Operative Versus Nonoperative Outcomes of Middle-Third Clavicle Fractures: A Systematic Review and Meta-Analysis

[Clavicle nonunion]

After conservative treatment nonunion (pseudarthrosis) of the clavicle can be observed approximately 10 times more frequently (15-24%) than after surgical treatment (1.4%). Risk factors include the fracture location, displacement, fracture type, sex, the severity of the accident and refractures. The diagnosis of pseudarthrosis of the clavicle can be made by a thorough medical history, clinical examination and imaging procedures. The main symptom is pain, often accompanied by malalignment, instability, neurological symptoms and restricted mobility of the affected shoulder. The diagnosis is confirmed by X‑ray images and, if necessary, a computed tomography (CT) scan. Pseudoarthrosis is classified according to the morphological appearance in X‑ray images and the cause. A differentiation is made between vital and nonvital pseudarthroses. Only symptomatic pseudarthrosis requires treatment. Nonoperative methods, such as magnetic field therapy or ultrasound are minimally effective. Surgical interventions are indicated for pain, movement restrictions or neurovascular problems. The goals of surgical treatment are to restore the vitality, bone length and stability through angular stable osteosynthesis. In cases of surgical pretreatment the anteroinferior plate position offers a good alternative to the superior plate position. In some cases double plating osteosynthesis can be indicated. Autogenous bone material, allogeneic substitute material and vascularized grafts are used for bony defects. Surgical treatment shows high rates of healing but also carries an increased risk of infection.

SHORTENING OF CLAVICLE FRACTURES: PHYSICAL VERSUS IMAGE EXAMINATIONS

Objective

Determine the reliability of three different methods of evaluating bone shortening in displaced midshaft clavicle fractures (DCMF).

Method

A cross-sectional analytical study evaluated bone shortening by metric tape (MT), radiography (X-ray), and computed tomography (CT). Twenty-six men had been evaluated and used clavícula not broken as control. The collection of data was of the blind type for three specialists. Differences and reliability were analyzed with the Friedman and Kappa tests and validated with the T-test (CI: 95%; significance index p<0.05; Software "R" version 3.2.2).

Results

The MT measurements (control) showed abnormal distribution and significant statistical difference concerning the imaging tests (p=0.000008). There was a similarity between X-ray and CT and Kappa agreement of 0.65. The fractured clavicles presented similar measurements between the three methods (p=0.059), and the T-tests proved that the similarity was caused by chance or possible measurement errors.

Conclusion

Measurement by metric tape showed a tendency to overestimate bone shortening. The CT showed more reliable results for the diagnosis; however, the X-ray was sufficient for decision-making by surgeons, and therefore, it is not possible to rule out the importance of this resource for DCMF. Level of Evidence IV; Case-Control Study.

A novel surgical method for treating fractures of the middle third of the clavicle

BACKGROUND

The clavicle is recognized as the bone most vulnerable to fractures. Moreover, approximately 80% of fractures occur in the middle third of the clavicle. Conservative treatment is associated with a higher rate of nonunion, while surgical treatment of fracture via internal fixation may have a variety of postoperative complications. Therefore, to improve patient satisfaction and reduce the complications related to internal fixation techniques, we modified the surgical approach to external fixation.

OBJECTIVE

The purpose of this study was to assess the modified intervention's prospects for clinical application.

METHODS

A total of 36 patients with middle clavicle fractures were treated with screw-rod external fixation between April 2015 and October 2019. We observed the operative time, intraoperative blood loss, length of hospital stay, and fracture healing time. The patients were followed up regularly, and the clinical efficacy of the modified intervention was evaluated. Finally, the patients' shoulder function was assessed based on the disabilities of the arm, shoulder, and hand (DASH) score.

RESULTS

For the screw-rod external fixation, the mean operative time was found to be 48.6 ± 6.8 min, the intraoperative blood loss was 30.6 ± 17.2 mL, the length of hospital stay was 4.5 ± 1.5 days, and the fracture healing time was 2.8 ± 0.4 months. Eventually, all the patients healed well, with the combined "excellent" and "good" rate of shoulder function being assessed to be as high as 94.44%. Furthermore, the DASH scores were all less than 10, with the average score being 4.65 ± 3.34.

CONCLUSIONS

The screw-rod external fixation technique offers the advantages of convenience, reliability, and good aesthetics, suggesting that it could be used as an alternative treatment method for fractures of the middle third of the clavicle.

Unicortical versus bicortical plate fixation for midshaft clavicular fractures

BACKGROUND

The aim of this study was to compare the functional and radiological outcomes of unicortical vs bicortical fixation in patients with midshaft clavicular fractures who were treated using pre-contoured locking plates.

