Open Reduction and Internal Fixation Versus Nonsurgical Treatment in Displaced Midshaft Clavicle Fractures: A Meta-Analysis

Long-term conservative treatment outcomes for midshaft clavicle fractures: a 10-to-30-year follow-up

BACKGROUND

Few reports exist on the long-term outcomes of midshaft clavicle fracture conservative treatments. Therefore, this study investigated the long-term outcome of this treatment in patients with midshaft clavicle fractures.

METHODS

Patients were treated conservatively for midshaft clavicle fractures with a figure-of-eight bandage between 10 and 30 years ago. Subsequently, a telephone survey was used to follow-up these patients, and 38 were successfully evaluated. The mean term after trauma was 17.0 years. Afterward, the American Shoulder and Elbow Surgeons Shoulder (ASES) score and Shoulder pain and disability index (SPADI) on the affected and unaffected sides were calculated based on the filled questionnaires. We defined patients whose ASES and SPADI on the affected side were worse than the unaffected side as the symptomatic group. Furthermore, plain radiographs measured proportional changes in clavicular length and displacement.

RESULTS

The ASES scores of the affected side were significantly lower than those of the unaffected side, and the SPADI of the affected side was significantly higher than that of the unaffected side. Furthermore, the symptomatic group's proportional changes in clavicular length and displacement were significantly larger than the asymptomatic group.

CONCLUSION

The affected shoulder side was more symptomatic than the unaffected side 10 to 30 years after the trauma when midshaft clavicle fractures were treated conservatively. Moreover, several patients became symptomatic for fractures with a larger proportional change in clavicular length or displacement.

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.

Patient-reported outcomes after initial conservative fracture treatment in primary healthcare – a survey study

Background

Primary healthcare in Norway has first-line responsibility for medical emergencies, including traumas and fractures. Normally, patients with suspected fractures are referred to specialist care. However, some municipalities have X-ray facilities and handle minor fractures locally. We investigated patient-reported outcome measures after initial treatment of radiologically diagnosed fractures of the wrist, collarbone, and ankle at a primary healthcare centre in a rural municipality with a large ski resort. The patients’ general satisfaction with the treatment was also investigated.

Methods

Validated questionnaires were sent to patients with fractures of the wrist or collarbone (Quick DASH—Disability of Arm, Shoulder and Hand) or the ankle (FAOS -The Foot and Ankle Outcome Score). Patients with wrist and collarbone fractures also answered the Quality-of-life questions that are a subscale of the FAOS questionnaire for ankle fractures. Patient satisfaction was measured for all fracture groups. The Quick DASH scale ranges from 0 (no disability at all) to 100 (great disability), while for FAOS a score of 100 indicates no symptoms and 0 indicates extreme disabilities.

Results

A total of 148 of 238 patients answered the questionnaire (62% response rate). Patients with distal radius fractures had a mean Quick DASH score of 5.1 (median 0, range 0–77), and scores were significantly lower for males (p = 0.013) and increased with age (p = 0.024). Patients with collarbone fractures had a mean Quick DASH score of 2.1 (median 0, range 0–32) with no significant age or gender differences. Patients with ankle fractures had the following mean subscale-scores: Pain, 93.8; Symptoms, 71.4; Activities of daily living, 97.4; Sport, 90.0; and Quality of life, 92.1. The scores did not differ significantly by specialization of the physician. A total of 88% of the patients were highly or very highly satisfied with the handling of their fracture.

Conclusions

The patients reported low rates of functional disability and high rates of satisfaction after initial radiological diagnosis and treatment of their fracture at the primary healthcare centre. Specialisation of the treating physician was not associated with the outcome in any of the fracture types.

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.

Identification of risk factors for surgical site infection after type II and type III tibial pilon fracture surgery

BACKGROUND

High-energy tibial pilon fractures are complex and severe fractures that are associated with a high risk of infection following open reduction and internal fixation. Infection can negatively impact patient outcomes.

AIM

To compare risk factors for postoperative infection after open reduction and internal fixation for a pilon fracture.

METHODS

Among the 137 patients included, 67 developed a surgical site infection. Demographic, clinical, and surgical factors were compared between the two groups. A binary logistic regression analysis was used to determine the odds ratio (OR) and corresponding 95%CI for significant risk factors for postoperative infection.

