Middle third clavicular fractures: to fix or not to fix?

Abstract

Clavicular fractures are common injuries with the incidence quoted between 29 and 198 per 10 000 population per year.1 They are classified into three types:- Type 1: Middle third Type 2: Lateral third (distal to coraco-clavicular ligament) Type 3: Medial third The majority of fractures (> 70%) are type 1. Traditionally these fractures have been treated conservatively with initial immobilisation in a broad arm sling, collar and cuff, or figure of eight strapping. The results of conservative treatment were generally felt to be satisfactory. Nordqvist et al2 in Malmo reviewed 225 mid clavicular fractures at an average of 17 years from injury. The great majority (185/82%) were symptom free. Thirty-nine (17%) had moderate pain and one patient was classified as poor. Fifty-three of the patients had a malunion and seven had nonunions. Forty of the patients with malunited fractures and three with nonunion were rated as good. Fagg1 reviewed the available literature and found an incidence of nonunion of 7% in displaced mid shaft fractures at that time. Thormodsgard et al3 looked at patient satisfaction after non-operative management of clavicular fractures using the Disabilities of the Arm, Shoulder and Hand (DASH) classification. They looked particularly at clavicular shortening and found that patients with shortening of over 2 cm had the highest DASH scores indicating disability and dissatisfaction with their outcome after the injury. They looked at all types of clavicular fracture but found that DASH scores were higher in type 1 fractures. They concluded, “patients with midshaft clavicle fractures with shortening of greater than 2 cm may be good candidates for operative repair.” Murray et al4 assessed the significant risk factors for nonunion in 941 conservatively treated mid shaft clavicular fractures in adults. One hundred and twenty-five (13.3%) had clinical and radiological evidence of nonunion. …