METHODS

We performed a prospective multicenter study of 45 individuals who underwent open reduction and internal fixation of midshaft clavicular fractures with precontoured locking plates between March 2017 and December 2019. Twenty-five patients were treated with bicortical screws and 20 patients with unicortical screws. Functional outcomes were assessed at 6 months and 12 months after surgery using the Constant score, the 11-item version of the Disabilities of Arm, Shoulder and Hand (Quick- DASH) score and the Single Assessment Numeric Evaluation (SANE) score. Pain was evaluated using a visual analog scale (VAS). The rate of return to work and sports was also recorded. Radiologic evaluation was obtained in the immediate postoperative day, monthly until fracture consolidation, at 6 months and 12 months. All intraoperative and postoperative complications were documented.

RESULTS

At both 6 and 12 months, the follow-up rates were 100%, and the mean age was 28.5 years (range, 20 to 45 years). The mean postoperative Constant score, Quick DASH, and SANE score at 12 months were 93.5 (±6), 2.3 (±3), and 92% (±7), respectively. There were no significant differences in the functional scores between the groups neither at 6 months nor at 12 months. Of the 30 active workers, 97% were able to return to their previous working routine and from the 25 patients who practiced sports before the injury,92% returned to sports all at the same level. All the fractures healed in both groups. There were 6 complications (13%).

CONCLUSION

In young, active patients with displaced midshaft clavicular fractures, both unicortical and bicortical locked plates achieved 100% bone consolidation, with excellent functional outcomes and a low rate of complications without significant differences between the groups. Therefore, locked plates with unicortical fixation could be a very good alternative for the management of young patients with midshaft clavicular fractures, potentially avoiding severe neurovascular complications.

LEVEL OF EVIDENCE

Prospective comparative (Level II).

Minimally invasive plate osteosynthesis for displaced midshaft clavicle fractures: An indirect reduction using joystick technique

BACKGROUND

A minimally invasive plate osteosynthesis (MIPO) technique has become increasingly popular in long bone fracture fixation as it could eliminate postoperative complications. However, the most challenging aspect of employing the MIPO for midshaft clavicle fractures among general orthopedic surgeons is the technically demanding that indirect reduction is typically a closed maneuver.

METHODS

We present a consecutive series of patients with displaced midshaft clavicle fractures undergoing clavicular fixation using the MIPO technique between January 2017 and October 2019. The joystick technique was used to obtain anatomical reduction. Clinical outcomes were assessed using the Constant-Murley and the American shoulder and elbow surgeons shoulder scores.

RESULTS

Thirty patients with a mean age of 42.44 years were included. The functional shoulder scores showed no disabilities compared with those of a healthy population. No major complications requiring re-operation were noted, and all fractures were completely healed with an average time of 12.53 weeks.

CONCLUSION

This study demonstrated that facilitating the MIPO for midshaft clavicle fractures using simple operative devices and techniques was possible. The joystick technique with the use of an external fixator for temporary stabilization is a safe and effective method that can be added to achieve anatomical alignment with the fracture site unexposed. This technique could be performed either in a fresh fracture or a delayed case with failed conservative treatment.

Evidence on treatment of clavicle fractures

Depending on the severity of the injury and the involvement of the soft tissue envelope, clavicle fractures can be treated operatively or non-operatively. In the past, displaced fractures of the clavicle shaft in adults have been treated non-operatively. However, the rate of nonunion following non-operative treatment seems to be higher than previously reported. In addition, publications reporting better functional outcomes following operative treatment are increasing. In recent years this has led to a paradigm shift towards an increase of operative fracture treatment. The aim of this review article was to summarize the currently available evidence on the treatment of clavicle fractures. Classifications, indications, and treatment options for different fracture patterns of the medial, midshaft, and lateral clavicles are presented and discussed.

Functional and radiological outcome of non-operative treated clavicle fractures and its association with acromioclavicular joint arthrosis

BACKGROUND

Clavicle fractures are traditionally treated non-operatively. This study determines the functional outcome of midshaft clavicle fractures treated non-operatively, the factors influencing it, and the incidence of acromioclavicular joint (ACJ) arthrosis.

METHODS

Patients with midshaft clavicular fractures treated non-operatively between 16 and 50 years old with no prior AC joint problems were assessed. Demographics, hand dominance, type of occupation, and smoking status were documented. Functional scoring using DASH score, CM score, and radiological evaluation was done with special tests to diagnose AC joint arthrosis. Two or more positive special tests were considered significant for this study.

