Fixation Of Midshaft Clavicle Fractures Research Articles

Comparative study of stabilization of a displaced midshaft clavicle fracture with either an intramedullary nail fixation or a superiorly placed plate.

This retrospective study compares two techniques of fixation of midshaft clavicle fractures: nail fixation versus plate fixation. We compared titanium elastic nail fixation with plate fixation in patients with uncomplicated midshaft clavicle fractures. In total, 84 patients were included in our study: 35 in the nail fixation group and 49 in the plate fixation group. We compared the 12-month postoperative shoulder function and scar assessment. Primary outcome was measured by the DASH score and POSAS score. Secondary outcome was measured by Constant score, surgery complications, implant removal, hospitalization days, and size and quality of the scar. Here was no significant difference in DASH and Constant scores between the two groups. However, the nail group leads in the POSAS (12 (12 - 12) 25 (17 - 30) p < 0.001) and in all scar parameters (size, scar influence). There were no significant differences in the complications despite implant removal where more removals were noted in the nail group (16 (44.4%) 4 (8.3%) p < 0.001). Fixation of uncomplicated midshaft clavicle fractures with nail provides better cosmetic results and scar quality than fixation with plate, and presents no significant differences in functional ability or complications.

Fixation of transverse midshaft clavicle fractures with nitinol staples vs. superior locked plating: a biomechanical study

Background: Nitinol staples have been used effectively for stabilization and compression at fracture sites. This study compared yield load, fracture displacement, and load to failure between nitinol staples and superior plating for midshaft clavicle fractures. Methods: Ten pairs of cadaveric clavicles underwent midshaft osteotomy. Each specimen in each pair was randomly assigned to fixation with superiorly placed nitinol staples or with superior plating. Specimens were loaded cyclically with increasing loads to a maximum of 1200 cycles and 60 N. Fracture displacement and construct stiffness were compared at each load. Load to failure was performed at the conclusion of testing. Results: The staple group demonstrated lower yield load and higher median fracture displacement at all levels of force compared to the plate group. Median displacement at physiologic load was 15.3 (IQR 12.8-16.5) mm for the staple construct and 2.9 (IQR 2.5-3.6) mm for plated constructs (P=2.04E-07). Median stiffness of plated constructs was significantly higher than staple constructs at all levels (P&lt;0.05). Median cycles to failure for staple constructs was significantly lower compared to plated constructs (P=0.004). Median load to failure was significantly higher for plated constructs compared to staple constructs (P=2.8E-06). Conclusions: Nitinol staple fixation of midshaft clavicle fractures demonstrated lower yield load, stiffness, increased displacement, and lower load to failure compared to superior plate fixation. However, staple constructs provided adequate stability to maintain reduction of the fracture at physiologic levels of repetitive stress, indicating a potential role for nitinol staples in clavicle fracture fixation.

Return to Sport After Operative Fixation of Midshaft Clavicle Fractures in Professional Jockeys.

Clavicle fractures are the most commonly observed fracture sustained in professional horse racing. This study is the first to report on time lost from injury and functional recovery after surgical fixation of midshaft clavicle fractures in professional jockeys. Retrospective cohort study. Professional Horse Racing Ireland; Patients (or Participants): Professional Jockeys in Ireland with midshaft clavicular fractures managed with Open Reduction Internal Fixation. Interventions (or Assessment of Risk Factors or Independent Variables): Operative fixation with Open Reduction Internal Fixation. Assessment of postoperative Quick Disabilities of Arm Shoulder and Hand (QuickDASH) score and Patient Reported Outcome Measures assessing for associated complications and time to return to competition among professional athletes. Between 07/06/2013 and 29/09/2022, 22 patients met the predetermined inclusion criteria. Ninety-five percent of patients returned to competition at their preinjury level, one patient failed to return to competition for reasons unrelated to his injury. The mean time for return to competition was 68.14 days postinjury. Few complications were reported, whereas functional recovery was excellent across the cohort, with an average QuickDASH score of 0.85 (0.0-2.3). Plate fixation of midshaft clavicle fractures is effective and safe in the setting of professional horse racing. Ninety-five percent of patients can be expected to return within 14 weeks of injury. Patients returning at less than 7 weeks after injury had no adverse outcomes, suggesting a potential role for more aggressive rehabilitation postoperatively and ultimately, a quicker return to competition.