RESULTS

The distribution of pathogenic bacteria among the 67 patients who developed a surgical site infection was as follows: Gram-positive, 58.2% (n = 39); Gram-negative, 38.8% (n = 26); and fungal, 2.9% (n = 2). The following factors were associated with postoperative infection (P < 0.05): a Ruedi–Allgower pilon fracture type III (OR = 2.034; 95%CI: 1.109–3.738); a type III surgical incision (OR = 1.840; 95%CI: 1.177–2.877); wound contamination (OR = 2.280; 95%CI: 1.378–3.772); and diabetes as a comorbidity (OR = 3.196; 95%CI: 1.209–8.450).

CONCLUSION

Infection prevention for patients with a Ruedi–Allgower fracture type III, surgical incision type III, wound contamination, and diabetes lowers the postoperative infection risk after surgical management of tibial pilon fractures.

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.

White-Light Body Scanning Captures Three-Dimensional Shoulder Deformity After Displaced Diaphyseal Clavicle Fracture

OBJECTIVE

We sought to determine if white-light three-dimensional (3D) body scanning can identify clinically relevant shoulder girdle deformity after displaced diaphyseal clavicle fracture (DCF).

METHODS

Adult patients with DCF (OTA/AO 15A) were prospectively enrolled. Four subcutaneous osseous landmarks were used to measure shoulder girdle morphology of the injured and uninjured shoulder. Measurements were made both manually with a tape measure and digitally with a white-light 3D scanner. Bilateral radiographs were obtained, and clavicle length was recorded. Quick-Disabilities of the Arm, Shoulder, and Hand surveys were administered at injury and at 6 and 12 weeks.

RESULTS

Twenty-two patients were included in the study. At the initial visit, all patients had significant differences in deformity measurements between injured and uninjured shoulders as measured by 3D scanning. There was no difference between shoulders measured using manual measurements. At 6 and 12 weeks, shoulder asymmetry was significantly less in patients treated with surgery compared with nonoperative patients as measured by the 3D scanner alone. Clavicle shortening measured on 3D scanning had weak and moderate positive correlations to radiographs (R = 0.27) and manual measurements (R = 0.53), respectively. Patients treated with surgery had significant functional improvements by 6 weeks, and a similar improvement was not seen until 12 weeks in nonsurgical patients.

CONCLUSION

White-light 3D scanning was able to identify and monitor clinically relevant shoulder girdle deformity after DCF. This tool may become a useful adjunct to clinical examination and radiographic assessment, when determining clinically relevant deformity thresholds. In the future, quantifying and understanding shoulder deformity may inform clinical decision making in these patients.

LEVEL OF EVIDENCE

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

Comparison of patient reported outcomes following clavicle operative fixation using supraclavicular nerve sparing and supraclavicular nerve sacrificing techniques- A cohort study

INTRODUCTION

Supraclavicular nerve injury is one of the common complications after clavicle open reduction internal fixation (ORIF) affecting up to 55% of patients. There is debate about whether sparing supraclavicular nerves improves functional outcomes and patient satisfaction. The purpose of this study was to compare numbness, patient-reported outcomes and surgical time in patients undergoing clavicle ORIF using supraclavicular nerve sparing and supraclavicular nerve sacrificing techniques.

PATIENTS AND METHODS

We conducted a retrospective cohort study with prospective survey of 108 patients with clavicular fractures treated with ORIF at a level 1 trauma centre. Patients were divided into two groups: 1) ORIF with supraclavicular nerve sparing techniques and 2) ORIF with supraclavicular nerve sacrificing techniques. Questionnaires were conducted and subjective numbness around supraclavicular nerve distribution was our primary outcome measure. Secondary outcome measures included the Quick Disability of the Arm, Shoulder and Hand (QuickDASH) score, a numeric rating scale for pain and satisfaction with treatment and surgical time.

RESULTS

An overall response rate of 92% was achieved with an average follow-up of 16 months. There were 20 patients in the supraclavicular nerve sparing group and 79 patients in the supraclavicular nerve sacrificing group. 76% of all patients experienced numbness post-operatively and 91% of these patients experienced persistent numbness at final follow-up. There was no significant difference between the groups for age, gender, time to follow-up and mechanism of injury. Patients in the supraclavicular nerve sparing group had significantly less numbness at final follow-up (35% vs 86%, P < 0.001; OR=0.21 95%CI 0.11-0.40). There was no significant difference in the QuickDASH score nor the NRS for pain and function. Sparing supraclavicular nerves did not result in a significantly longer operation.

