Abstract
BackgroundDistal clavicle fractures (DCF) are a management challenge frequently encountered by shoulder surgeons. Despite an array of surgical fixation strategies, the indications and role of surgery are unclear, with there being no gold standard or consensus regarding their management. The aim of this study was to identify current United Kingdom (UK) clinical practices relating to DCFs and to inform a future randomised control trial (RCT).MethodsAn online survey was sent to the consultant surgeon members of the British Elbow and Shoulder Society (BESS). Questions covered respondent indications for surgical fixation, important factors considered for management of DCFs, fixation strategies, the volume of patients treated, and willingness to participate in the conduct of a randomized trial.ResultsThe response rate was 84/327 (26%). 64-67% of respondents reported surgically managing DCFs classified as Neer type 2A, 2B and 5. The most important factors considered by surgeons when deciding between operative and nonoperative intervention were degree of displacement (90%), clinical assessment of impending open fracture (87%), and age of the patient (74%). For conservatively managed DCFs, the preferred length of complete immobilization was 2-4 weeks (46%), followed by 4-8 weeks (17%). 30% reported not immobilizing their patients at all. For operative intervention, the locking plate was the preferred fixation method by most respondents (68%), although there was no clear consensus regarding other fixation methods. Most surgeons (52%) reported treating a low volume of patients with DCFs (0-10) per year. 58% of respondents were willing to randomize patients to non-operative treatment in a multi-centre RCT, with a further 22% undecided. Finally, 68% (n=79) of respondents would consider being co-investigators in such a trial.ConclusionThere is considerable heterogeneity in the management of patients with DCFs in the UK. The indications for surgery and the optimal surgical fixation method remain uncertain. There is a clear need for pragmatic multi-centre clinical research in this area.
Highlights
Fractures of the clavicle account for 2-4% of all fractures, of which injuries affecting the distal clavicle third account for 10-30%
Questions covered respondent indications for surgical fixation, important factors considered for management of Distal clavicle fractures (DCF), fixation strategies, the volume of patients treated, and willingness to participate in the conduct of a randomized trial
The most important factors considered by surgeons when deciding between operative and nonoperative intervention were degree of displacement (90%), clinical assessment of impending open fracture (87%), and age of the patient (74%)
Summary
Fractures of the clavicle account for 2-4% of all fractures, of which injuries affecting the distal clavicle third account for 10-30%. Distal clavicle fractures (DCF) are a management challenge frequently encountered by shoulder surgeons. The clinical significance of non-union is uncertain, with many patient’s remaining asymptomatic [5]. Combining this with the significant reported complications and re-operation rates of operative fixation, as well as the poorly defined indications, the role of operative fixation is unclear [5,6,7]. Despite an array of surgical fixation strategies, the indications and role of surgery are unclear, with there being no gold standard or consensus regarding their management. The aim of this study was to identify current United Kingdom (UK) clinical practices relating to DCFs and to inform a future randomised control trial (RCT)
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