Clavicle Fractures Research Articles

Kirschner wire intramedullary fixation combined with improved nice knot-end cerclage temporarily fixation-assisted reduction before plate osteosynthesis in treating displaced and comminuted clavicle fractures.

Nice knots have been used as an assisted reduction technique in surgery for displaced and comminuted fractures. This study aims to investigate the clinical efficacy of Kirschner wire intramedullary fixation combined with improved Nice knot-end cerclage temporarily fixation-assisted reduction before plate osteosynthesis in treating displaced and comminuted clavicle fractures. A retrospective study selected 210 patients with comminuted displaced clavicle fractures (January 2017-December 2020) in our hospital. The patients were divided into two groups via the fracture reduction method: the observation group (intramedullary Kirschner's wire fixation combined with modified Nice node-to-end cerclage temporarily fixation-assisted reduction; n = 42) and the control group (including four subgroups with 42 cases in each subgroup, with assisted reduction methods of clamp fixation, screw fixation, square knot fixation and Kirschner wire fixation; each subgroup n = 42). The operation time, intraoperative bleeding, visual analogue scale (VAS) score at 24h after the operation, healing time, postoperative limb functional activities, patients' self-perception, subjective satisfaction and shoulder joint function were compared. The operation time and the intraoperative blood loss of the observation group was significantly lower than that of each subgroup in the control group (p < 0.05). The VAS score of the observation group 24h after the operation was significantly lower than that of each subgroup in the control group apart from the screw fixation group (p < 0.05). The Neer score of the observation group was significantly higher than that of each subgroup in the control group apart from the square knot fixation group (p < 0.05). The square knot is relatively better than the other four methods. Patients were generally satisfied with the modified Nice treatment. The use of a Kirschner wire intramedullary fixation combined with improved Nice knot-end cerclage temporarily fixation-assisted reduction before plate osteosynthesis in treating displaced and comminuted clavicle fractures can achieve satisfactory postoperative clinical results.

Simultaneous clavicular hook plate fixation in bilateral distal clavicle fractures (Neer type II): A case report.

Bilateral distal clavicle fractures (BDCF) are exceedingly rare types of fractures. This study aimed to evaluate the surgical treatment under a single anesthesia for trauma-induced BDCF (Neer type II) through a case report. The patient brought to the emergency department due to a motor vehicle accident exhibited severe pain, tenderness, swelling, and deformity in both shoulder regions upon physical examination. No significant pain or tenderness was detected in other areas of the body. There were also no signs of additional neurological deficits or vascular pathology in the extremities. Radiographic examinations led to a diagnosis of BDCF (Neer type II). Surgical intervention involved the simultaneous application of a neutral-angled hook plate to both clavicles via open reduction. Postoperative radiographs taken at the 12th week demonstrated complete healing in both fractures and no functional limitations in shoulder movements. BDCF can compromise the stability of the shoulder girdle, necessitating surgical intervention with anatomical reduction and rigid fixation.

Return to Sport After Conservative Management of Midshaft Clavicle Fractures in Professional Jockeys.

This study explores the functional recovery and rates return to play (RTP) of professional jockeys following midshaft clavicle fractures, which have been managed conservatively. The high incidence of these fractures in horse racing underscores the importance of evaluating nonsurgical recovery paths for effective RTP. We used a retrospective cohort study to assess treatment outcomes. The research is set in the professional horse racing scene of Ireland. Sixteen professional Irish jockeys with conservatively managed midshaft clavicular fractures were examined. Jockeys who underwent surgery or were inactive at injury time were excluded. The study involved no direct interventions. Recovery was assessed using the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score and Patient-Reported Outcome Measures, alongside racing records to track RTP. The all-male cohort had an average age of 27 years. Results showed an average 67.1-day absence from racing, with 94% returning to preinjury competition levels. Complications were minimal, and patient outcomes were positive, as indicated by a mean QuickDASH score of 2.58, suggesting minimal residual disability. Findings highlight the success of conservative management for midshaft clavicle fractures in professional jockeys, enabling them to return to prior competitive levels with few complications and excellent functional recovery.

