Conservative treatment of fractures of the clavicle

Functional Outcomes in Surgically Treated Clavicle Fractures: A Longitudinal Observational Study

Introduction The clavicle is the most unique long bone and has a significant incidence in terms of fractures. Operative fixation for clavicle fractures has seen a steep rise in terms of technique as well as type of implant. Although extensive studies have been carried out in relation to clavicle fractures and their treatment modalities, no proper guidelines or approach has been identified as ideal, and hence, this study was carried out to evaluate operative fixation as a viable strategy. Objective The objective of this article was to assess functional outcomes of plate fixation in clavicle fractures. Materials and methods This longitudinal prospective observational study included 30 patients treated for clavicle fractures with plate fixation in the Orthopedics Department of Himalayan Institute Hospital Trust (HIHT), Jollygrant, Dehradun, over a period of one year. Functional outcomes were assessed as Constant-Murley shoulder scores, and complications were recorded. Radiological assessment was done on the basis of time to union through follow-up skiagrams. Statistical analysis was performed using the SPSS statistical package version 17.0 (IBM Inc., Armonk, New York). Continuous variables are presented as mean ± SD, and categorical variables are presented as absolute numbers and percentages. Continuous variables and constant score values over time within the groups were analyzed using repeated measures analysis of variance (ANOVA) followed by Bonferroni's post hoc testing. A p-value of <0.05 was considered statistically significant. Results The mean age of patients undergoing surgical fixation of clavicle fractures was 36 ± 12.53 years, ranging from 18-65 years. Of the entire study group, 83.3% were males and 16.7% were females. Road traffic accident (RTA) was the most common cause of clavicle fracture, constituting 76.7% of the entire study population, followed by fall on the floor (20.0%), and one patient sustained trauma by being hit by a bull (3.3%). Our study demonstrated a mean Constant score of 73.87 ± 2.64, 82.80 ± 2.20, and 92.40 ± 2.37 at one-month, two-month, and four-month follow-up times, respectively, which was found to be statistically significant in terms of progression (p value<0.001). The mean union time of clavicle fractures in our study population was 12.1 weeks. Two patients in our study developed implant impingement. Conclusion Our study revealed that patients with clavicle fractures treated with plate fixation had statistically significant good functional outcome (Constant) scores at sequential follow-ups, consistent with available literature. Mean union time was also comparable to existing literature. Non-union was not noted in our study, and only two cases developed implant impingement. Hence, we conclude that early primary plate fixation for displaced clavicle fractures is a promising technique with good overall functional outcomes and patient satisfaction, especially in young, active patients.

Operative stabilisation versus non-operative management of mid-shaft clavicle fractures

INTRODUCTION

Fractures of the mid-shaft clavicle are commonly encountered in clinical practice. These can be managed either by conservative method or operative by internal fixation. This study aims to compare the outcomes of conservative and operative management.

METHODS

Forty patients with displaced and comminuted mid-shaft clavicle fractures were included in the study, among which twenty-five patients were treated conservatively and 15 patients underwent surgery and were followed up for a period of 1 year. Time taken for union, functional outcome, complications, and patient satisfaction were compared.

RESULTS

In the non-operative group, 28% of the fractures took less than twelve weeks to unite, whereas in the operative group 60% of them took less than 12 weeks to unite. At the end of 1 year, there was no statistical difference in mean UCLA (University of California and Los Angeles) score and the mean DASH score of the non-operative group and operative group. There were more complications in the operative group. Re-operative rate in the operative group was 40%. Patient satisfaction was 80% in the non-operative group, whereas 48% of patients were satisfied in the operative group.

CONCLUSION

Displaced and comminuted mid-shaft clavicle fractures treated conservatively have more advantages when compared to surgically treated fractures.

Assessment of the measurement methods in midshaft clavicle fracture

Background

Clavicle fractures account for approximately 5% of all fractures in adults and 75% of clavicle fractures occur in the midshaft. Shortening greater than two centimeters is an indicative of surgical treatment. Radiographic exams are often used to diagnose and evaluate clavicle fractures but computed tomography (CT) scan is currently considered the best method to assess these deformities and shortening.

Goal

1- To investigate whether different methods of performing the radiographic exam interfere on the measurement of the fractured clavicle length.