RESULTS

101 patients were recruited, 83 male and 18 female patients. The average age of 34.7 ± 13.93 years. The average follow-up was 32.7 months (range: 24-75; SD ± 9.9 months). 48.5% were blue-collar workers, and 60.4% involved the dominant upper limb. 44.6% were cigarette smokers. There was 20 mm and more shortening in 21.8% of subjects. 40.6% had a significant special test, and 36.6% had radiological changes of AC joint osteoarthritis. Positive two or more special tests were significantly associated with radiological evidence of arthrosis (p = .00). The mean DASH score was 28.28 ± 17.4, and the mean CM score was 27.58 ± 14.34. Most have satisfactory to excellent scores. Hand dominance, smoking, and blue-collar work were significantly associated with poorer CM scores, and hand dominance was significant for Dash scores.

CONCLUSION

There is an equal distribution poor, satisfactory and excellent functional outcomes in patients with midshaft clavicle fractures treated non-operatively. The poor outcomes may be attributed to ACJ arthrosis. Hand dominance, smoking and blue-collar work affected the functional outcome. Shortening of the clavicle had no bearing on the clinical and radiological findings of osteoarthritis and functional scores. The presence of two or more positive special tests is an accurate predictor of AC joint arthritis.

Treatment of Symptomatic Medial Clavicle Nonunion with Intramedullary Tendon Allograft: A Case Report

CASE

A 67-year-old patient sustained a medial clavicle fracture (MCF) treated with open reduction and fixation with cerclage sutures. A year later, he presented with symptomatic nonunion and skin prominence, which was revised with an intramedullary tendon allograft fixation including the sternoclavicular joint. At 31 months after the procedure, the patient showed no pain or clinical instability.

CONCLUSION

MCF is an uncommon injury. Symptomatic nonunion after the failure of fixation is rarely described. Although the best way to treat this complication is debatable, revision fixation using an intramedullary tendon allograft can be a viable option in elderly patients.

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.

Treatment and outcome of fracture-related infection of the clavicle

INTRODUCTION

The number of operatively treated clavicle fractures has increased over the past decades. Consequently, this has led to an increase in secondary procedures required to treat complications such as fracture-related infection (FRI). The primary objective of this study was to assess the clinical and functional outcome of patients treated for FRI of the clavicle. The secondary objectives were to evaluate the healthcare costs and propose a standardized protocol for the surgical management of this complication.

METHODS

All patients with a clavicle fracture who underwent open reduction and internal fixation (ORIF) between 1 January 2015 and 1 March 2022 were retrospectively evaluated. This study included patients with an FRI who were diagnosed and treated according to the recommendations of a multidisciplinary team at the University Hospitals Leuven, Belgium.

RESULTS

We evaluated 626 patients with 630 clavicle fractures who underwent ORIF. In total, 28 patients were diagnosed with an FRI. Of these, eight (29%) underwent definitive implant removal, five (18%) underwent debridement, antimicrobial treatment and implant retention, and fourteen patients (50%) had their implant exchanged in either a single-stage procedure, a two-stage procedure or after multiple revisions. One patient (3.6%) underwent resection of the clavicle. Twelve patients (43%) underwent autologous bone grafting (tricortical iliac crest bone graft (n = 6), free vascularized fibular graft (n = 5), cancellous bone graft (n = 1)) to reconstruct the bone defect. The median follow-up was 32.3 (P₂₅-P₇₅: 23.9-51.1) months. Two patients (7.1%) experienced a recurrence of infection. The functional outcome was satisfactory, with 26 out of 28 patients (93%) having full range of motion. The median healthcare cost was € 11.506 (P₂₅-P₇₅: € 7.953-23.798) per patient.

CONCLUSION

FRI is a serious complication that can occur after the surgical treatment of clavicle fractures. In our opinion, when treated adequately using a multidisciplinary patient-specific approach, the outcome of patients with an FRI of the clavicle is good. The median healthcare costs of these patients are up to 3.5 times higher compared to non-infected operatively treated clavicle fractures. Although not studied individually, we consider factors such as the size of the bone defect, condition of the soft tissue, and patient demand important when it comes to guiding our surgical decision making in cases of osseous defects.

Pseudoaneurysm of the subclavian artery as a delayed complication of a clavicle fracture

Vascular complications are relatively rare following surgical fixation of midshaft clavicle fractures. Here, we report a case of a woman in her 30s presenting 10 years after right clavicular open reduction and internal fixation with revision 6 years prior with sudden and rapidly progressive neck swelling. Physical examination revealed a soft pulsating mass in her right supraclavicular fossa. Ultrasound and CT angiography of the head and neck showed a pseudoaneurysm of her right subclavian artery with a surrounding haematoma. She was admitted to the vascular surgery team for endovascular repair with stenting. Postoperatively, she developed arterial thrombi requiring thrombectomy (twice) and is now on lifelong anticoagulation. It is crucial to be aware of complications that can develop in patients with a history of clavicular fracture managed non-operatively or operatively even years later and highlights the importance of risk and benefit discussions and counselling.