Treatment of Neer IIb distal clavicular fracture with locking plate under arthroscope

To investigate the feasibility and clinical effect of the treatment of NeerⅡb distal clavicular fracture with locking plate under arthroscopy. Between June 2018 and September 2022, the medical records of 15 patients with NeerⅡb distal clavicular fracture treated with locking plate under arthroscope were retrospectively analyzed, including 9 males and 6 females, aged from 25 to 57 years old with an average of (42.50±7.75) years old, 5 left shoulder, 10 right shoulder, and duration of the disease ranged from 4 to 7 days with an average of (5.16±0.98) d. Visual analog score (VAS), Constant-Murley shoulder joint score scale and Neer standard score were used before operation, 1 month after operation and the last follow-up. All patients successfully completed the treatment of NeerⅡb distal clavicular fracture with locking plate under arthroscopy, with the operation time ranging from 0.3 to1.0 h with an average of (0.55±0.24) h. All patients were healed at stageⅠ. The follow-up time ranged from 6 to 15 months with an average of (9.2±2.8) months. The preoperative VAS score was 7.23±0.67, the Constant-Murley shoulder joint score was (19.57±0.91), and the Neer standard score was (11.27±1.12);The VAS score was (1.56±0.81), the Constant-Murley shoulder joint score was (52.62±1.54), and the Neer standard score was (61.98±2.99) in the first month after operation;At the last follow-up, the VAS was (0.42±0.54), the Constant-Murley shoulder joint score was (91.24±1.97), and the Neer standard score was (93.24±3.38). The difference between VAS, Constant-Murley shoulder joint score and Neer standard score was statistically significant at one month postoperative and preoperative (P<0.05), and the difference between the last follow-up visit and one month postoperative was statistically significant (P<0.05). The treatment of NeerⅡb distal clavicular fracture with locking plate under arthroscope can restore the function of shoulder joint, with definite curative effect and feasibility.

Fracture Mapping in High-Energy Chest Trauma

Background: High-energy chest trauma often results in rib fractures and associated chest injuries. This study explored fracture distribution patterns in high-energy chest trauma, using three-dimensional (3D) fracture mapping technology. Methods: This retrospective study analyzed cases of high-energy chest trauma with rib fractures treated at a Level 1 Trauma Center, from February 2012 to January 2023. Specifically, 3D computed tomography (CT) was used to reconstruct rib fractures and create fracture-frequency heat maps, analyzing the influence of other thoracic fractures on rib fracture distribution. Results: Rib fractures were frequently found in the anterior and posterior thoracic areas. On average, patients sustained 7 ± 3.87 rib fractures, with clavicle fractures in 25.5% and scapular fractures in 19.6% of cases. Scapular fractures led to more posterior rib fractures, while sternal fractures were associated with more anterior rib fractures. Clavicle fractures were linked to fractures of the first to third ribs. Conclusions: Rib fractures in high-energy chest trauma occurred most often in the anterior and posterior regions. Fractures of the scapula and sternum influence the positioning of the fracture lines. Clavicular fractures are associated with a higher incidence of upper rib fractures. These findings can help inform surgical decisions and complication management.

Factors associated with neonatal brachial palsy in shoulder dystocia: a longitudinal study.

The main goal is to analyze factors related to brachial plexus injury (BPI) after Shoulder Dystocia (SD). Longitudinal prospective analysis of SD arose in a tertiary hospital from 1/1st/ 2019 to 12/31st/ 2020. A multivariable logistic regression for BPI after SD and a survival analysis for BPI recovery after SD were performed. In this period 13,414 deliveries were attended, 10,676 of those were vaginal deliveries (79.6%) reporting 69 cases of SD, with an incidence of 0.65%. SD required 102.1 seconds (SD) 10.8) as an average for solving it. Internal maneuvers were needed in 42.0% of SD reported. Neonatal BPI was suspected in 23 newborns (33.3%) at birth. Neonatal BPI at 48 hours of life was statistically associated with maternal BMI above 30 kg/m² (OR = 7.91; CI95% 1.3-47.7; p = 0.024), > 120 seconds for solving SD (OR = 14.4; CI95% 1.7-121.82; p = 0.014) and operative delivery (OR = 6.8; CI 95% 1.2-37.6; p = 0.028). The BPI recovery was statistically associated with clavicle fracture (HR = 0.31 CI95% 0.10-0.96 p = 0.042) and specific rehabilitation treatment (HR = 9.2 CI 95% 1.87-45.23 p = 0.006). The following factors were associated with neonatal BPI at 48 hours of life: Maternal BMI above 30 kg/m², operative delivery, or shoulder dystocia that requires more than 120 seconds for solving it. The BPI recovery was associated with clavicle fracture and specific rehabilitation treatment.