2- Compare the clavicle length measurements obtained by the different radiographic exam methods with the CT scan measurements, used as a reference.

Materials and methods

Twenty-five patients with acute (< 3 weeks) midshaft clavicle fracture were evaluated. Patients underwent six radiographic images: PA Thorax (standing and lying), AP Thorax (standing and lying) and at 10° cephalic tilt (standing and lying), and the computed tomography was used as reference.

Results

The mean length (cm) obtained were: 14,930 on CT scan, 14,860 on PA Thorax Standing, 14,955 on PA Thorax Lying, 14,896 on AP Thorax Standing, 14,960 AP Thorax Lying, 15,098 on 10° cephalic tilt Standing and 15,001 on 10° cephalic tilt Lying, (p > 0,05).

Conclusion

1- There is no significant statistical difference in the clavicle fracture length measurement among the variety of radiographic exam performances.

2- The method that comes closest to computed tomography results is the PA thorax incidence, with the patient in the lying position.

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

Background

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

Methods

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

Results

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

Conclusion

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

Medial Clavicle Fracture Fixation Including the Sternum: A Case Report

CASE

A 29-year-old man presented with a displaced medial clavicle fracture. Surgical repair was performed using a precontoured plate designed for the contralateral distal clavicle, and medial fixation was accomplished at the sternum. The patient had no complications and demonstrated full strength and range of motion at the 8-month follow-up.

CONCLUSION

Medial clavicle fractures with a small medial fragment can be immobilized using a plate designed for the contralateral distal clavicle that crosses the sternoclavicular joint to obtain medial fixation in the sternum. This technique may provide a viable treatment modality for this unique fracture pattern.

Epidemiology of Clavicle Fractures Sustained at a Colorado Ski Resort

Background

Although clavicle fractures are a common sports injury, there are limited studies on the incidence and causes of clavicle fractures among winter sports athletes.

Purpose

To evaluate the characteristics and injury mechanisms associated with clavicle fractures among patients evaluated at a Colorado ski resort.

Study Design

Descriptive epidemiology study.

Methods

This was a retrospective descriptive analysis of patients with clavicle fractures at the Denver Health Winter Park Medical Center during the 2012-2013 to 2016-2017 ski seasons. Chart review was performed on the patient cohort to confirm clavicle fracture diagnosis and to evaluate factors associated with clavicle fracture.

Results

A total of 393 clavicle fractures (6.2% of total clinic visits) occurred during the study period, corresponding to an overall clavicle fracture incidence of 8.4 per 100,000 participant-visits. The mean patient age was 26.4 years (range, 5-73 years). The majority were middle-third fractures (85.5%), occurring mainly in men (87.3%). More than half of the fractures were comminuted (54.5%) and occurred in snowboarders (55.0%). The most common mechanism of injury was a fall onto snow while skiing or snowboarding (92.4%). Women sustained more clavicle fractures while skiing compared with snowboarding (82.0% vs 18.0%; P < .001), while men sustained more fractures while snowboarding compared with skiing (60.3% vs 39.7%; P < .001).

Conclusion

Clavicle fractures are relatively common, but there are scant incidence data for clavicle fractures in mountain sports. Consistent with prior studies, clavicle fractures were more common in younger patients and men. The most common anatomic fracture location was the midclavicle. A greater proportion of clavicle fractures among men were sustained during snowboarding and among women during skiing.

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

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

Influence of radiographic projection and patient positioning on shortening of the fractured clavicle

Background

Radiographic measurements of shortening and vertical displacement in the fractured clavicle are subject to a variety of factors such as patient positioning and projection. The aims of this study were (1) to quantify differences in shortening and vertical displacement in varying patient positions and X-ray projections, (2) to identify the view and patient positioning indicating the largest amount of shortening and vertical displacement, and (3) to identify and quantify the inter- and intraobserver agreement.

Methods

A prospective clinical measurement study of 22 acute Robinson type 2B1 clavicle fractures was performed. Each patient underwent 8 consecutive standardized and calibrated X-rays in 1 setting.