CONCLUSIONS

Our study demonstrates that identification and protection of the supraclavicular nerves result in significantly less numbness following clavicle ORIF but does not affect patient reported functional outcomes.

Bilateral Clavicle Fractures - A Rare Injury

Both surgical or nonsurgical management of bilateral clavicle fractures have advantages and disadvantages. Hence a patient must be advised for shared decision making. Our patient was a painter by occupation with a left-sided dominant hand. Considering his job and financial constraints, we fixed his left clavicle fracture surgically and treated his right-sided clavicle fracture conservatively. We suggest based on our report concerning this rare injury, is that not all fractures need to be fixed surgically. Patient needs and other factors should be taken into consideration before taking the patient for surgical management.

Factors Affecting Patient Decision-Making Regarding Midshaft Clavicle Fracture Treatment

Introduction Midshaft clavicle fractures are a common problem encountered by orthopedic surgeons. There remains debate between non-surgical and surgical treatment options for certain midshaft clavicle fractures. Due to the lack of a clear treatment strategy, this presents an opportunity for shared decision-making, which has been shown to be important to patients. Methods A 19-question survey was created encompassing basic demographic information, then taking respondents through a simulation of a midshaft clavicle fracture patient encounter. Subjects were subsequently asked their preferred treatment choice as well as shared decision-making preferences for the simulated encounter. A pilot study was performed with medical students from our home institution to assess study sample size. The survey was then distributed through an online software platform (Amazon Mechanical Turk). Statistical analysis was performed using STATA, Microsoft Excel, and Qualtrics. Results 253 subjects responded to the online survey. Over 70% of respondents had no to minimal knowledge of clavicle fractures and potential medical interventions/treatments. 67.6% of respondents preferred shared decision-making, over autonomous or paternalistic models. 45.5% of respondents wanted additional time outside the physician-patient consultation before making a treatment decision. A majority of the respondents who selected surgery (44.3%; 43/97) and no surgery (69.9%; 109/156), based their decisions on outcomes data provided in the simulation alone. There was no statistically significant relationship between income, race/ethnicity, education level, work status, sex, or type of visual fracture representation (i.e., radiograph vs. cartoon image) and treatment decision (p>0.05). Younger age (p=0.007) and being married (p=0.001) were associated with increased likelihood to select surgery as the treatment decision.  Conclusion Most respondents had no-to-minimal knowledge about clavicle fractures, placed a high value in shared decision-making for midshaft clavicle fractures, and prioritized outcomes data in making treatment decisions. Younger age and marital status may increase the likelihood of a patient selecting to proceed with surgery over non-operative treatment.

Displaced Midshaft Clavicle Fracture Union Can Be Accurately Predicted with a Delayed Assessment at 6 Weeks Following Injury: A Prospective Cohort Study

BACKGROUND

It is unclear if clinical recovery following a midshaft clavicle fracture can accurately predict fracture-healing. The additional information that can be assessed at 6 weeks after injury may have superior predictive value compared with information available at the time of the injury.

METHODS

A prospective study of all patients (≥16 years of age) who sustained a fully displaced midshaft clavicle fracture was performed. We assessed patient demographic characteristics, injury factors, functional scores, and radiographic predictors with a standardized protocol at 6 weeks. Conditional stepwise regression modeling was used to assess which factors independently predicted nonunion at 6 months after the injury as determined by computed tomography (CT). The nonunion predictor 6-week model was compared with a previously validated model based on factors available at the time of the injury, which included smoking, comminution, and fracture displacement.

RESULTS

At 6 months, 200 patients completed follow-up. The CT-defined nonunion rate was 14% (27 of 200). Of the functional scores, the QuickDASH (the abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire) had the highest accuracy on receiver operator characteristic (ROC) curve analysis with a 39.8-point threshold, above which was associated with nonunion (area under curve [AUC], 76.8%; p < 0.001). Sixty-nine percent of the cohort had a QuickDASH score of <40 points at 6 weeks, and 95% (131 of 138) of these patients had fracture union. On regression modeling, a QuickDASH score of ≥40 points (p = 0.001), no callus on radiographs (p = 0.004), and fracture movement on examination (p = 0.001) were significant predictors of nonunion. If none were present, the predicted nonunion risk was 3%, found in 40% (80 of 200) of the cohort. Conversely, if ≥2 of the predictors were present, found in 23.5% of the cohort, the predicted nonunion risk was 60%. The nonunion predictor model at 6 weeks appeared to have superior accuracy (AUC, 87.3%) when compared with the nonunion predictor model at the time of injury (AUC, 64.8%) for fracture-healing on ROC curve analysis.