Low rate of secondary surgery and implant removal following superior, precontoured plating of midshaft clavicle fractures

Background Surgical fixation of midshaft clavicle fractures with a single 3.5 mm superior clavicular plate has been associated with a high rate of hardware removal due to symptomatic hardware. Because of this, dual-plating techniques with lower-profile implants have been proposed. However, dual-plating systems have disadvantages, including increased cost and increased surgical morbidity. The aim of this study was to define the rate of symptomatic hardware removal for all midshaft clavicle fractures. Methods We retrospectively reviewed information on all patients from 2014 to 2018 at a single level 1 trauma institution with surgeries performed by two fellowship-trained orthopedic trauma surgeons. Documented removal of hardware and the reason for removal were recorded. We then contacted all patients at their listed telephone number to confirm the hardware was still in place and to administer patient outcome questionnaires. If patients did not answer, attempts were made to contact them multiple times on multiple days. Those who were not reached but had documented hardware removal were included in the total number of patients with hardware removal. Results The search revealed 158 patients, of whom 89 (61.8%) were included in the study. Average follow up was 4.09 years (range 2.02–6.50 years). Five patients (5.56%) underwent hardware removal. Removal was for symptomatic or irritating hardware in two of these patients (2.22%). Average abbreviated Disability of Arm, Shoulder, and Hand score was 6.27, and average American Society of Shoulder and Elbow Surgeons shoulder score was 93.6. Conclusion In our series, the rate of symptomatic hardware removal was 2.22%, well below reported removal rates. Hardware removal rates for prominent symptomatic superior clavicular plates may be significantly lower than previously reported, and these fractures may be adequately treated with a single, superior plate.

Operative Fixation of Displaced Midclavicular Fractures in Adult by Titanium Elastic Nailing System

Introduction and aim: Clavicular fractures are very common, and it usually treated conservatively. However, recent shift to surgical intervention had been observed. The guidelines seem to be in its road to change. The aim of this work is to asses clinical and radiological results of surgical fixation of midshaft clavicle fractures by Titanium Elastic Nailing System.&#x0D; Methodology: Fifteen patients with mid-shaft (middle third) displaced fractures of the clavicle were included. All were assessed in systematic manner (history, examination and investigations). Then, eligible patients provided an informed consent and underwent surgical treatment according to study protocol. All were followed up for 6 months and their outcome was ranged according to Constant and Murley Score.&#x0D; Results: Ten patients (66.7%) had excellent, 3 patients (20%) had good, one patient (6.7%) had fair, and one patient (6.7%) had poor outcome. Pain was absent or mild in the majority of patients (93.3%). 86.7% of patients return to full work, and all had unaffected sleep. Union was achieved in 14 patients (93.3%). One patient had an infection, two had medial end skin irritation and one had hypertrophic non-union. Younger age and absence of any associated medical disease were associated with excellent outcome.&#x0D; Conclusion: Titanium Elastic Nailing could be considered as a reasonable alternative approach to the management of displaced mid-shaft clavicular fractures, as it is associated with excellent outcome, low pain, and early return to normal daily activities.

Dual mini-fragment plate fixation of midshaft clavicle fractures is biomechanically equivalent to anatomic pre-contoured plating.