Results

In the upright patient position, the difference of absolute shortening was 4.5 mm (95% confidence interval [CI]: 3.0-5.9, P < .0001) larger than in the supine patient position. For vertical displacement, the odds of being scored a category higher in the upright patient position were 4.7 (95% CI: 2.2-9.8) times as large as the odds of being scored a category higher in supine position. The odds of being scored a category higher on the caudocranial projection were 5.9 (95% CI: 2.8-12.6) times as large as the odds of being scored a category higher on the craniocaudal projection.

Conclusion

Absolute shortening, relative shortening, and vertical displacement were found to be the greatest in the upright patient positioning with the arm protracted orientation on a 15° caudocranial projection. No statistically significant differences were found for a change in position of the arm between neutral and protracted.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Does altering projection of the fractured clavicle change treatment strategy?

BACKGROUND

Shortening of the fractured clavicle is proposed and debated as an indicator for surgical intervention. There is no standardized or uniform method for imaging and measuring shortening. Different methods and techniques can lead to different measured outcomes. However, the question remains whether a difference in measured shortening using a different technique has any short-term clinical relevance in terms of treatment strategy. The aim of this study was to investigate whether a different projection of the same midshaft clavicular fracture would lead to a different choice in treatment strategy.

METHODS

Thirty-six AO-OTA (Arbeitsgemeinschaft für Osteosynthesefragen-Orthopaedic Trauma Association) 15A.1-15A.3 midshaft clavicular fractures were digitally reconstructed into radiographs using both 15° caudocranial and 15° craniocaudal projections. The 72 projections were rated in random order by 23 orthopedic trauma or upper-extremity surgeons on the need for either conservative or operative treatment.

RESULTS

On average, the raters altered their treatment strategy with a different projection of the same midshaft clavicular fracture 12.2 times among the 36 cases (33.9%), ranging from 5 times (13.9%) to 19 times (52.8%). A statistically significant increase in choice for surgical treatment was identified when using the 15° caudocranial projection (P = .01).

CONCLUSION

This study reveals the influence the projection of the midshaft clavicular fracture has on the surgeon's decision of treatment strategy. The decision changes from operative to nonoperative or vice versa in 33.9% of the cases.

Shoulder and Elbow Fractures in Athletes

PURPOSE OF REVIEW

The purposes of this review are to discuss the management of shoulder and elbow fractures in athletes to optimize the return to sport and to highlight treatment impact on the return to play.

RECENT FINDINGS

Fractures of the shoulder and elbow can have profound implications in an athlete career. Recent technique of fractures management trended toward to preserve soft tissue which is critical for an early recovery in athletic population. Arthroscopy presents a strong interest for the treatment of intra-articular fracture, and minimally invasive approach as developed in humeral shaft fracture can be considered to avoid soft tissue damage. Non-articular, stable, and minimally displaced fractures are mainly treated conservatively. However, we encourage a more aggressive approach in shoulder and elbow injuries in the athletes including minimally invasive and stable fixation to preserve vascularity and muscle environment.

Does candidate for plate fixation selection improve the functional outcome after midshaft clavicle fracture? A systematic review of 1348 patients

INTRODUCTION

The hypothesis of this study was that patient selection for midshaft clavicle fracture (open reduction internal fixation with plate versus conservative) would give better functional outcome than random treatment allocation.

METHODS

We performed a systematic literature search for primary studies providing functional score and non-union rate after conservative or surgical management of midshaft clavicle fractures. Six randomized controlled trial and 19 non-randomized controlled trial studies encompassing a total of 1348 patients were included.

RESULTS

Patients treated with surgical management were found to have statistically superior Constant scores in non-randomized controlled trials than in randomized controlled trials (94.76 ± 6.4 versus 92.49 ± 6.2; p < 0.0001). For conservative treatment, randomized controlled trials were found to have significantly better functional outcome. The prevalence of non-union (6.1%) did not show significant statistical difference between non-randomized controlled trial and randomized controlled trial studies. The functional outcome after surgical management was significantly higher than after conservative management in both randomized controlled trial and non-randomized controlled trial groups. The non-union rate after surgery (1.1% for both non-randomized controlled trial and randomized controlled trial) was significantly lower than following conservative treatment (9.9% non-randomized controlled trial versus 15.1% randomized controlled trial).

DISCUSSION

This review shows that patient selection for surgery may influence functional outcome after midshaft clavicle fracture. Our results also confirm that plate fixation provides better functional outcome and lower non-union rate.