Is the clavicla pro humero a reliable reconstruction for paediatric proximal humerus sarcomas?

The proximal humeral reconstruction is challenging. This study aims to investigate the survival, function and complications of clavicla pro humero (CPH) for pediatric proximal humeral reconstruction. A retrospective cohort study was conducted on eight patients (4 males, and 4 females) who underwent clavicla pro humero reconstruction between January 2009 and December 2020 in our institution. The average age was 10.4 ± 2.7 years (range, 6 to 14 years). The functional outcomes were assessed by the Musculoskeletal Tumor Society Score (MSTS-93), the Toronto Extremity Salvage Score (TESS), the American Shoulder and Elbow Surgeons (ASES) score and the range of motion (ROM) of the shoulder. The complications and overall survivorship of clavicla pro humero were recorded in the follow-up. The mean follow-up of all patients was 54.6 ± 23.9 months (range, 24 to 84 months) and 73.3 ± 8.5 months (range, 72 to 84 months) in all survivors. All patients had a bone union at an average of 3.8 months after the initial procedure. Only one patient had no complications in the follow-up. The most common complications were clavicle fracture (87.5%, 7/8), followed by pseudarthrosis (62.5%, 5/8), proximal clavicle osteolysis (37.5%, 3/8) and skin flap necrosis (12.5%, 1/8). The average MSTS-93 score was 79% (range, 73-86%), the average TESS was 82% (range, 76-86%) and the average ASES was 70% (68-73%), respectively. The clavicla pro humero procedure provides rapid bone union but has a high complication rate. Therefore, we do not recommend this technique as a routine surgical procedure for paediatric proximal humeral reconstruction when other methods are available. level IV therapeutic study.

Minimally Invasive Plate Osteosynthesis with Mini-Open Technique and Supraclavicular Nerve Preservation Reduces Postoperative Numbness in Acute Displaced Midshaft Clavicle Fracture

Background: Minimally invasive plate osteosynthesis (MIPO) for clavicular shaft fracture yields favorable functional outcomes and results in less surgery-related soft tissue injury than other techniques. Anterior chest and shoulder skin numbness, a common complication after open reduction and plate fixation, is related to injury to the supraclavicular nerves. We propose MIPO combined with a mini-open approach without fluoroscopy for nerve preservation to minimize the risk of postoperative numbness compared with traditional open plating without nerve preservation. Methods: A total of 59 patients were retrospectively identified, with a follow-up period of 6 months. Thirty-two patients underwent MIPO with mini-open and nerve preservation technique (MIPO group), and 27 patients underwent traditional open plating without nerve preservation (open group). Constant–Murley shoulder outcome score, operation time, wound length, skin numbness, and number of implant removals were compared between the groups. Results: The MIPO group had significantly lower rates of anterior chest and shoulder skin numbness than the open group (MIPO: 12.5% vs. open: 55.6%; p &lt; 0.001). Operation time was significantly longer in the MIPO group than in the open group (MIPO: 109.38 ± 18.83 vs. open: 81.48 ± 18.85; p &lt; 0.001). Wound length was significantly shorter in the MIPO group than in the open group (MIPO: 4.73 ± 0.79 vs. open: 9.76 ± 1.64; p &lt; 0.001). Both groups had similarly excellent Constant–Murley shoulder scores. There were significantly fewer implant removals in the MIPO group than in the open group (MIPO: 6.3% vs. open: 25.9%; p = 0.036). Neither group experienced any infection, implant failure, or nonunion. Conclusions: Our technique combining MIPO with the mini-open approach and supraclavicular nerve preservation yields a lower incidence of skin numbness than traditional open plating without nerve preservation.