To biomechanically compare the stiffness of midshaft synthetic clavicle osteotomies fixed with either superior anatomic pre-contoured locking plates, anterior anatomic pre-contoured locking plates, or short-segment dual orthogonal mini-plate fixation. Controlled laboratory study. Specimens Twenty-one synthetic pre-osteotomized clavicles were separated into three groups: superior plating, anterior plating, or dual-plating. Each clavicle was sequentially tested in non-destructive cycles of axial compression, three-point bending, and torsion. Load and displacement were recorded. Stiffness was calculated. No statistically significant differences were found between construct stiffness during axial compression, three-point bending, or torsional testing. One superior plated clavicle suffered catastrophic failure during axial compression. One dual mini-fragment plated clavicle suffered catastrophic failure during torsion. Orthogonal dual mini-fragment fixation of transverse clavicle fractures is biomechanically similar to superior and anterior pre-contoured anatomic locking plate fixation. No statistically significant differences in construct stiffness were found in axial compression, three-point bending, or torsion testing. Further clinical research is required to determine the long-term stability of dual mini-fragment plate fixation. IV.

Intramedullary nailing versus plating fixation for the treatment of midshaft clavicular fractures: A meta-analysis of randomized controlled trials

PurposeThis study was to test the hypothesis that intramedullary (IM) nailing fixation of midshaft clavicle fractures could result in better clinical outcomes and lower complications rates than plating fixation. MethodsPubMed, Embase, and the Cochrane Library database were used to search all English language published randomized controlled trials (RCTs) of midshaft clavicle fractures using plating versus IM nailing. The characteristics of the study participants were collected. Outcomes of postoperative shoulder functional measurements, operative data and complications rates were meta-analyzed. ResultsEight hundred and ninety-five patients in ten RCTs and three quasi-RCTs were involved in the meta-analysis. The results of meta-analysis of these studies showed that the functional outcome evaluated by the Constant Shoulder and Disabilities of the Arm, Shoulder and Hand (DASH) scores after accepting IM nailing was significantly better than that of plating fixation at one year post-operatively (P < 0.01), with the heterogeneity of 43% and 91%, respectively. Sensitivity analyses of the pooled results of Constant and DASH scores displayed that the functional advantage of IM nailing fixation comes from the subgroup of locked IM nailing. Further, regarding the operative statistics, operative time, blood loss and wound length were significantly less in the IM nailing group than the plating group (P < 0.001). The rates of infection, major complications and complications-related revision surgery were significantly higher in the plating group than the IM nailing group; however, there were no significantly statistical differences in other complications, e.g., nonunion, refracture after hardware removal, implant failure, symptomatic hardware, etc. (P > 0.05). ConclusionThe observations in this review suggested that IM nailing, especially locked IM nailing, could provide better shoulder functional outcome at one-year follow-up. Moreover, IM nailing fixation could effectively reduce operative time, blood loss, rates of infection, major complications, and revision surgery than plating. Further high-quality clinical trials with large samples and consistent designs are still needed to verify the long-term functional advantage of locked and unlocked IM nailing for midshaft clavicle fractures. Level of evidenceLevel II.

Biomechanical Evaluation of Different Plate Configurations for Midshaft Clavicle Fracture Fixation: Single Plating Compared with Dual Mini-Fragment Plating.

