSIONS

This study indicated that dysfunction of the anterior band of the inferior glenohumeral ligament causes decreased posterior, increased inferior, and decreased medial translation of the humeral head during active shoulder abduction-external rotation.