Influence of x-ray direction on measuring shortening of the fractured clavicle

BACKGROUND

Midshaft clavicle fractures are often associated with a certain degree of shortening. There is great variety in the imaging techniques and methods to quantify this shortening. This study aims to quantify the difference in measurements of shortening and length of fracture elements between 5 views of the fractured clavicle. Furthermore, the interobserver and intraobserver agreement between these views using a standardized method is evaluated.

MATERIALS AND METHODS

Digitally reconstructed radiographs were created for 40 computed tomography datasets in the anteroposterior (AP), 15° and 30° craniocaudal, and 15° and 30° caudocranial views. A standardized method for measuring the length of fracture elements and the amount of shortening was used. Interobserver and intraobserver agreement for each of the 5 views was calculated.

RESULTS

The interobserver and intraobserver agreement was excellent for all 5 views, with all intraclass correlation coefficient values greater than 0.75. The measured differences in relative and absolute shortening between views were statistically significant between the 30° caudocranial view and all other views. The increase in median shortening measured between the commonly used 30° caudocranial view (2.7 mm) and the AP view (8.5 mm) was 5.8 mm (P < .001). The relative median shortening between these views increased by 3.5% (P < .001).

CONCLUSION

The length of fracture elements and the amount of shortening in the fractured clavicle can be reliably measured using a standardized method. The increase in absolute and relative shortening when comparing the caudocranial measurements with the AP and craniocaudal measurements may indicate that the AP and craniocaudal views provide a more accurate representation of the degree of shortening.

Midshaft clavicle fractures: Current concepts

Clavicle fractures are common fractures and the optimal treatment strategy remains debatable. The present paper reviews the available literature and current concepts in the management of displaced and/or shortened midshaft clavicle fractures.

Operative treatment leads to improved short-term functional outcomes, increased patient satisfaction, an earlier return to sports and lower rates of non-union compared with conservative treatment. In terms of cost-effectiveness, operative treatment also seems to be advantageous.

However, operative treatment is associated with an increased risk of complications and re-operations, while long-term shoulder functional outcomes are similar.

The optimal treatment strategy should be one tailor-made to the patient and his/her specific needs and expectations by utilizing a shared decision-making model.

Cite this article: EFORT Open Rev 2018;3:374-380. DOI: 10.1302/2058-5241.3.170033

Preferences of orthopedic surgeons for treating midshaft clavicle fracture in adults

Objective

To determine the current clinical practice in Latin America for treating midshaft clavicle fractures, including surgical and non-surgical approaches.

Methods

A cross-sectional study using a descriptive questionnaire. Shoulder and elbow surgeons from the Brazilian Society of Shoulder and Elbow Surgery and from the Latin American Society of Shoulder and Elbow were contacted and asked to complete a short questionnaire (SurveyMonkey^®) on the management of midshaft fractures of the clavicle. Incomplete or inconsistent answers were excluded.

Results

The type of radiographic classification preferably used was related to description of fracture morphology, according to 41% of participants. Allman classification ranked second and was used by 24.1% of participants. As to indications for surgical treatment, only the indications with shortening and imminence of skin exposure were statistically significant. Conservative treatment was chosen in cortical contact. Regarding immobilization method, the simple sling was preferred, and treatment lasted from 4 to 6 weeks. Although the result was not statistically significant, the blocked plate was the preferred option in surgical cases.

Conclusion

The treatment of midshaft clavicle fractures in Latin America is in accordance with the current literature.

Reliability of measurements of the fractured clavicle: a systematic review

BACKGROUND

The objective of this systematic review was to evaluate the reliability and reproducibility of measurements of shortening in midshaft clavicle fractures (MSCF) using any available imaging technique.

METHODS

Electronic databases (PubMed, EMBASE, and Cochrane) were searched. The 4-point-scale COSMIN checklist was used to evaluate the methodological quality of studies.

RESULTS

Four studies on reliability of measurement of MSCF were identified. These studies were of fair and poor quality. The reported intrarater reliability varied between none to fair, and intrarater reliability was minimal.

CONCLUSION

No definite conclusions could be drawn. In order to optimize future studies and the realization of comparable results, more research is necessary to identify a standardized method of imaging and measuring. Level of Evidence III.