Background:Dual-plate constructs have become an increasingly common fixation technique for midshaft clavicle fractures and typically involve the use of mini-fragment plates. The goal of this technique is to reduce plate prominence and implant irritation. However, limited biomechanical data exist for these lower-profile constructs. The study aim was to compare dual mini-fragment orthogonal plating with small-fragment clavicle plates for biomechanical noninferiority and to determine if an optimal plate configuration could be identified using a cadaveric model.Methods:Twenty-four cadaveric clavicles were randomized to 1 of 6 groups, stratified by computed tomography-based bone mineral content (BMC): precontoured superior or anterior fixation using a single 3.5-mm Locking Compression Plate (LCP), and 4 different dual-plating constructs utilizing 2.4-mm and 2.7-mm Adaptation plates or LCPs. An inferior butterfly fracture was created. Axial, torsional, and bending (anterior and superior surface loading) stiffnesses were determined through nondestructive cyclic testing, followed by a load-to-failure test in 3-point superior surface bending.Results:For axial stiffness, the 2 dual-plate constructs with a superior 2.4-mm and anterior 2.7-mm plate (either Adaptation or LCP) were significantly stiffer than the other 4 constructs (p = 0.021 and p = 0.034). For both superior and anterior bending, the superior 2.4-mm and anterior 2.7-mm plate constructs were significantly stiffer when compared with the 3.5-mm superior plate (p = 0.043). No significant differences were found in torsional stiffness or load to failure between the different constructs.Conclusions:Dual plating using mini-fragment plates is biomechanically superior for the fixation of midshaft clavicle fractures when compared with a single, superior, 3.5-mm plate and has biomechanical properties similar to those of a 3.5-mm plate placed anteriorly. With the exception of axial stiffness, no significant differences were found when different dual-plating constructs were compared with each other.Clinical Relevance:This study validates the use of dual plating for midshaft clavicle fractures.

Intramedullary headless compression screw fixation for midshaft fractures of the clavicle: A case report study

Historically, displaced midshaft clavicle fractures have been managed conservatively. However, recent literature has supported operative management of displaced and shortened clavicle fractures. Several options exist for surgical fixation, including plating and intramedullary (IM) fixation. IM fixation has the potential advantages of a smaller incision and decreased dissection and soft-tissue exposure and less prominent hardware.Rockwood and Hagie pins represented the most popular form of IM fixation during the last two decades,but concerns exist regarding stability and complications. The use of alternative IM implants, such as Kirschner wires, titanium elastic nails, and cannulated screws, also has been described in limited case series. However, concerns persist regarding the complications associated with the use of these implants, including implant failure, migration, skin complications, prominent screw head and construct stability. Our technique describes intramedullary fixation of midshaft clavicle fractures using a single headless compression screw (HCS) 4.5–6.5-mm. which is simple, affordable, and allows intramedullary compression, stability, load sharing, little periosteal stripping, very limited skin incision and rapid recovery after surgery.

Clavicular osteotomy to assess subclavian vein injury during internal fixation of midshaft clavicle fractures.

Midshaft clavicle fractures are commonly fixed with locking plates. The subclavian vein risks injury during this procedure and the consequences can be fatal. The purpose of this present study is to describe a clavicular osteotomy technique in order to equip orthopaedic surgeons with a means of rapidly accessing a subclavian vein injury. The osteotomy should only be performed following an urgent intraoperative vascular surgery assessment. There must be shared consensus from both orthopaedic and vascular surgery that direct repair of the subclavian vein is necessary, and further exposure is required. The results of the technique performed on thirteen embalmed cadaveric specimens are also included. The osteotomy was able to expose 3.16 cm (SD = 0.60) of the subclavian vein and both the fracture and osteotomy site of all clavicles (100%) were able to be reduced and fixed using a single pre-contoured fifteen-hole lateral plate intended for use on the contralateral shoulder. This surgical technique study confirms that in the rare circumstance that the osteotomy is utilized, adequate exposure of the subclavian vein is achieved.

Comparative effectiveness of treatment options for displaced midshaft clavicle fractures : a systematic review and network meta-analysis.