Clavipectoral fascial plane block versus superficial cervical plexus block for fracture clavicle surgery: a randomized clinical trial

Background &amp; objective: Both, the clavipectoral fascial plane block as well as superficial cervical plane block have been utilized as a regional anesthesia technique for clavicular fracture surgery. We compared the efficacy and safety of clavipectoral plane block with superficial cervical plexus block for intraoperative and postoperative pain relief in clavicular fracture surgery under general anesthesia (GA). Methodology: This double-blinded randomized controlled trial included 84 patients, aged between 21 and 60 y, ASA classification I and II, with fracture clavicle, either isolated or part of other trauma, undergoing fracture clavicle fixation. The patients were divided into two groups. The first group received a clavipectoral fascial plane block and the other received a superficial cervical plane block. The visual analogue scale (VAS) scores were recorded as primary outcome, while the patients’ hemodynamics, time to first rescue analgesic, and total morphine consumption were the secondary outcomes at post-anesthesia care unit (PACU) then every 2 h in the ward till 8 h. Results: Compared to the superficial cervical plexus block the clavipectoral plane block was superior in analgesia and more effective during surgical dissection and intraoperative manipulations with a clinically and statistically significant difference all the time from PACU to 8 h postoperatively. The heart rate and arterial blood pressure were much more stable in the clavipectoral group. Also, time to first rescue analgesic was more in the clavipectoral group than in the superficial cervical block. Total morphine consumption was significantly less in the clavipectoral group than in the superficial cervical group. Conclusion: Clavipectoral plane bock is superior to superficial cervical block in fracture clavicle surgeries regarding efficacy and safety. Postoperative pain, measured by VAS, was less with clavipectoral plane block, with more hemodynamic stability and less opioid consumption postoperatively. Abbreviations: PACU - post-anesthesia care unit; CFP - Clavipectoral fascial plane; SCP - Superficial cervical plexus Keywords: Clavipectoral Plane Bock; Fracture Clavicle; Pain, Postoperative; Superficial Cervical Plexus Block Citation: Sayed AG, Abdelmoez WA, Ali OM, Elshafeey AE. Clavipectoral fascial plane block versus superficial cervical plexus block for fracture clavicle surgery: a randomized clinical trial. Anaesth. pain intensive care 2024;28(5):945−950; DOI: 10.35975/apic.v28i5.2573 Received: April 03, 2024; Reviewed: May 13, 2024; Accepted: July 02, 2024

Fixing Cho Type IIC Distal Clavicle Fractures with Hook Plates Leads to a High Incidence of Subacromial Osteolysis: A Retrospective Study and Literature Review.

This retrospective study investigates the complications, particularly subacromial osteolysis (SAO), associated with hook plate (HP) fixation, in the treatment of unstable distal clavicle fractures characterized by complete coracoclavicular (CC) ligament rupture. The decision-making process for employing HP in fractures of this nature, such as Neer types IIB and V and Cho classification IIC, involves considerations of distal fragment size and displacement. While HP offers advantages in clinical practice, it is not without complications, with SAO being a notable concern. Factors such as non-anatomic hook tip placement and fracture classification may influence the risk of SAO. The study comprises a retrospective analysis of unstable distal clavicle fractures treated with HP at our institution from 2019 to 2022. Exclusions include non-displaced fractures, those treated with other locking plates, and pathologic fractures. A total of 91 patients with displaced distal clavicle fractures underwent open reduction and internal fixation with HP. Cho classification was employed to differentiate cases with CC ligament rupture. Patient demographics, classifications, postoperative radiographs, distal fragment size, plate position, timing of implant removal, and complications, including SAO, were recorded. Among the 91 patients, 32 were classified as Cho IIB, 43 as Cho IIC, and 16 as Cho IID. Ninety-one percent exhibited solid union before implant removal. The prevalence of SAO was 43.8%, 76.7%, and 62.5% in Cho IIB, IIC, and IID, respectively. Univariate analysis revealed a significant difference only in Cho classification (p = 0.014). Binary logistic regression identified Cho classification type IIC as the sole risk factor for SAO (p = 0.021; odds ratio, 4.48; 95% confidence interval, 1.56-12.87). Cho type IIC fractures, characterized by CC ligament deficiency causing horizontal instability, demonstrated the highest SAO rate. In contrast, Neer type IIB fractures retained the trapezoid ligament, and Neer type V fractures had intact CC ligaments, resulting in lower SAO rates. Biomechanically, combining HPs with CC ligament reconstruction provided better structural stability than using HPs alone in treating Cho type IIC fractures.