Surgical management of clavicle fractures in Australia: an analysis of Australian Medicare Benefits Schedule database from 2001 to 2020

BACKGROUND

There is no consensus on the optimal management of clavicle fractures, with advocates of both operative and non-operative management. The objective of this study is to assess the trends in the management of clavicle fractures in Australia over the past two decades.

METHODS

The incidence of surgical fixation of clavicle fractures from 2001 to 2020 was analysed using the Australian Medicare Benefits Schedule database, reflective of operations performed on privately insured patients, thus excluding public patients and compensable cases. An offset term was utilized with data from the Australian Bureau of Statistics to account for population changes over the study period.

RESULTS

A total of 17 089 procedures for the management of clavicle fractures were performed from 2001 to 2020. The incidence of operative intervention increased from 1.87 per 100 000 in 2001 to a peak of 6.63 per 100 000 in 2016. An overall increase was seen in males (310%) and females (347%) over the study period, as well as across all age groups. A greater proportion of operative interventions was performed on males (n = 14 075, 82%) than females (n = 3014, 18%, P < 0.001). The greatest increase in intervention was noted in those aged 65 or older (14% increase per year, 95% CI 11%-17%, P < 0.05). In 2020, the incidence of operative intervention decreased to a level last seen in 2013.

CONCLUSIONS

The incidence of operative interventions for clavicle fractures has increased in Australia over the 20-year study period. This increase is in keeping with recent evidence suggesting several advantages when displaced mid-shaft clavicle fractures are operatively managed.

Plate fixation of midshaft clavicle fractures for delayed union and non-union is a cost-effective intervention but functional deficits persist at long-term follow-up

BACKGROUND

The primary aim of this study was to compare the long-term functional outcome of midshaft clavicle fracture fixation for delayed (≥3 month) and non-union (≥6 month) compared to a matched cohort of patients that achieved union with non-operative management. The secondary aim was to assess cost-effectiveness of fixation.

METHODS

A consecutive series of patients over 10-years were retrospectively reviewed using the QuickDASH, Oxford Shoulder Score and EuroQol five-dimension summary index (EQ-5D). These patients were compared to a matched cohort that achieved union after non-operative management using propensity score matching.

RESULTS

Sixty patients (follow-up 79%, n = 60/76) at 4.1 years post-operative (1.1-10.0 years) had a QuickDASH of 16.5 (95% CI 11.6-21.5), Oxford Shoulder Score 41.5 (39.0-44.1) and EQ-5D 0.7621 (0.6822-0.8421). One in five patients were dissatisfied with their final outcome (n = 13/60). Functional outcome was inferior following fixation when compared to patients that united with non-operative management (QuickDASH 16.5 vs. 5.5, p < 0.001 and EQ-5D 0.7621 vs. 0.9073, p = 0.001). However, significant improvements were found when compared to pre-operative scores (QuickDASH p < 0.001 and EQ-5D p < 0.001). The cost per QALY for fixation was £5624.62 for the study cohort.

CONCLUSIONS

Clavicle fixation for delayed and non-union is a cost-effective intervention but outcomes are worse compared to patients that unite with non-operative management.

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.

Safe and Effective Treatment of Compromised Clavicle Fracture of the Medial and Lateral Third Using Focused Shockwaves

A delay or failure to heal is the most common possible complication in clavicle fractures, especially in cases primarily treated conservatively. As the current standard therapy, surgical revision achieves good healing results, but is associated with potential surgery-related complications. Shockwave therapy as a non-invasive therapy shows similar reasonable consolidation rates in the non-union of different localizations, but avoids complications. Compromised clavicle fractures in the middle and lateral third treated with focused high-energy shockwave therapy were compared with those treated with surgical revision (ORIF). In addition, a three-dimensional computer simulation for evaluating the pressure distribution during shockwave application accompanied the clinical study. A comparable healing rate in bony consolidation was achieved in both groups. Significantly fewer complications, however, occurred in the shockwave group. The simulations showed safe application in this instance, particularly in avoiding lung tissue affection. When applied correctly, shockwaves represent a safe and promising therapy option for compromised clavicle fractures in the middle and lateral third.