AimsThe aims of this network meta-analysis (NMA) were to examine nonunion rates and functional outcomes following various operative and nonoperative treatments for displaced mid-shaft clavicle fractures.MethodsInitial search strategy incorporated MEDLINE, PubMed, Embase, and the Cochrane Library for relevant randomized controlled trials (RCTs). Four treatment arms were created: nonoperative (NO); intramedullary nailing (IMN); reconstruction plating (RP); and compression/pre-contoured plating (CP). A Bayesian NMA was conducted to compare all treatment options for outcomes of nonunion, malunion, and function using the Disabilities of the Arm Shoulder and Hand (DASH) and Constant-Murley Shoulder Outcome scores.ResultsIn all, 19 RCTs consisting of 1,783 clavicle fractures were included in the NMA. All surgical options demonstrated a significantly lower odds ratio (OR) of nonunion in comparison to nonoperative management: CP versus NO (OR 0.08; 95% confidence interval (CI) 0.04 to 0.17); IMN versus NO (OR 0.07; 95% CI 0.02 to 0.19); RP versus NO (OR 0.07; 95% CI: 0.01 to 0.24). Compression plating was the only treatment to demonstrate significantly lower DASH scores relative to NO at six weeks (mean difference -10.97; 95% CI -20.69 to 1.47).ConclusionSurgical fixation demonstrated a lower risk of nonunion compared to nonoperative management. Compression plating resulted in significantly less disability early after surgery compared to nonoperative management. These results demonstrate possible early improved functional outcomes with compression plating compared to nonoperative treatment. Surgical fixation of mid-shaft clavicle fractures with compression plating may result in quicker return to activity by rendering patients less disabled early after surgery.Cite this article: Bone Jt Open 2021;2(8):646–654.

Plate fixation of midshaft clavicle fractures for delayed union and non-union is a cost-effective intervention but functional deficits persist at long-term follow-up.

The primary aim of this study was to compare the long-term functional outcome of midshaft clavicle fracture fixation for delayed (≥3 month) and non-union (≥6 month) compared to a matched cohort of patients that achieved union with non-operative management. The secondary aim was to assess cost-effectiveness of fixation. A consecutive series of patients over 10-years were retrospectively reviewed using the QuickDASH, Oxford Shoulder Score and EuroQol five-dimension summary index (EQ-5D). These patients were compared to a matched cohort that achieved union after non-operative management using propensity score matching. Sixty patients (follow-up 79%, n = 60/76) at 4.1 years post-operative (1.1-10.0 years) had a QuickDASH of 16.5 (95% CI 11.6-21.5), Oxford Shoulder Score 41.5 (39.0-44.1) and EQ-5D 0.7621 (0.6822-0.8421). One in five patients were dissatisfied with their final outcome (n = 13/60). Functional outcome was inferior following fixation when compared to patients that united with non-operative management (QuickDASH 16.5 vs. 5.5, p < 0.001 and EQ-5D 0.7621 vs. 0.9073, p = 0.001). However, significant improvements were found when compared to pre-operative scores (QuickDASH p < 0.001 and EQ-5D p < 0.001). The cost per QALY for fixation was £5624.62 for the study cohort. Clavicle fixation for delayed and non-union is a cost-effective intervention but outcomes are worse compared to patients that unite with non-operative management.

Does a skin incision along Langer's lines reduce complications following fixation of displaced middle-third clavicle fractures?

Internal fixation of displaced middle-third clavicle fractures is a widely used treatment but is frequently associated with post-operative complications. The aim of this study is to investigate whether or not using a skin incision along Langer's lines, as opposed to a traditional transverse incision, reduces complications. We retrospectively reviewed data on 108 patients who underwent open reduction and internal fixation of mid-shaft clavicle fractures between 2014 and 2018. Either an oblique incision along Langer's lines or a transverse incision was used according to surgeon's preference. A pre-contoured diaphyseal locking plate was used in all cases. We collected data on fracture classification, minor complications (irritation from plate, chest wall numbness, superficial wound infection) and major complications (irritation from plate necessitating metalwork removal, periprosthetic fracture, deep infection, neurovascular injury and non-union). Statistical analysis was performed using multivariant regression analysis and Fisher's exact tests. Fifty-seven patients underwent fixation using the oblique incision and 51 via the transverse incision. Age, gender and fracture pattern in the two groups were comparable. There were 14 minor and 6 major complications in the oblique group. In the transverse group, there were 16 minor and 5 major complications. The major complication rate was 10.5% in the oblique group and 9.8% in the transverse group. The overall major complication rate was 10.2%. No statistically significant difference in the rate of complications between the two groups was identified. Based on our data, an incision following Langer's lines does not reduce the rate of complications following fixation of displaced middle-third clavicle fractures.