CONCLUSIONS

Delayed assessment at 6 weeks following displaced midshaft clavicle fracture enables an accurate prediction of patients who are likely to have union with nonoperative management. One in 4 patients are at an increased risk of nonunion and may benefit from operative intervention.

LEVEL OF EVIDENCE

Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Clavicle hook plate versus distal clavicle locking plate for Neer type II distal clavicle fractures

Background

The purpose of this meta-analysis was to compare clavicle hook plates versus distal clavicle locking plates for the treatment of Neer type II distal clavicle fractures.

Methods

PubMed (1996 to January 2019), Embase (1980 to January 2019), Web of Science (1990 to January 2019), the Cochrane Library (January 2019), and the China National Knowledge Infrastructure (January 2019) were systematically searched without language restrictions for literature retrieval. The Constant-Murley shoulder joint function score at 3 and 6 months after the operation and the postoperative complications after the operation (shoulder joint pain, abduction restriction, fracture delay healing, subacromial impingement) were the outcomes. Stata 12.0 was used for the meta-analysis.

Results

A total of 9 clinical trials involving 446 patients were finally included in this meta-analysis. The results showed that the improvement in the Constant-Murley shoulder joint function score in the distal locking plate group was better than that in the clavicle hook plate group at 3 and 6 months after the operation (P < 0.05). There were fewer cases of shoulder joint pain and restricted shoulder abduction range of motion in the distal locking plate group, and the difference was statistically significant (P < 0.05). There were no statistically significant differences in fracture delay healing and subacromial impingement between the two groups (P > 0.05).

Conclusion

Compared with the clavicular hook plate, the distal clavicle locking plate for the treatment of Neer type II distal clavicle fractures is associated with better shoulder function recovery and fewer complications related to pain and abduction restriction.

Operative management of clavicular malunion in midshaft clavicular fractures: a report of 59 cases

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.

Mid-Term Patient Satisfaction and Residual Symptoms After Plate Fixation or Nonoperative Treatment for Displaced Midshaft Clavicular Fractures

OBJECTIVES

To evaluate mid-term patient-reported satisfaction and residual symptoms after plate fixation (PF) or nonoperative treatment (NOT) for displaced midshaft clavicular fractures.

DESIGN

Follow-up survey of randomized controlled trial.

SETTING

Sixteen teaching and nonteaching hospitals.

PARTICIPANTS

All 160 patients with a fully displaced, midshaft clavicular fracture who had been randomized were approached by telephone.

INTERVENTION

Randomization for open reduction and internal PF or a sling for 2 weeks (NOT).

MAIN OUTCOME MEASUREMENTS

Outcomes were satisfaction with the received treatment, with the cosmetic result and with shoulder function (on a scale of 1-10), and presence of residual symptoms.

RESULTS

Seventy-nine patients (40 after PF and 39 after NOT) could be contacted. The median follow-up was 53 (34-79) months. Overall satisfaction was similar for PF and NOT (mean ± SD: 7.7 ± 2.1 vs. 6.9 ± 2.4, P = 0.12), as was satisfaction with the shoulder function (8.9 ± 1.6 vs. 8.4 ± 2.0, P = 0.27). Satisfaction with the cosmetic result was higher after PF (8.2 ± 1.6 vs. 6.8 ± 2.0, P = 0.002). Residual symptoms were frequently present in both groups (55% for PF vs. 41% for NOT, P = 0.26). After PF, 88% of patients would prefer the same treatment again compared with 41% after NOT (P < 0.001).

CONCLUSIONS

Aspects of satisfaction seem higher after PF. Residual symptoms, however, were common after both treatments for clavicular fractures. The present results can be used to manage patients' expectations and provide objective information regarding both treatment options before a shared treatment decision is made.

LEVEL OF EVIDENCE

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