Surgical treatment, complications, reoperations, and healthcare costs among patients with clavicle fracture in England

INTRODUCTION

The clinical and economic burden of clavicle fractures in England is not well documented. This study evaluated rates of surgical treatment, post-surgical complications, reoperations and costs in patients with clavicle fractures using the Clinical Practice Research Datalink (CPRD) database.

METHODS

CPRD data were linked to National Health Service Hospital Episode Statistics data. Patients with a diagnosis of clavicle fracture between 2010-2018 were selected in CPRD (date of fracture = index date). Of those, patients with surgical intervention within 180 days from index fracture were identified. Rates of post-surgical complications (i.e., infection, non-union, and mal-union), reoperations (for device removal or for postoperative complications), post-operative costs and median time to reoperations were evaluated up to 2 years after surgery.

RESULTS

21,340 patients with clavicle fractures were identified (mean age 35.0 years(standard deviation (SD): 26.5), 66.7% male). Surgery was performed on 672 patients (3.2% of total cohort) at an average 17.1 (SD: 25.2) days post-fracture. Complications (i.e., infection, non-union, or malunion) affected 8.1% of surgically treated clavicle fracture patients; the rate of infection was 3.5% (95% CI, 1.7%- 5.2%), non-union 4.4% (95% CI, 2.4%-6.5%), and mal-union 0.3% (95% CI, 0%-0.7%). Adjusting for age, gender, comorbidities and time to surgery, the all-cause reoperation rate was 20.2% (13.2%-30.0%) and the adjusted rate of reoperation for implant removal was 17.0% (10.7%-25.9%)-84% of all-cause reoperations were thus performed for implant removal. Median time to implant removal was 254 days. The mean cost of reoperations for all causes was £5,000. The most expensive reoperations were for cases that involved infection (mean £6,156).

CONCLUSIONS

Complication rates following surgical clavicle fracture care averaged 8.1%. However, reoperation rates exceed 20%, the vast majority of reoperations being performed for device removal. Technologies to alleviate secondary device removal surgeries would address a significant clinical unmet need.

Current trends in patient-reported outcome measures for clavicle fractures: a focused systematic review of 11 influential orthopaedic journals

BACKGROUND

Many patient-reported outcome measures (PROMs) have been used to follow clavicle fractures, providing an objective means to track outcomes. However, lack of standardization of PROM usage makes cross-study comparison difficult. Therefore, we reviewed articles on clavicle fractures from 11 of the most influential orthopedic journals to assess trends in PROM usage over time and based on geographic location.

METHODS

A focused systematic review of 11 of the most influential orthopedic journals was performed using PubMed. All articles published between 1981 and 2020 with greater than 9 patients reporting clinical outcomes of clavicle fractures were included. For each article, patient demographics, treatment modality, geographic location, and outcome measures used were recorded. Temporal trends were identified using the Cochran-Armitage test for trend and linear regression. Pearson chi-square and Kruskal-Wallis tests were used to compare between journals, geographic location, study type, and fracture classification.

RESULTS

From the initial literature search of 623 articles, 151 studies reporting on 15,853 primary clavicle fractures were included. Fractures of the middle one-third of the clavicle were most studied in the included literature (71%). Seventeen different PROMs were used, with an average of 1.6 outcome measures per study, and there was a significant increase in the number of PROMs used per article over time (P < .001). The Constant-Murley score was the most-reported outcome measure (44%) followed by the Disabilities of the Arm, Shoulder, and Hand score (27%), visual analog scale for pain (23%), and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES; 14%). There was a significant difference between the measures used based on geography (P = .002), the most notable being that North American authors use the ASES score more frequently.

CONCLUSIONS

The use of PROMs in studies evaluating clavicle fracture treatment outcomes has increased over time, with recent studies reporting more PROMs than older studies, and there are notable differences in usage of the various scores based on geography and journal. Although there is no consensus on the most reliable PROM for assessing clavicle fractures, we recommend the use of at least 2 of the commonly reported PROMs in future studies to facilitate cross-study comparisons.

Biomechanical Evaluation of Different Plate Configurations for Midshaft Clavicle Fracture Fixation: Single Plating Compared with Dual Mini-Fragment Plating

Background:

Dual-plate constructs have become an increasingly common fixation technique for midshaft clavicle fractures and typically involve the use of mini-fragment plates. The goal of this technique is to reduce plate prominence and implant irritation. However, limited biomechanical data exist for these lower-profile constructs. The study aim was to compare dual mini-fragment orthogonal plating with small-fragment clavicle plates for biomechanical noninferiority and to determine if an optimal plate configuration could be identified using a cadaveric model.