Intramedullary Screw Fixation of Mid-shaft Clavicle Fractures

Aim: To investigate the use of intramedullary screw for fixation of mid-shaft clavicle fractures including indications, preoperative planning, operative technique, and complications during the study period. Setting and design: Prospectively we used intramedullary screw for fixation of mid-shaft clavicle fractures either nondisplaced, minimally displaced guided by fluoroscopy. Patients and methods: The study included 20 patients after obtaining informed consent who underwent mid-shaft clavicle fractures using intramedullary screw fixation between February 2018 and January 2019.Statistical analysis used: The software for statistical package for social sciences for Windows 10 was used for all statistical calculations. Each variable was tested for its normal value using the Mann-Whitney Test and exact P values were calculated. Significance was set at the P value of less than 0.05.Results: All cases had “good to excellent” functional results according to the Constant and Murley shoulder score. Conclusion: Our results show that intramedullary screw fixation of mid-shaft clavicle fractures inserted from the lateral to the medial fragment is a simple, reliable and effective method of treatment with overall satisfactory functional and cosmetic results and low morbidity.

Plate osteosynthesis of midshaft clavicle fractures in adolescent contact sports athletes - adolescent clavicle fracture.

Surgical treatment of mid-shaft clavicle fractures via anatomical plates in adult athletes is documented to be safe and effective. Functional and cosmetic outcomes in adolescent contact sports athletes have not been well documented. Adolescent athletes (age 11-19) surgically treated for mid-shaft clavicle fractures between 1 May 2011 and 30 October 2017 were included in this study. Twenty-one adolescent athletes with a mean follow-up of 44 months were reviewed. Retrospective chart reviews were performed. Functional and cosmetic outcomes, return to sports time/rate were analyzed using Nottingham Clavicle Scores and a 'Custom Questionnaire'. Return of function and healing, evidenced on radiographs, was achieved in all 21 patients. All patients returned back to competitive sports. The mean time to return back to training was 45.9 ± 16 (24-76) days. Sixteen (76.1%) of the patients reported Nottingham Clavicle Scores with a mean score of 91.7 (85-98). In the Custom Questionnaire, 16 patients who participated in the phone interview were satisfied with the cosmetic outcomes. The most common complaint was implant prominence and irritation in 6 (40%) patients, subsequently requiring implant removal in 3 (18.8%). Surgical fixation of mid-shaft clavicle fractures can lead to excellent union and cosmetic outcomes and a rapid return to sports in adolescent contact sport athletes. However, one should consider the outcomes of implant-related complaints and the possibility of implant removal surgery in the future.

Klavikula cisim kırıklarının cerrahi tedavisinin orta-uzun dönem sonuçları

Aim: The aim of the study is to represent surgical and functional outcomes of plate fixation of mid-shaft clavicle fractures (MCF) via anatomical locking plate, in a large patient population including highly active patients. Methods: We retrospectively evaluated 94 patients surgically treated for MCF between May 1st 2011 and October 30th 2017. Patients with minimum one-year of follow-up were included to the study. The mean follow-up was 42 ± 27.7 months (12 to 83) months. All patients were followed up until radiological and clinical healing was achieved. All fractures were classified according to the OTA classification. Medical charts were retrospectively reviewed for demographic data, cause of injury, time to surgery, athletic activity, operative complications, radiographic and functional healing time. Constant score was applied to patients at final follow-up to evaluate functional outcomes. Results: The mean age at the time of injury was 31.4±15.4 (11 to 74) years. Ninety-one clavicles (96.8%) demonstrated radiologic and functional healing in a mean of 62 ± 33 days. The mean Constant score at the final follow-up was 91 ± 6.6 (76 to 100). The major underlying cause was sports related injuries (n=53, 56.3%) followed by motorcycle accidents (n=17,18.0%) and low falls (n=12, 12.7%). Forty-three patients (45.7%) were involved in regular athletic activity at least 3 times weekly. The overall complication rate was 19.1% (n=18). The most common complication was implant irritation in 11 patients (11.7%), 6 of which underwent implant removal surgery. The overall non-union rate was 3.2% (n=3). Conclusion: Operative treatment of displaced mid-shaft clavicle fractures with precontoured locking plate provides high union rates and satisfactory mid to long-term functional outcomes. However, one should consider the significant, potentially serious operative complications.