Finite element analysis of anatomic plate fixation for proximal clavicular fractures

To explore establishment and finite element analysis of personalized proximal clavicular anatomical plate screw fixation model. A 40-year-old male healthy volunteer was selected and the finite element analysis modules of 3D reconstruction software Mimics 15.01, Hypermesh 2019 and Abaqus 2020 were used. The finite element model of anatomic plate at the proximal clavicle was established, and a vertical load of 250 N was applied to the distal end of long axis of clavicle about 15 mm, then the overall structure, plate and screw displacement cloud image, Mises stress distribution were observed. The displacement distribution of the overall structure shows the maximum displacement was distributed on the distal clavicle. Under the four conditions of normal upper limb weight, longitudinal clavicle fracture, oblique fracture and shoulder impact violence during fall, longitudinal clavicle fracture and oblique fracture, the maximum displacement were 1.04 mm, 1.03 mm, 1.35 mm and 1.33 mm, respectively. The displacement cloud map of titanium alloy steel plate showed the largest displacement was distributed near the distal clavicular bone, and the maximum displacement were 0.89 mm, 0.88 mm, 1.10 mm and 1.09 mm, respectively. The displacement cloud map of titanium alloy screw showed the largest displacement was distributed at the root of the distal screw, and the maximum displacement were 0.88 mm, 0.87 mm, 1.08 mm and 1.06 mm, respectively. Mises stress distribution showed the maximum stress was mainly distributed on titanium alloy plates and screws, and the stress on the clavicle was very small. Mises stress distribution cloud showed the maximum Mises stress was distributed at the second row of screw holes near the clavicle, and the maximum Mises stress were 673.1, 678.1, 648.5, 654.4 MPa, respectively. The maximum stresses of titanium alloy screws were 414.5, 417.4, 415.8 and 419.7 MPa, respectively. The biomechanical changes of personalized proximal clavicular anatomical plates are demonstrated by using 3D finite element method to provide biomechanical data for personalized proximal clavicular anatomical plates.

Risk Factors for Neonatal Clavicular Fractures: A Population-Based Case-Control Study.

Neonatal clavicular fractures represent the most common fracture during delivery. We aimed to define risk factors associated with these fractures in a large population-based database. Data were extracted from Clalit Health Services' electronic health records from 2000 to 2020. Newborns with clavicular fractures were compared with a healthy control group. The following parameters were compared-for the newborns: sex, birth weight, birth height, and head circumference; for the delivery process: assisted delivery, cesarean section, use of epidural, birth week, and number of fetuses; and for the mother: age at delivery, socioeconomic status, height, weight, and body mass index (BMI). We found a rate of 0.28% for neonatal clavicular fractures (5015 clavicular fractures/1 755 660 deliveries). Male gender and heavier birth weight were found to be significantly associated with clavicular fractures (P < .001). Increased risk was also associated with lower socioeconomic status, baseline weight, and maternal BMI (P < .001 for all). Assisted delivery increased the risk of clavicular fracture (OR = 2.274; 95% CI, 1.661-3.115; P < .0001), while cesarean section and use of epidural were found to be protective (OR = 0.149; 95% CI, 0.086-0.26; P < .0001; and OR = 0.687; 95% CI, 0.0531-0.89; P < .004, respectively). This study provides insight into the risk factors associated with neonatal clavicular fractures on the largest group of patients reported to date.

