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Qvist AH, Jensen SL. Minimal early functional gains after operative treatment of midshaft clavicular fractures: a meta-analysis of 10 randomized controlled trials including 1333 patients. JSES Int 2024; 8:400-406. [PMID: 38707583 PMCID: PMC11064720 DOI: 10.1016/j.jseint.2023.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024] Open
Abstract
Background There is substantial evidence that operative treatment reduces the risk of nonunion but offers no long-term functional gains compared with nonoperative treatment. Despite some studies citing quicker recovery with surgery, the promise of accelerated functional recovery remains under-investigated. The aim of this meta-analysis of randomized controlled trials was to investigate the possible early functional gains (≤6 months) after operative treatment of displaced midshaft clavicular fractures compared with nonsurgical treatment. Methods A systematic search was performed to identify randomized controlled trials comparing plate osteosynthesis with nonoperative treatment. We evaluated shoulder function outcomes measured by Constant Score or Disability of the Arm, Shoulder, and Hand (DASH) questionnaire. Other outcomes of interest were sick leave and return to previous activity (work, leisure). Results Ten studies including 1333 patients were included. The mean difference in DASH score after 6 weeks was 9.4 points (95% confidence interval [CI] 13.7-5.1) in favor of operative treatment. At 3 months, the difference was 3.6 points (95% CI 6.9-0.4), and at 6 months, the difference was 3.2 points (95% CI 5.2-1.1), both in favor of operative treatment. Results for Constant Score were similar to that of DASH score. Conclusion This meta-analysis shows that there is an early functional gain at six weeks following plate fixation of midshaft clavicular fractures compared with nonoperative treatment. At three and six months, the functional gain is lesser and not clinically relevant.
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Affiliation(s)
- Andreas H. Qvist
- Department of Orthopedics, Aarhus University Hospital, Aarhus, Denmark
| | - Steen L. Jensen
- Department of Orthopedics and Orthopaedic Research Unit, Aalborg University Hospital, Aalborg, Denmark
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Ashworth H, Martin D, Nagdev A, Lind K. Clavipectoral plane block performed in the emergency department for analgesia after clavicular fractures. Am J Emerg Med 2023; 74:197.e1-197.e3. [PMID: 37865557 DOI: 10.1016/j.ajem.2023.09.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 08/31/2023] [Accepted: 09/27/2023] [Indexed: 10/23/2023] Open
Abstract
Clavicle fractures are common injuries in the Emergency Department (ED). Adequate pain control with oral or intravenous medications is the central aspect of treatment. The ultrasound-guided clavipectoral plane block (CPB), previously described in anesthesia literature, offers complete analgesia of the clavicle with a low adverse effect profile. In this case series, we describe the first reported utilization of the CPB for analgesia for acute clavicular fractures in the ED. We performed the CPB for distal and midshaft clavicular fractures on patients who suffered from a variety of traumatic accidents including bicycle accidents, motorcycle accidents, and motor vehicle accidents. All patients experienced significant reductions in their reported pain without any reported complications. Given the need to provide patients with appropriate pain control in the ED, the CPB offers an effective, simple method for providing analgesia without known significant risks, including without the risks associated with high-dose systemic analgesia.
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Affiliation(s)
- Henry Ashworth
- Department of Emergency Medicine, Highland Hospital - Alameda Health System, Oakland, CA, United States of America.