Methods:

Twenty-four cadaveric clavicles were randomized to 1 of 6 groups, stratified by computed tomography-based bone mineral content (BMC): precontoured superior or anterior fixation using a single 3.5-mm Locking Compression Plate (LCP), and 4 different dual-plating constructs utilizing 2.4-mm and 2.7-mm Adaptation plates or LCPs. An inferior butterfly fracture was created. Axial, torsional, and bending (anterior and superior surface loading) stiffnesses were determined through nondestructive cyclic testing, followed by a load-to-failure test in 3-point superior surface bending.

Results:

For axial stiffness, the 2 dual-plate constructs with a superior 2.4-mm and anterior 2.7-mm plate (either Adaptation or LCP) were significantly stiffer than the other 4 constructs (p = 0.021 and p = 0.034). For both superior and anterior bending, the superior 2.4-mm and anterior 2.7-mm plate constructs were significantly stiffer when compared with the 3.5-mm superior plate (p = 0.043). No significant differences were found in torsional stiffness or load to failure between the different constructs.

Conclusions:

Dual plating using mini-fragment plates is biomechanically superior for the fixation of midshaft clavicle fractures when compared with a single, superior, 3.5-mm plate and has biomechanical properties similar to those of a 3.5-mm plate placed anteriorly. With the exception of axial stiffness, no significant differences were found when different dual-plating constructs were compared with each other.

Clinical Relevance:

This study validates the use of dual plating for midshaft clavicle fractures.

Functional outcomes and adverse effects following three interventions for displaced midshaft clavicular fractures: A Bayesian network meta-analysis of randomized controlled trials

INTRODUCTION

The efficacy of the most commonly used interventions for clavicle fractures remains controversial. These interventions are: open reduction and plate fixation (ORPF), non-surgical intervention (NSI), and use of an intramedullary nail (IMN). In adult patients with clavicle fractures, choosing which intervention might be best is challenging.

MATERIALS AND METHODS

PubMed, Journals@Ovid Full Text, Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, and Embase were performed to search English-language studies from the inception to February 2020. Randomized controlled trials (RCTs) comparing any of these three interventions were included. Patient and baseline characteristics, nonunion, major complications, Constant-Murley score (CMS), and Disabilities of the Arm, Shoulder and Hand score (DASH) were extracted. Then, we evaluated the functional outcomes and adverse effects after use of these three interventions for the management of displaced midshaft clavicle fractures in a Bayesian network meta-analysis.

RESULTS

A Bayesian random-effects model was conducted, and nonunion and major complications were evaluated with: risk ratio (RR) and 95% confidential interval (CI); while CMS and DASH were evaluated with mean differences (MD) and the corresponding 95% confidential interval CI. The rank probability of each endpoint was assessed on the basis of the surface area under the cumulative ranking curve (SUCRA).

DISCUSSION

ORPF is most likely to be successful in achieving objective functional outcomes as captured by the CMS, and IMN demonstrates significant efficacy for subjective functional outcomes, as captured by DASH scores. Compared with the other interventions examined, IMN was associated with decreased risk for adverse effects.

LEVELS OF EVIDENCE

I; meta-analysis.

Protocol of BRICS: Brazilian multicentric pragmatic randomised trial of surgical interventions for displaced diaphyseal clavicle fracture study: MIPO versus ORIF for the treatment of displaced midshaft clavicle fractures

INTRODUCTION

Fractures of the diaphysis of the clavicle are common; however, treatment guidelines for this condition are lacking. Surgery is associated with a lower risk of non-union and better functional outcomes but a higher risk of complications. Open reduction and internal fixation with plates and screws are the most commonly performed techniques, but they are associated with paraesthesia in the areas of incisions, extensive surgical exposure and high rates of implant removal. Minimally invasive techniques for treating these fractures have a lower rate of complications. The aim of this study is to evaluate which surgical treatment option (minimally invasive osteosynthesis or open reduction and internal fixation) has better prognosis in terms of complications and reoperations.

METHODS AND ANALYSIS

The study proposed is a multicentric, pragmatic, randomised, open-label, superiority clinical trial between minimally invasive osteosynthesis and open reduction and internal fixation for surgical treatment of patients with displaced fractures of the clavicle shaft. In the proposed study, 190 individuals with displaced midshaft clavicle fractures, who require surgery as treatment, will be randomised. The assessment will occur at 2, 6, 12, 24 and 48 weeks, respectively. The primary outcome of the study will be the number of complications and reoperations. For sample size calculation, a moderate effective size between the techniques was considered in a two-tailed test, with 95% confidence and 90% power. Complications include cases of infection, hypertrophic scarring, non-union, refracture, implant failure, hypoesthesia, skin irritation and shoulder pain. Reoperations are defined as the number of surgeries for pseudoarthrosis, implant failure, infection and elective removal of the implant.