Low-Profile Dual Small Plate Fixation Is Biomechanically Similar to Larger Superior or Anteroinferior Single Plate Fixation of Midshaft Clavicle Fractures

Background: Limited biomechanical data exist for dual small plate fixation of midshaft clavicle fractures, and no prior study has concurrently compared dual small plating to larger superior or anteroinferior single plate and screw constructs. Purpose: To biomechanically compare dual small orthogonal plating, superior plating, and anteroinferior plating of midshaft clavicle fractures by use of a cadaveric model. Study Design: Descriptive laboratory study. Methods: The study used 18 cadaveric clavicle specimens (9 pairs total), and 3 plating techniques were studied: anteroinferior, superior, and dual. The dual plating technique used smaller diameter plates and screws (1.6-mm thickness) than the other, single plate techniques (3.3-mm thickness). Each of the 9 clavicle pairs was randomly assigned a combination of 2 plating techniques, and randomization was used to determine which techniques were used for the right and left specimens. Clavicles were plated and then osteotomized to create an inferior butterfly fracture model, which was then fixed with a single interfragmentary screw. Clavicle specimens were then potted for mechanical testing. Initial bending, axial, and torsional stiffness of each construct was determined through use of a randomized nondestructive cyclic testing protocol followed by load to failure. Results: No significant differences were found in cyclical axial (P = .667) or torsional (P = .526) stiffness between plating groups. Anteroinferior plating demonstrated significantly higher cyclical bending stiffness than superior plating (P = .005). No significant difference was found in bending stiffness between dual plating and either anteroinferior (P = .129) or superior plating (P = .067). No significant difference was noted in load to failure among plating methods (P = .353). Conclusion: Dual plating with a smaller plate-screw construct is biomechanically similar to superior and anteroinferior single plate fixation that uses larger plate-screw constructs. No significant differences were found between dual plating and either superior or anteroinferior single plating in axial, bending, or torsional stiffness or in bending load to failure. Dual small plating is a viable option for fixing midshaft clavicle fractures and may be a useful low-profile technique that avoids a larger and more prominent plate-screw construct. Clinical Relevance: Plate prominence and hardware irritation are commonly reported complaints and reasons for revision surgery after plate fixation of midshaft clavicle fractures. Dual small plate fixation has been used to improve cosmetic acceptability, minimize hardware irritation, and decrease reoperation rate. Biomechanically, dual small plate fixation performed similarly to larger single plate fixation in this cadaveric model of butterfly fracture.

Potential Economic Benefits of Limited Clinical and Radiographic Follow-up After Plate Fixation of Midshaft Clavicle Fractures.

The role of routine clinical and radiographic follow-up after clavicle fractures are healed was evaluated. A retrospective study performed in two level-1 trauma centers included 246 adults with healed clavicle fractures treated surgically between 2000 and 2013 and at least 24-month follow-up. Based on radiographs, changes in fracture alignment or implant position from union to final follow-up were documented. The average reimbursement for a follow-up clinical visit and a clavicle radiograph was estimated. Mean time to union and mean time of follow-up were of 4.8 and 31.4 months, respectively. No changes in implant position or fracture alignment occurred after the fracture had healed. The amount reimbursed to our institution for two clinical visits and two clavicle radiographs was approximately $300 to $540. Once clavicle fractures are healed, further radiographic imaging does not provide any notable information. Limiting routine follow-up is safe and could be cost-effective for the healthcare system. Level-III retrospective cohort study.