| | - David Martin
- Department of Emergency Medicine, Highland Hospital - Alameda Health System, Oakland, CA, United States of America
| | - Arun Nagdev
- Department of Emergency Medicine, Highland Hospital - Alameda Health System, Oakland, CA, United States of America
| | - Karen Lind
- Department of Emergency Medicine, Highland Hospital - Alameda Health System, Oakland, CA, United States of America
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Irfan SA, Ali AA, Ashkar A, Akram U, Fatima S, Baig MMA, Khan MW. Predictors requiring special attention to prevent clavicle fracture nonunion: a systematic review of literature. Trauma Surg Acute Care Open 2023; 8:e001188. [PMID: 38020862 PMCID: PMC10679979 DOI: 10.1136/tsaco-2023-001188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 11/12/2023] [Indexed: 12/01/2023] Open
Abstract
Background Clavicle fracture (CF) is the tenth most prevalent fracture, accounting for an annual incidence of 37/10,000. This systematic review highlights the factors contributing to the nonunion union of the clavicular fracture. Method A systematic search was conducted using three web-based databases up to August 12, 2022, for conducting qualitative analysis. Articles were screened for relevance, and only studies that met inclusion criteria based on PECOS; P (patients): participants diagnosed with clavicular fracture; E (exposure): nonunion, C (control): not applicable; O (outcomes): factors contributing to nonunion or delayed union; S (studies): trials and observational studies. The Newcastle-Ottawa Scale was used to assess the quality of the cohort studies. The Cochrane risk of bias tool was used to assess the bias in randomized control trials. Results Ten studies were selected after the final literature search. Two thousand seven hundred and sixty-six adult participants who were radiologically and clinically diagnosed with nonunion clavicular fracture were included to pool the qualitative results. Fall was the most dominant cause of clavicular fracture, followed by road traffic collisions. Open reduction was widely used to treat nonunion correction. The qualitative results suggested a prominent correlation of nonunion with advancing age, female gender, high energy trauma, high Disabilities of the Arm, Shoulder, and Hand Score, smoking, fracture displacement, clavicular shortening, the callus on radiography, and fracture movement. The mid-shaft fracture was the most dominant type of fracture in the included studies; highly associated with nonunion in comparison to medial or lateral CF. The previous history of operation was an independent factor contributing to nonunion. Conclusion The results of this systematic review suggested the predictors contributing to nonunion in the CF. Demographic factors such as advancing age with female gender are at higher risk of developing clavicular nonunion. Smoking was the most dominantly highlighted environmental factor contributing to nonunion. Diaphyseal or midshaft fracture was the most common site for nonunion. Therefore, we suggested that patients with the predictors mentioned above require special attention to prevent nonunion of the CFs. More studies should be conducted on this subject to assess the factors that pose a risk associated with the nonunion of the bone for better clinical management and outcomes of the fracture.
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Affiliation(s)
- Shayan Ali Irfan
- Orthopedic, Dow University of Health Sciences, Karachi, Sindh, Pakistan
| | - Abid Anwar Ali
- Orthopedic, Dow University of Health Sciences, Karachi, Sindh, Pakistan
| | - Anusha Ashkar
- Orthopedic, Dow University of Health Sciences, Karachi, Sindh, Pakistan
| | - Usama Akram
- Orthopedic, Dow University of Health Sciences, Karachi, Sindh, Pakistan
| | - Sameen Fatima
- Orthopedic, Dow University of Health Sciences, Karachi, Sindh, Pakistan
| | - Mirza M Ali Baig
- Orthopedic, Dow University of Health Sciences, Karachi, Sindh, Pakistan
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Imazato H, Takahashi N, Sawaguchi A, Hirakawa Y, Yamaguchi Y, Hiyoshi M, Tajima T, Chosa E. Insertion sites of the muscles attached to the clavicle: a cadaveric study of the clavicle. BMC Musculoskelet Disord 2023; 24:160. [PMID: 36864447 PMCID: PMC9983183 DOI: 10.1186/s12891-023-06266-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 02/23/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Clavicle fractures are common injuries, especially in young, active individuals. Operative treatment is recommended for completely displaced clavicle shaft fractures, and plate fixation is stronger than the use of intramedullary nails. Few studies have reported on iatrogenic injuries to the muscle attached to the clavicle during fracture surgery. The aim of this study was to clarify the area of the insertion sites of muscles attached to the clavicle in Japanese cadavers using gross anatomy and three-dimensional (3D) analysis. We also aimed to compare the effects of anterior plate templating and superior plate templating on clavicle shaft fractures using 3D images. METHODS Thirty-eight clavicles from Japanese cadavers were analyzed. We removed all clavicles to identify the insertion sites and measured the size of the insertion area of each muscle. Three-dimensional templating was performed on both the superior and anterior plates of the clavicle using data obtained from computed tomography. The areas covered by these plates on the muscles attached to the clavicle were compared. Histological examination was performed on four randomly selected specimens. RESULTS The sternocleidomastoid muscle was attached proximally and superiorly; the trapezius muscle was attached posteriorly and partly superiorly; and the pectoralis major muscle and deltoid muscles were attached anteriorly and partially superiorly. The non-attachment area was located mainly in the posterosuperior part of the clavicle. It was difficult to distinguish the borders of the periosteum and pectoralis major muscles. The anterior plate covered a significantly broader area (mean 6.94 ± 1.36 cm2) of the muscles attached to the clavicle than did the superior plate (mean 4.11 ± 1.52 cm2) (p < 0.0001). On microscopy, these muscles were inserted directly into the periosteum. CONCLUSION Most of the pectoralis major and deltoid muscles were attached anteriorly. The non-attachment area was located mainly from the superior to posterior part of the clavicle midshaft. Both macroscopically and microscopically, the boundaries between the periosteum and these muscles were difficult to demarcate. The anterior plate covered a significantly broader area of the muscles attached to the clavicle than that by the superior plate.