Clavicular Refracture at the Site of Angular Malunion in Young Athletes

OBJECTIVE

The treatment of midshaft clavicle fractures has, in the last 2 decades, shifted markedly towards operative management. Prospective trials have defined accepted clinical and radiographic indications for the surgical management of clavicle fractures. This report documents 3 cases of clinically united angular malunion of the midshaft clavicle in young athletes that subsequently refractured to highlight angular deformity in the absence of displacement as a potential indication for surgical fixation.

DESIGN

Case series.

SETTING

A level 1 trauma centre.

PATIENTS/PARTICIPANTS

Three young athletic patients with angular malunion of the midshaft clavicle who experienced refracture, requiring surgical fixation.

INTERVENTION

Surgical fixation of midshaft clavicle fracture, as treatment for refracture after angular malunion.

RESULTS

All 3 patients required subsequent surgical fixation of their midshaft clavicle fracture, correcting the angular malunion and restoring shoulder function.

CONCLUSIONS

Midshaft clavicular fractures that malunite with significant angulation in the absence of displacement represent a risk for subsequent refracture. For this reason, angular deformity should be considered as a potential indication for surgical fixation in acute clavicular fractures.

LEVEL OF EVIDENCE

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

Management of mid-shaft clavicular fractures: comparison between non-operative treatment and plate fixation in 60 patients

Clavicle fracture is a common injury due to its subcutaneous and relatively anterior position. Fractures affecting the middle third account for majority of all clavicular fractures. Both non-operative and surgical methods have been described for the management of this injury. However, there is no uniform consensus on the definite choice of treatment. Hence, this study was undertaken to compare conservative approach with primary internal plate fixation in mid-shaft clavicular fractures in terms of subjective outcome, functional outcome, the rates of nonunion and malunion and other local complications. Patients were allocated into two groups, each including 30 patients on alternate basis. Group 1 patients were managed conservatively, consisting of a figure-of-eight bandage and a sling, whereas patients of group 2 were treated surgically by plate fixation. Follow-up examination was done at 06 weeks, 03 and 06 months using patient’s subjective evaluation, functional outcome, radiographic assessment and other complications. The study showed that time to union was significantly shorter in patients treated surgically and this group also showed a favorable Constant shoulder score at all follow-ups. Though there was no statistically significant difference between the groups with regard to complication rate, subjective outcome or functional outcome, the surgical intervention group fared better especially when considering overall outcome results. The present study showed that the time to union was lesser, rate of malunion and nonunion was lower, and Constant shoulder scores were higher in the surgical group. This affirms that while conservative treatment remains the treatment of choice for simple undisplaced mid-shaft clavicle fractures, for displaced and comminuted fractures the surgical intervention gives better outcomes and early functional recovery in young active adults.

Does clavicular shortening after nonoperative treatment of midshaft fractures affect shoulder function? A systematic review

INTRODUCTION

Clavicular shortening due to non-anatomical healing of displaced clavicular fractures is believed to have a negative effect on shoulder function after recovery. The evidence for this, however, is equivocal. This review aimed to systematically evaluate the available literature to determine whether the current beliefs about clavicular shortening can be substantiated.

MATERIALS AND METHODS

This systematic review was performed following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. PubMed, EMBASE, Web of Science and the Clinical Trial Registry were searched to identify all studies published in English that evaluated the association between clavicular shortening and shoulder function in patients aged ≥16 years with a nonoperatively treated, displaced midshaft clavicular fracture. Relevant data from the selected studies was extracted and summarized. Risk of bias of the included studies was assessed using the MINORS instrument.

RESULTS

Six studies, of which five were retrospective, were included in this review analyzing a total of 379 patients. Due to heterogeneity in methods and reporting across studies, a pooled analysis of the results was not feasible. No clear associations were found between shortening and shoulder function scores (DASH and Constant score) or arm strength in each of the included studies.

CONCLUSION

The existing evidence to date does not allow for a valid conclusion regarding the influence of shortening on shoulder function after union of nonoperatively treated midshaft clavicular fractures. Shortening alone is currently not an evidence-based indication to operate for the goal of functional improvement. Well-powered prospective comparative studies are needed to draw firm conclusions.