When to Radiate and When to Stop? Timing Radiographic Surveillance During Nonoperative Treatment of Pediatric Diaphyseal Clavicle Fractures

Introduction: Conservative management of most pediatric clavicle fractures is standard. Despite a predictable nonoperative course, evidence about the timeliness of healing is lacking. The goal of this study was to identify when radiographic signs of healing should be expected during routine conservative management of closed pediatric diaphyseal clavicle fractures. Methods: Patients 18 years or younger with an acute diaphyseal clavicle fracture treated at a large academic multispecialty orthopaedic practice over 5 years were retrospectively reviewed. Patients who completed nonoperative management until radiographic and clinical evidence of union were included and categorized into 3 age groups: infants and toddlers (0 to 2 y old), school-aged children (3 to 9 y old), and adolescents (10 to 18 y old). Radiographic healing was analyzed within each 2- to 4-week interval. Results: Among 390 patients, 303 met inclusion criteria. Overall shortening and displacement averaged 0.3±0.6 centimeters and 42.6%±43.0%, respectively. Follow-up averaged 50±24 days with an orthopaedic physician and 16.3±14.8 months for a well-child check. No clinically relevant or statistically significant improvements in the number of cortices bridged were observed in infants/toddlers after 4 weeks (average 20.4±4.3 d from injury), in school-aged children after 8 weeks (average 39.7±7.9 d from injury), or in adolescents after 12 weeks (average 66.4±8.1 d from injury). Conclusions: This study provides an age-dependent timeline during which adequate radiographic healing should be expected in nonoperatively managed pediatric diaphyseal clavicle fractures. Radiographic protocols can be purposefully timed to visualize sufficient healing in infants and toddlers by 4 weeks, school-aged children by 8 weeks, and adolescents by 12 weeks. Level of Evidence: Level III.

Trends in inpatient versus outpatient upper extremity fracture surgery from 2008 to 2021 and their implications for equitable access: a retrospective cohort study.

The aim of this study is to describe trends in inpatient and outpatient upper extremity fracture surgery between 2008 and 2021, along with identifying patient factors (age, sex, race, socioeconomic status) associated with outpatient surgery. Retrospectively, 12,593 adult patients who underwent upper extremity fracture repair from 2008 to 2021 at one of five urban hospitals in the Northeastern USA were identified. Using Distressed Communities Index (DCI), patients were divided into five quintiles based on their level of socioeconomic distress. Multivariable logistic regression was performed on patients from 2008 to 2019 to identify independent factors associated with outpatient management. From 2008 to 2019, outpatient procedures saw an average increase of 31%. The largest increases in the outpatient management were seen in humerus (132%) and forearm fractures (127%). Carpal and hand surgeries had the lowest percent increase of 8.1%. Clavicle and wrist fractures were independently associated with outpatient management. Older age, male sex, higher Elixhauser comorbidity index, DCI scores in the 4th or 5th quintile, and fractures of the scapula, humerus, elbow, and forearm were associated with inpatient management. During the onset of the COVID-19 pandemic, there was a decrease in outpatient procedures. There is a shift toward outpatient surgical management of upper extremity fractures from 2008 to 2021. Application of our findings can serve as an institutional guide to allocate patients to appropriate surgical settings. Moreover, physicians and institutions should be aware of the potential socioeconomic disparities and implement plans to allow for equal access to care.

Risk factors for adverse events after clavicle fracture open reduction and internal fixation: A NSQIP study

BackgroundMidshaft clavicle fractures are often subject to increased complications when treated nonoperatively, so surgical treatment with open reduction and internal fixation (ORIF) is a favored alternative. Despite safer outcomes, adverse events such as surgical site infections may still persist, particularly in the presence of certain patient characteristics. The objective of this study was to determine risk factors for and the frequency of adverse events following ORIF for clavicle fractures. MethodsA retrospective review of the National Surgical Quality Improvement Program (NSQIP) database from 2012 to 2021 identified patients undergoing isolated ORIF for clavicle fractures. Patient demographics and 30-day complications were collected. Bivariate analyses with a student's t-test or chi-square test were used to identify possible predictor variables for either AAE or SSI, and demographic metrics with P < 0.2 were included in a multivariable regression model. Multivariable analyses identified significant independent patient risk factors for any adverse event (AAE) or SSI within 30-days of surgery. Adjusted odds ratios were reported for each variable included in the model. Statistical significance was set a prior at P < 0.05. ResultsThe 6,753 selected patients who underwent ORIF for clavicle fractures between 2012 and 2021 were 38.1 ± 15.3 years of age, BMI 26.2 ± 4.9 kg m-12, and 77.3 % male. Of this cohort, 88.4 % received treatment on an outpatient basis. Postoperative adverse events were experienced by 128 (1.9 %) patients within 30 days of surgery, and SSI were prevalent in 0.77 % of patients, followed by wound dehiscence in 0.12 % of patients. After controlling for patient demographics and comorbidities, notable risk factors for adverse events included current smoking status (OR=2.036; P < 0.001) and patient age (OR=1.025; P < 0.001). Outpatient status (OR=0.528; P = 0.004) was protective. ConclusionThe present study noted significantly increased risk of postoperative adverse events in older patients, as well as patients who smoke. Outpatient setting was significantly protective for adverse events. These findings help to provide further clinical context to guide surgical decision making and inform surgeons on current risks and outcomes.