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Affiliation(s)
- Hiroyuki Imazato
- grid.410849.00000 0001 0657 3887Division of Orthopaedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Nobuyasu Takahashi
- Department of Anatomy, Ultrastructural Cell Biology, Faculty of Medicine, University of Miyazaki, 5200, Kihara, Kiyotake, Miyazaki, Japan.
| | - Akira Sawaguchi
- grid.410849.00000 0001 0657 3887Department of Anatomy, Ultrastructural Cell Biology, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki Japan
| | - Yusuke Hirakawa
- grid.410849.00000 0001 0657 3887Division of Orthopaedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Yoichiro Yamaguchi
- grid.410849.00000 0001 0657 3887Division of Orthopaedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Masaru Hiyoshi
- grid.410849.00000 0001 0657 3887Division of Orthopaedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Takuya Tajima
- grid.410849.00000 0001 0657 3887Division of Orthopaedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Etsuo Chosa
- grid.410849.00000 0001 0657 3887Division of Orthopaedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
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Patel M, Heyworth BE, Dehghan N, Mehlman CT, McKee MD. Clavicular Fractures in the Adolescent. J Bone Joint Surg Am 2023; 105:713-723. [PMID: 36753567 DOI: 10.2106/jbjs.22.01036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
➤ Current evidence suggests that the majority of clavicular fractures in adolescents can and should be treated nonoperatively. ➤ Although rare, in certain patients or fracture patterns, nonoperative management may be associated with delayed healing, prolonged disability, and/or poor functional outcome requiring secondary reconstruction. ➤ When warranted, primary open reduction and internal fixation with plate and screw application has consistently good outcomes with a low complication rate, with the most common complication being implant-related symptoms requiring a secondary surgical procedure for implant removal. ➤ Prospective, comparative studies examining operative and nonoperative treatment, including measures of early return to function, injury burden, return to athletic activity, complication and reoperation rates, and shoulder-girdle-specific, long-term outcome measures are warranted to further elucidate which fractures may benefit from primary fixation.
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Affiliation(s)
- Midhat Patel
- Department of Orthopedics, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona
| | - Benton E Heyworth
- Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts
| | | | - Charles T Mehlman
- Division of Pediatric Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michael D McKee
- Department of Orthopedics, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona
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Bernstein J. Not the Last Word: Masks and the Veil of Ignorance. Clin Orthop Relat Res 2021; 479:1665-1668. [PMID: 34180863 PMCID: PMC8277289 DOI: 10.1097/corr.0000000000001891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 06/09/2021] [Indexed: 01/31/2023]
Affiliation(s)
- Joseph Bernstein
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
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Fourman MS. CORR Insights®: Minimal Pain Decrease Between 2 and 4 Weeks after Nonoperative Management of a Displaced Midshaft Clavicle Fracture Is Associated with a High Risk of Symptomatic Nonunion. Clin Orthop Relat Res 2021; 479:139-141. [PMID: 33298742 PMCID: PMC7899724 DOI: 10.1097/corr.0000000000001606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 07/23/2020] [Indexed: 01/31/2023]
Affiliation(s)
- Mitchell S Fourman
- M. S. Fourman, Orthopaedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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