Management Of Midshaft Clavicle Fractures Research Articles

Comparison of the use of biocompatible materials and titanium in the treatment of midshaft clavicle fractures with a patient-specific plate: a finite element analysis study.

Clavicular midshaft fractures treated with titanium plates may encounter complications like implant failure. We assess if alternative biocompatible materials suchs as PLA, PLA/HA, PEEK offer comparable stability. Our study evaluates the biomechanical performance of these materials in surgical management of midshaft clavicle fractures. We simulated a personalized fixation implant with four different materials and conducted finite element analysis in ANSYS to assess maximum von Mises stress (MvMs). The MvMs occurring on the plates, screws, clavicle, and fracture site were recorded. MvMs on titanium material at the 6th hole level (764.79MPa) and the 6th screw level (503.38MPa), with the highest stresses observed at 48.52MPa on the lateral clavicle at the 1st hole level and 182.27MPa on the medial clavicle at the 6th hole level. In PLA material analyses, the highest MvMs were observed at the 3rd hole level (340.6MPa) and the 3rd screw level (157.83MPa), with peak stresses at 379.63MPa on the lateral clavicle fracture line and 505.44MPa on the medial clavicle fracture line. In PLA/HA material analyses, the highest MvMs were at the 3rd hole (295.99MPa) and 3rd screw (128.27MPa), with peak stresses at 220.33MPa on the lateral clavicle and 229.63MPa on the medial clavicle fracture line. In PEEK material analyses, the highest MvMs were at the 3rd hole (234.74MPa) and 6th screw (114.48MPa), with peak stresses at 184.36MPa on the lateral clavicle and 180.1MPa on the medial clavicle. Our findings indicate that titanium material shows significantly higher stresses on plates and screws compared to those on the clavicle, suggesting a risk of implant failure. PLA and PLA/HA were inadequate for fixation. Although stress on the plate with PEEK material is higher than on the clavicle, it remains lower than titanium, indicating potential stability at fracture site. Further research is needed to confirm these findings.

Superior versus anterior plating of midshaft clavicle fractures: 6 months follow up (union rates, risks, and complications: hardware irritation and need for removal)

Background Operative management of midshaft clavicle fractures is gaining popularity. The clavicle is a tubular bone with a flat lateral end. Open reduction and internal fixation could be achieved by the application of plates and screws either to the superior or anterior surface of the clavicle. However, there is no consensus in the literature to support one technique over the other. This study aims to compare the early functional and radiographic outcomes of anterior versus superior plating for the treatment of midshaft clavicle fractures. Patients and methods From March 2021 to November 2022, a prospective randomized clinical trial was conducted at our institute. We included all patients with isolated midshaft clavicle fractures. Thirty-six patients were randomized by the closed envelope technique, 18 were managed with superior plating (superior group), and the other 18 patients were managed using anterior plating (anterior group). All patients were followed up for 6 months. All patients were assessed clinically for union, range of motion, and functional scores. The secondary outcome measures included operative time, complications, hardware irritation, and the need for hardware removal or secondary procedure. Results The mean time to full union was 11.28 weeks in the anterior group and 11.72 weeks in the superior group. Mean constant shoulder score for the anterior group was 84.11 while for the superior group it was 82.67. No patients had skin and wound complications in the anterior group versus one patient in the superior group that got superficial infection successfully managed by repeated dressing and antibiotics. There was no statistically significant difference between superior and anterior plating regarding union, functional scores, return to ADLs, hardware problems, or complications. Conclusion Both superior and anterior plating of the clavicle fractures are safe treatment options for displaced midshaft clavicle fractures, and they lead to similar functional outcomes, functional scores, and complication rates. Moreover, the selection of the technique of plating depends on surgeon preferences.

Management of midshaft clavicle fracture and ipsilateral acromioclavicular joint dislocation through combination of reconstruction locking plate and clavicular hook locking plate: an exposition of case series and literature review

Management of midshaft clavicle fracture and ipsilateral acromioclavicular joint dislocation through combination of reconstruction locking plate and clavicular hook locking plate: an exposition of case series and literature review

A prospective comparative study on management of midshaft clavicle fractures: Conservative versus surgical

Abstract Background: With nonunion rates up to 15% and unsatisfactory patient-reported outcomes in around a third of patients treated conservatively, recent research on displaced midshaft clavicular fractures points to a considerable unmet medical need. These findings have prompted a recent increase in surgical fixation of displaced midshaft clavicular fractures. Objective: In addition to open reduction and plate fixation, intramedullary pins, wires, or nails may also be used to treat clavicle fractures. In this study, we compare the clinical, radiological, and functional results of midshaft clavicular fractures managed with open reduction and plate fixation versus conservative therapy, as well as their overall complication rates. Materials and Methods: All skeletally mature patients presenting to outpatient department/inpatient department with clavicle fracture less than 3 weeks old and displacement/loss of cortical contact between fractured ends of more than 2 cm were included in the study. Patients were randomly allocated to either conservative or surgical management. For conservative management, strapping of the involved side and application of figure-of-eight bandage was done. The minimum follow-up requirement of all patients was 1 year. The clinical assessment involved the assessment of complications, grading of results according to Constant and Murley score as well as the Disabilities of the Arm, Shoulder, and Hand score (DASH score). A radiological assessment for the union of the fracture was also done. Results: In the conservative management group (n = 52), the mean age of the group was 36 years (range, 19–58 years), and the mean follow-up was 1.6 years (range, 1–2.2 years). At 1 year follow-up, the mean DASH score was 7.9 ± 2.1, and the mean Constant score was 90.2 ± 15. The overall complication rate was found to be 21/52 (40.3%) in the operative management group. In the operative management group (n = 50), the mean age of the group was 42 years (range, 24–57 years) and the mean follow-up was 1.3 years (range, 1.1–1.8 years). At 1-year follow-up, the mean DASH score was 10.8 ± 1.1, and the mean Constant score was 93.1 ± 13. The overall complication rate was found to be 14/50 (28%) in the operative management group. In comparison, the overall rate of complications was significantly lower in the operative management group compared with the conservative management group (P = 0.001). Conclusions: Conservative management of midshaft clavicular fractures was associated with similar clinical and radiological outcomes compared to operative management. However, the overall complication rate was lower for operatively managed patients.