Operative treatment of clavicle fractures results in more opioids prescribed as compared to non-operative management.

The operative treatment of mid-shaft clavicle fractures shows benefit in union rates, return to work, and lower pain scores relative to non-operative treatment. We sought to determine if the surgical treatment of isolated mid-shaft clavicle fractures would result in fewer opioids prescribed as compared to those managed non-operatively. All mid-shaft clavicle fractures treated at a Level 1 trauma center were identified from 2012 to 2016. Demographics, fracture characteristics, surgical complications/outcomes, non-operative outcomes, and all narcotics prescribed for 6 months post-injury were collected. Narcotic prescriptions, in morphine equivalents (ME), were obtained through the state prescription drug monitoring program (PDMP). One hundred and ten operative and 48 non-operative patients were included. Age, gender, previous alcohol, tobacco or drug use, and final range of motion were similar between groups. Pre-treatment fracture shortening (1.8cm vs. 0.7cm, p < 0.001) and displacement (150% vs. 70%, p < 0.001) were greater in the operative group. Total ME's (604 vs. 187, p < 0.001) and post-operative ME's (420 vs. 187, p < 0.001) were greater for the operative group. In either group, no other variable influenced ME's prescribed. Clavicles treated operatively receive substantially more opiates than those treated non-operatively, despite data suggesting that operative treatment makes clavicle fractures less painful. The total amount of narcotic analgesics obtained by operatively treated patients was over three times that obtained by non-operatively managed patients, which equates to 55 5mg oxycodone pills or 85 5mg hydrocodone pills per patient. While there may certainly be advantages to the operative treatment of clavicle fractures, they must be weighed against the risks of a significant increase in opiate prescribing and potential consumption.

Surgical Management of Clavicle Fracture with Precontoured Locking Plate

Surgical Management of Clavicle Fracture with Precontoured Locking Plate

Magnetic resonance neurography in the diagnosis of neurological subtypes of thoracic outlet syndrome.

Neurological thoracic outlet syndrome (TOS) can be challenging to diagnose, particularly given its described subtypes of neurogenic TOS (NTOS) and disputed TOS (DTOS) that exhibit variable clinical presentations and etiologies. The diagnostic workup of TOS often includes magnetic resonance neurography (MRN) of the brachial plexus. Specific MRN imaging modifications for TOS evaluation are required to maximize spatial and contrast resolution to increase the conspicuity of nerve segments and their relationships to surrounding osseous structures. Dynamic assessment with arm positioning is used to evaluate outlet narrowing and compression of the plexus. Individual nerve segments are interrogated for their longitudinal and cross-sectional morphologies and signal characteristics. In patients with NTOS, MRN may reveal focal impingement of the C8/T1 nerve roots and/or lower trunk with accompanying abnormal T2-weighted signal hyperintensity. Predisposing anatomical entities include cervical ribs, rib synostoses, hypertrophic callous following clavicular fracture, remnant first thoracic rib from prior incomplete resection, and variable perineural scarring. In comparison, DTOS patients frequently demonstrate signal hyperintensity and enlargement of the mid plexus (trunk and division level), with narrowing of the costoclavicular interval. Following comprehensive diagnostic workup that frequently includes electrodiagnostic testing, patients are directed to different management pathways. Nonsurgical management is considered for all cases of DTOS; all patients with NTOS or DTOS who fail conservative treatment warrant referral for a surgical opinion. If surgery is pursued, MRN can be helpful in preoperative planning.

"Dr. AI Will See You Now": How Do ChatGPT-4 Treatment Recommendations Align With Orthopaedic Clinical Practice Guidelines?