ETHICS AND DISSEMINATION

Study approved by the institutional ethics committee (number 34249120.9.0000.5505-V.3). The results will be disseminated by publications in peer-reviewed journals and presentations in medical meetings.

TRIAL REGISTRATION NUMBER

RBR-3czz68)/UTN U1111-1257-8953.

Acute plate fixation of displaced midshaft clavicular fractures is not associated with earlier return of normal shoulder function when union is achieved

Aims

It is unclear whether acute plate fixation facilitates earlier return of normal shoulder function following a displaced mid-shaft clavicular fracture compared with nonoperative management when union occurs. The primary aim of this study was to establish whether acute plate fixation was associated with a greater return of normal shoulder function when compared with nonoperative management in patients who unite their fractures. The secondary aim was to investigate whether there were identifiable predictors associated with return of normal shoulder function in patients who achieve union with nonoperative management.

Methods

Patient data from a randomized controlled trial were used to compare acute plate fixation with nonoperative management of united fractures. Return of shoulder function was based on the age- and sex-matched Disabilities of the Arm, Shoulder and Hand (DASH) scores for the cohort. Independent predictors of an early recovery of normal shoulder function were investigated using a separate prospective series of consecutive nonoperative displaced mid-shaft clavicular fractures recruited over a two-year period (aged ≥ 16 years). Patient demographics and functional recovery were assessed over the six months post-injury using a standardized protocol.

Results

Data from the randomized controlled trial consisted of 86 patients who underwent operative fixation compared with 76 patients that united with nonoperative treatment. The recovery of normal shoulder function, as defined by a DASH score within the predicted 95% confidence interval for each respective patient, was similar between each group at six weeks (operative 26.7% vs nonoperative 25.0%, p = 0.800), three months (52.3% vs 44.2%, p = 0.768), and six months post-injury (86.0% vs 90.8%, p = 0.349). The mean DASH score and return to work were also comparable at each timepoint. In the prospective cohort, 86.5% (n = 173/200) achieved union by six months post-injury (follow-up rate 88.5%, n = 200/226). Regression analysis found that no specific patient, injury, or fracture predictor was associated with an early return of function at six or 12 weeks.

Conclusion

Return of normal shoulder function was comparable between acute plate fixation and nonoperative management when union was achieved. One in two patients will have recovery of normal shoulder function at three months, increasing to nine out of ten patients at six months following injury when union occurs, irrespective of initial treatment.

Cite this article: Bone Jt Open 2021;2(7):522–529.

Surgical treatment of anterior sternoclavicular dislocation associated with midshaft clavicle fracture: A case report

A combination of an anterior sternoclavicular (SC) joint dislocation with a midshaft clavicle fracture is an extremely rare injury. If left untreated, it can lead to severely impaired function of the shoulder with a high risk for complications. A 45-year-old male patient presented with pain and impaired range of motion (ROM) in the left shoulder after a mountain bike crash. Radiographs and a computed tomography scan showed an anterior dislocation of the left SC joint and an ipsilateral midshaft fracture of the clavicle. Open reduction and internal fixation (ORIF) of the clavicle combined with SC joint stabilization using transosseous sutures was performed. Postoperatively, a shoulder-arm bandage was applied with passive motion starting on the first postoperative day. During follow-up, the patient showed an improved clinical function and could return to work after three weeks. Radiographs at eight weeks showed fracture healing without any signs of recurrent SC dislocation. At the final follow-up at 12 weeks, the patient returned to his pre-injury activity level and recreational sports. Despite minimal redislocation in the SC joint, the Constant-Murley Score showed a continuous improvement with 93%, compared to the contralateral side. In conclusion, surgical treatment of anterior SC joint dislocation with a midshaft clavicle fracture can restore shoulder function with no surgery-associated complications.

Fracture nonunion in long bones: A literature review of risk factors and surgical management

Nonunion following a long bone fracture causes considerable morbidity when it occurs. Risk factors depend on specific fractures but there is a complex interplay of injury severity, comorbidities, patient medication and infection. The majority of nonunions occur after long bone fractures with the tibia, femur, forearm, humerus and clavicle predominating. Despite interest in the biological augmentation of fracture healing, the majority of nonunions can be effectively managed with conventional surgical techniques. In this review we present a review of risk factors for nonunion and the outcome following surgical management.