Measurement of Clavicle Fracture Shortening Using Computed Tomography and Chest Radiography

Background

Nonoperative management of midshaft clavicle fractures has resulted in widely disparate outcomes and there is growing evidence that clavicle shortening poses the risk of unsatisfactory functional outcomes due to shoulder weakness and nonunion. Unfortunately, the literature does not clearly demonstrate the superiority of one particular method for measuring clavicle shortening. The purpose of this study was to compare the accuracy of clavicle shortening measurements based on plain radiographs with those based on computed tomography (CT) reconstructed images of the clavicle.

Methods

A total of 51 patients with midshaft clavicle fractures who underwent both a chest CT scan and standardized anteroposterior chest radiography on the day of admission were included in this study. Both an orthopedic surgeon and a musculoskeletal radiologist measured clavicle shortening for all included patients. We then determined the accuracy and intraclass correlation coefficients for the imaging modalities. Bland-Altman plots were created to analyze agreement between the modalities and a paired t-test was used to determine any significant difference between measurements.

Results

For injured clavicles, radiographic measurements significantly overestimated the clavicular length by a mean of 8.2 mm (standard deviation [SD], ± 10.2; confidence interval [CI], 95%) compared to CT-based measurements (p < 0.001). The intraclass correlation was 0.96 for both plain radiograph- and CT-based measurements (p = 0.17).

Conclusions

We found that plain radiograph-based measurements of midshaft clavicle shortening are precise, but inaccurate. When clavicle shortening is considered in the decision to pursue operative management, we do not recommend the use of plain radiograph-based measurements.

Correlation of the degree of clavicle shortening after non-surgical treatment of midshaft fractures with upper limb function

Background

Despite the use of non-surgical methods to treat for the majority of midshaft fractures of the clavicle, it is remains controversial whether shortening of this bone following non-surgical treatment of a middle third fracture affects upper limb function.

Methods

We conducted a cohort study by sequentially recruiting 59 patients with a fracture of the middle third of the clavicle. All patients were treated nonsurgically with a figure-of-eight bandage until clinical and radiological findings indicated healing of the fracture. Functional outcome was assessed using the Disability of Arm, Hand and Shoulder (DASH) score revalidated for the Portuguese language, other outcomes assessed included: pain measured by visual analogue scale (VAS); radiographies to measure the degree of shortening, fracture consolidation and fracture malunion. Information were also collected regarding the mechanism of injury, patient’s daily activities level and epidemiological features of the patient cohort. The results of our findings are expressed as the comparison of the functional outcome with the degree of shortening.

Results

Patients were assessed six weeks and one year after injury. In the first evaluation, the mean DASH score was 28.84 and pain measured by VAS was 2.57. In the second evaluation (one year after injury) the mean DASH score was 8.18 and pain was 0.84. The mean clavicle shortening was 0.92 cm, ranging from 0 to 3 cm (SD = 0.64). There were no correlation between the degree of shortening and DASH score after six weeks and one year (p = 0.073 and 0.706, respectively). When only patients with of shortening greater than 2 cm were assessed for correlation, the result did not change.

Conclusion

We conclude that clavicle shortening after nonsurgical treatment with a figure-of-eight bandage does not affect limb function, even when shortening exceeds 2 cm.

Trial registration

ISRCTN85206617. Registered 12 May 2014

Minimally invasive plate osteosynthesis using 3D printing for shaft fractures of clavicles: technical note

This article describes a minimally invasive plate osteosynthesis technique for midshaft fractures of clavicles using intramedullary indirect reduction and prebent plates with 3D printing models. This technique allows for easy reduction of fractures with accurate prebent plates and minimal soft tissue injury around the fracture site.

Comparison of treatment of fracture midshaft clavicle in adults by external fixator with conservative treatment

PURPOSE

High rate of malunion and non union in displaced fracture clavicle treated conservatively lead to use of different types of internal fixation methods which also were found to be associated with various complications. Moreover their superiority over conservative treatment has not been established. This study was designed to compare clinical outcome of conservative treatment with external fixator in cases with displaced midshaft clavicle fractures.