Biomechanical comparison between solid and cannulated intramedullary devices for midshaft clavicle fixation

BackgroundA method of closed reduction and internal fixation with cannulated screws was proposed as a surgical treatment of midshaft clavicle fractures. However, there are no mechanical studies about the cannulated screw used in the fixation of midshaft clavicle fracture. We conducted this study to compare the construct bending stiffness of a fixation midshaft clavicle fracture with a Knowles pin, cannulated screw and reconstruction plate. In addition, purchase lengths of both intramedullary devices were measured.MethodsAfter transverse osteotomy over the midpoint for fracture simulation, eighteen synthetic clavicles were assigned to 3 groups and fixed with reconstruction plate, Knowles pin or cannulated screw. Purchase length was defined as the engaged length of the intramedullary portion of the two intramedullary devices Stiffness, yield load and maximum load of the cantilever bending test were calculated of each tested synthetic bones.ResultsThe Knowles pin group had a significantly longer average intramedullary purchase length compared with that of the cannulated screw group. The construct stiffness in the reconstruction plate group (5.6 ± 0.9 N/mm) was higher than that of the intramedullary devices; the Knowles pin group (3.1 ± 0.6 N/mm) provided a greater construct stiffness than did the cannulated screw group (1.7 ± 0.4 N/mm) (p = 0.007). The cannulated screw group had the lowest yield and maximum load compared with the reconstruction plate and Knowles pin groups. Both the reconstruction plate and Knowles pin failed at the implant-bone interface. However, the cannulated screw group failed at the osteotomy site with broken implants.ConclusionThis study suggests that fixation of midshaft clavicle fractures with cannulated screws may lead to early failure due to inadequate mechanical strength. Ideal intramedullary clavicle devices should supply adequate intramedullary purchase lengths and mechanical strength.

Complications After Plate Fixation of Displaced Pediatric Midshaft Clavicle Fractures.

Operative treatment of displaced pediatric midshaft clavicle fractures has become increasingly popular, despite lack of evidence that surgical management leads to superior outcomes. Complications, such as plate irritation necessitating removal and wound infection, have been reported in adults. The purpose of this study was to evaluate complications after plate fixation of midshaft clavicle fractures in the pediatric population. We retrospectively identified patients 10 to 18 years old who had undergone plate fixation of a displaced midshaft clavicle fracture between 2009 and 2014. Patients who had surgery for a malunion or nonunion, and patients with <6 months of follow-up were excluded. Demographic data, radiographic union, time to return to activity, and complications were recorded. Any complication that led to unplanned surgery was considered a major complication. We analyzed 36 patients (25 males, 11 females) with 37 fractures. The average age at surgery was 14.5±1.7 years and mean follow-up was 1.3±1.0 years. All of the fractures healed and average time to return to activity was 58±28 days. The overall postoperative complication rate was 86% (32/37): 59% (22/37) implant prominence or irritation, 16% (6/37) anterior chest wall numbness, 5% (2/37) superficial wound dehiscence or infection, 3% (1/37) refracture adjacent to the plate, and 3% (1/37) refracture after implant removal. The major complication rate was 43% (16/37). Fifteen patients underwent a second surgery for implant removal secondary to prominence or pain. One patient underwent revision open reduction and internal fixation after he sustained a refracture at the distal aspect of the plate that resulted in a painful nonunion. Only 1 patient had a refracture after implant removal and this was treated nonoperatively. Implant prominence or irritation is common after plate fixation of displaced pediatric midshaft clavicle fractures. A second surgery for implant removal may be necessary. Patients should be appropriately counseled regarding complications before plate fixation of midshaft clavicle fractures. Level IV-therapeutic.