Outcomes and complications after dual plate vs. single plate fixation of displaced mid-shaft clavicle fractures: A systematic review and meta-analysis

INTRODUCTION

Open reduction and internal fixation (ORIF) of displaced midshaft clavicle fractures is associated with higher union rates and earlier functional recovery. However, ORIF with plate fixation is associated with complications including implant irritation and implant failure. Dual plate fixation provides fixation in orthogonal planes, and uses a lower profile fixation technique in comparison to pre-contoured and surgeon-contoured small-fragment locking plates, which may be more prominent. The objective of this study was to conduct a systematic review to summarize outcomes and complications associated with surgical fixation of displaced acute midshaft clavicle fractures with dual plate fixation.

METHODS

Using a predetermined study protocol in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, the databases MEDLINE, EMBASE, and CENTRAL were searched from inception to 2020 to identify studies reporting outcomes in acute midshaft clavicle fractures treated with dual plate fixation. All clinical studies which reported on outcomes of dual plating in patients with acute midshaft clavicle fractures were included. Baseline demographics, plate fixation constructs, fracture union rates, implant removal rates, maintenance of reduction, symptomatic implant rates, wound complications, and functional outcomes were extracted. All extracted data were recorded, and descriptive statistics were summarized. Meta-analysis was performed on fracture union rates and implant removal rates using random-effects modeling using Mantel-Haenszel weighting.

RESULTS

Our literature search identified 2226 unique abstracts, of which eight studies met our study inclusion criteria following review. A total of 278 patients made up of 79.8% male with an average age of 36.0 years were included. The overall dual plate implant removal rate was 4.2% with excellent rates of union reported. Moreover, single plate fixation was associated with a 3.9-fold increased implant removal rate compared to dual plate fixation.

CONCLUSION

Results from this systematic review demonstrate that ORIF of displaced midshaft clavicle fractures using a dual plate fixation technique is a viable option to reduce the incidence of implant removal, without negatively impacting the rate of fracture union.

LEVEL OF EVIDENCE

Therapeutic Level III.

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.

Sonographic bridging callus at six weeks following displaced midshaft clavicle fracture can accurately predict healing

AIMS

To evaluate if union of clavicle fractures can be predicted at six weeks post-injury by the presence of bridging callus on ultrasound.

METHODS

Adult patients managed nonoperatively with a displaced mid-shaft clavicle were recruited prospectively. Ultrasound evaluation of the fracture was undertaken to determine if sonographic bridging callus was present. Clinical risk factors at six weeks were used to stratify patients at high risk of nonunion with a combination of Quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) ≥ 40, fracture movement on examination, or absence of callus on radiograph.

RESULTS

A total of 112 patients completed follow-up at six months with a nonunion incidence of 16.7% (n = 18/112). Sonographic bridging callus was detected in 62.5% (n = 70/112) of the cohort at six weeks post-injury. If present, union occurred in 98.6% of the fractures (n = 69/70). If absent, nonunion developed in 40.5% of cases (n = 17/42). The sensitivity to predict union with sonographic bridging callus at six weeks was 73.4% and the specificity was 94.4%. Regression analysis found that failure to detect sonographic bridging callus at six weeks was associated with older age, female sex, simple fracture pattern, smoking, and greater fracture displacement (Nagelkerke R2 = 0.48). Of the cohort, 30.4% (n = 34/112) had absent sonographic bridging callus in addition to one or more of the clinical risk factors at six weeks that predispose to nonunion. If one was present the nonunion rate was 35%, 60% with two, and 100% when combined with all three.

CONCLUSION

Ultrasound combined with clinical risk factors can accurately predict fracture healing at six weeks following a displaced midshaft clavicle fracture. Cite this article: Bone Joint Res 2021;10(2):113-121.

Plate osteosynthesis for mid-shaft clavicle fractures: An update

INTRODUCTION

Over the last few years, treatment of mid-shaft clavicle fractures seems to have shifted from conservative to surgical. Our study reports the results of plate osteosynthesis of mid-shaft clavicle fractures and compares them with literature.

MATERIALS AND METHODS

A retrospective cohort study was conducted on 32 patients with mid-shaft clavicle fractures treated with plate and screws between January 2009 and December 2014. All the patients followed the same post-operative rehabilitation program with radiographic and clinical evaluation (DASH score and Constant score) at a minimum follow-up of 24 months.

RESULTS

All the patients healed clinically and radiographically, without deformities or non-unions, with complete and early functional recovery and return to their pre-injury sport activities. At one year follow-up the mean Constant Score was 93.8 (SD 4.8) and the mean DASH score was 42 (SD 5.0).

CONCLUSIONS

Osteosynthesis with plate and screws of mid-shaft clavicle fractures allows not only restoration of the anatomy, but also early recovery of shoulder function. For this reason, such surgical treatment should always be considered when facing this particular fracture group, also in accordance with recent literature.