Artificial intelligence (AI) is engineered to emulate tasks that have historically required human interaction and intellect, including learning, pattern recognition, decision-making, and problem-solving. Although AI models like ChatGPT-4 have demonstrated satisfactory performance on medical licensing exams, suggesting a potential for supporting medical diagnostics and decision-making, no study of which we are aware has evaluated the ability of these tools to make treatment recommendations when given clinical vignettes and representative medical imaging of common orthopaedic conditions. As AI continues to advance, a thorough understanding of its strengths and limitations is necessary to inform safe and helpful integration into medical practice. (1) What is the concordance between ChatGPT-4-generated treatment recommendations for common orthopaedic conditions with both the American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines (CPGs) and an orthopaedic attending physician's treatment plan? (2) In what specific areas do the ChatGPT-4-generated treatment recommendations diverge from the AAOS CPGs? Ten common orthopaedic conditions with associated AAOS CPGs were identified: carpal tunnel syndrome, distal radius fracture, glenohumeral joint osteoarthritis, rotator cuff injury, clavicle fracture, hip fracture, hip osteoarthritis, knee osteoarthritis, ACL injury, and acute Achilles rupture. For each condition, the medical records of 10 deidentified patients managed at our facility were used to construct clinical vignettes that each had an isolated, single diagnosis with adequate clarity. The vignettes also encompassed a range of diagnostic severity to evaluate more thoroughly adherence to the treatment guidelines outlined by the AAOS. These clinical vignettes were presented alongside representative radiographic imaging. The model was prompted to provide a single treatment plan recommendation. Each treatment plan was compared with established AAOS CPGs and to the treatment plan documented by the attending orthopaedic surgeon treating the specific patient. Vignettes where ChatGPT-4 recommendations diverged from CPGs were reviewed to identify patterns of error and summarized. ChatGPT-4 provided treatment recommendations in accordance with the AAOS CPGs in 90% (90 of 100) of clinical vignettes. Concordance between ChatGPT-generated plans and the plan recommended by the treating orthopaedic attending physician was 78% (78 of 100). One hundred percent (30 of 30) of ChatGPT-4 recommendations for fracture vignettes and hip and knee arthritis vignettes matched with CPG recommendations, whereas the model struggled most with recommendations for carpal tunnel syndrome (3 of 10 instances demonstrated discordance). ChatGPT-4 recommendations diverged from AAOS CPGs for three carpal tunnel syndrome vignettes; two ACL injury, rotator cuff injury, and glenohumeral joint osteoarthritis vignettes; as well as one acute Achilles rupture vignette. In these situations, ChatGPT-4 most often struggled to correctly interpret injury severity and progression, incorporate patient factors (such as lifestyle or comorbidities) into decision-making, and recognize a contraindication to surgery. ChatGPT-4 can generate accurate treatment plans aligned with CPGs but can also make mistakes when it is required to integrate multiple patient factors into decision-making and understand disease severity and progression. Physicians must critically assess the full clinical picture when using AI tools to support their decision-making. ChatGPT-4 may be used as an on-demand diagnostic companion, but patient-centered decision-making should continue to remain in the hands of the physician.

Neonatal cardiorespiratory failure caused by splenic hemorrhages: a case report on a fatal and a rescued case

Two cases of neonatal splenic hemorrhage with acute cardiorespiratory failure are described in this report. The first case involves a full-term neonate who was found unresponsive without any witnesses and could not be successfully resuscitated. A postmortem diagnosis revealed a splenic hemorrhage. Second case is an extremely premature neonate who experienced a witnessed cardiovascular collapse on the 14th day of life. Rapid cardiovascular support was administered, resulting in a positive outcome. While splenic hemorrhage is commonly associated with traumatic events, these cases highlight the need of considering spontaneous splenic hemorrhages as a potential cause of acute neonatal compromise, even in the absence of birth-related trauma (e.g., asphyxia, prolonged labor, clavicle fractures, brachial plexus injuries). This report emphasizes the importance of including splenic hemorrhage timely in the differential diagnosis of neonatal cardiorespiratory instability, especially in the absence of more common diagnoses, and discusses the challenges associated with its recognition and treatment.