METHODS

Fifty adult consenting cases of acute midshaft fracture clavicle, displaced >15 mm were included. Twenty five cases were allotted to conservative (group A) and external fixator (group B) each. In group A treatment was given in form of clavicle brace. In group B schanz pins were inserted obliquely between supero-inferior and anterior-posterior direction and connected with rod. The outcome was measured by Constant score, union time and complications.

RESULTS

Mean radiographic union time in group A was 23.45 ± 1.40 weeks (with 8% non union and 80% malunion) and in group B it was 9.36 ± 1.49 weeks. Mean Constant score at 6 months in group A was 78.28 ± 6.45 and in group B 92.72 ± 1.48. Mean shortening at 6 months in group A was 19.36 mm. In group B shortening at 6 months was noticed in three cases (6, 5, 6 mm).

CONCLUSION

Close reduction of acute fracture mid clavicle and application of external fixator is a simple procedure providing the benefits of rigid fixation and undisturbed fracture environment. Pain relief is faster, union time is shorter and there are no hardware related problems.

Intraobserver and interobserver agreement in the classification and treatment of midshaft clavicle fractures

BACKGROUND

With the recent emphasis on performing open reduction and internal fixation on midshaft clavicle fractures with complete displacement, comminution, and >2 cm of shortening, it is important to determine the reliability of orthopaedic surgeons to assess these variables on standard plain radiographs and to determine the agreement among orthopaedic surgeons in choosing the treatment.

PURPOSE

To determine the intra- and interobserver reliability in the classification of midshaft clavicle fractures via standard plain radiographs and to determine the intra- and interobserver agreement in the treatment of these fractures.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 3.

METHODS

Charts of patients seen by the 2 senior authors from 2006 to 2011 were reviewed to identify patients treated for clavicle fractures (CPT codes 23500 and 23515). Anteroposterior and 30° cephalad radiographs were selected, representing midshaft clavicle fractures treated both operatively and nonoperatively. Thirty pairs of radiographs were included in the investigation. The radiographs were standardized for size to allow accurate measurements within a non-PACS (picture archiving and communications system) program, and a PDF document was created with all representative radiographs. Clinical scenarios were created for each set of radiographs, and the evaluators were asked to (1) measure the degree of shortening in millimeters, (2) determine the percentage displacement, (3) determine whether the fracture was comminuted, and (4) state whether they would treat the fracture operatively or nonoperatively. The radiographs, along with instructions on how to use the measuring tool with Adobe Reader, were distributed to 22 shoulder/sports medicine fellowship-trained orthopaedic surgeons, then reordered and redistributed approximately 3 months later. Sixteen surgeons completed 1 round of surveys, and 13 surgeons completed both rounds.

RESULTS

Interrater agreement was moderate for displacement of 0%-49% (κ = 0.71, P < .001) and >100% (κ = 0.73, P < .001), with minimal agreement for displacement of 50%-100% (κ = 0.39, P < .001). There was moderate interrater agreement for the presence/absence of comminution (κ = 0.75, P < .001). Interrater agreement was weak for shortening of 0-5.0 mm (κ = 0.58, P < .001) and >30.0 mm (κ = 0.51, P < .001), with minimal agreement for shortening of 5.1-10.0 mm (κ = 0.22, P < .001) and no agreement for the other 4 categories. Interrater analysis showed weak agreement on whether surgical treatment was recommended (κ = 0.40, P < .001). Intrarater agreement was strong for comminution (κ = 0.80, P < .0001), moderate for both displacement (κ = 0.76, P < .001) and operative treatment (κ = 0.64, P < .001), and minimal for shortening (κ = 0.38, P < .001). The following variables statistically predicted whether surgery was recommended (P < .001): (1) the odds of surgery were 2.26 if comminution was noted, holding displacement and the interaction between displacement and shortening constant, and (2) the odds of surgery were 3.37 if there is displacement of >100% compared with displacement of 0%-49%, holding comminution and shortening constant.

CONCLUSION

Standard plain unilateral radiographs of the clavicle are insufficient to reliably determine the degree of shortening of clavicle fractures and the need for surgery among shoulder/sports medicine fellowship-trained orthopaedic surgeons. Consideration should be made to not use shortening as the sole determinant for whether to proceed with surgical intervention or to use other radiographic modalities to determine the amount of shortening.