A comparative study between plating versus titanium elastic nail system in the management of mid-shaft clavicle fractures

A comparative study between plating versus titanium elastic nail system in the management of mid-shaft clavicle fractures

Prospective Study of Surgical Management of Midshaft Clavicle Fractures

Introduction: Fractures of the clavicle constitute 2.6% of all fractures, account for 44% of the injuries around the shoulder girdle, approximately 70%–80% of which occur in the middle third. Even when significantly displaced, conventionally these fractures are treated without surgery. Conservative treatments either by sling/figure of eight bandage/clavicular brace are favored by patients, but the results are much inferior to what was reported previously. The present study conducted to operate fresh fracture with displacement >2 cm, nonunion by open reduction and internal fixation (ORIF) with locking plate with or without bone grafting. The objective is relief from pain, restoration of activities as far as possible and better cosmetic appearance. Materials and Methods: Twenty-eight cases of the clavicle in healthy active individuals between 18 and 65 years of age operated between December 2019 and September 2022 in Hazaribag Medical College, Hazaribag, Jharkhand. Patients with minimally displaced fracture were excluded from the study. Fracture is classified by Allman in three groups as middle 1/3rd, distal 1/3rd, and medial 1/3rd. Indications for surgery are either open fracture, vascular injuries, initial displacement >2 cm, nonunion, cosmetically conscious patients. Results: Fifteen cases of fresh, 6 cases of symptomatic delayed union, and 7 cases of nonunion operated with precontoured plate with or without bone grafting. The average hospital stay was 3–7 days. The average time of fracture union was 10 weeks (8–12 weeks). Patients were followed weekly up to 4 weeks and then after 2 and 6 months. The functional outcome according to Constant and Murley score is excellent in 17 (60.7%) patients, good in 10 (35.7%) patients and satisfactory in 1 (3.6%) case. There was no major complication, one patient had superficial infection, deep infection in 1 case, nonunion in 1 case and plate breakage in one patient. Results were compared with cases treated conservatively. Conclusion: In the present era of competition, cosmesis and advancement with least morbidity and excellent results is required. ORIF in selected cases is a very good option in comparison to accept morbidity, cosmetic disfigurement and below-average functional results.

Management of Displaced Midshaft Clavicle Fractures in Pediatrics and Adolescents: Operative vs Nonoperative Treatment.

The purpose of the current review is to describe the management of displaced midshaft clavicle fractures in pediatric and adolescent patients. Midshaft clavicle fractures are relatively common in pediatric and adolescent patients. They most commonly occur from direct trauma and are often related to sports participation in adolescents. Recent literature in the management of adult midshaft clavicle fractures has supported operative management due to improved functional outcomes, decreased time to union, leading to early return to activity. A similar trend of increasing frequency in operative management has been seen in pediatric and adolescent patients with no consensus in the literature on optimal management. Nonoperative treatment consists of with a brief period of sling immobilization followed by range of motion. Operative management may be considered for open fractures, fractures with significant neurovascular compromise and soft tissue complications. Studies have shown comparable mid- to long-term functional and patient-reported outcomes after operative and nonoperative management of midshaft clavicle fractures in pediatric patients.

Closed midshaft clavicle fractures : an evidence-based triage management algorithm.

The management of mid-shaft clavicle fractures (MSCFs) has evolved over the last three decades. Controversy exists over which specific fracture patterns to treat and when. This review aims to synthesize the literature in order to formulate an appropriate management algorithm for these injuries in both adolescents and adults. This is a systematic review of clinical studies comparing the outcomes of operative and nonoperative treatments for MSCFs in the past 15 years. The literature was searched using, PubMed, Google scholar, OVID Medline, and Embase. All databases were searched with identical search terms: mid-shaft clavicle fractures (± fixation) (± nonoperative). Using the search criteria identified, 247 studies were deemed eligible. Following initial screening, 220 studies were excluded on the basis that they were duplicates and/or irrelevant to the research question being posed. A total of 27 full-text articles remained and were included in the final review. The majority of the meta-analyses draw the same conclusions, which are that operatively treated fractures have lower nonunion and malunion rates but that, in those fractures which unite (either operative or nonoperative), the functional outcomes are the same at six months. With regard to the adolescent population, the existing body of evidence is insufficient to support the use of routine operative management. Regarding adult fractures, the key to identifying patients who benefit from operative management lies in the identification of risk factors for nonunion. We present an algorithm that can be used to guide both the patient and the surgeon in a joint decision-making process, in order to optimize patient satisfaction and outcomes.Cite this article: Bone Jt Open2022;3(11):850-858.

Rates of readmission and reoperation after operative management of midshaft clavicle fractures in adolescents.

The present letter to the editor is a commentary on the study titled “Rates of readmission and reoperation after operative management of midshaft clavicle fractures in adolescents”. There is a debate over whether surgical treatment of clavicle shaft fractures improves clinical outcomes in adolescents. The readmission and reoperation rates following surgery should be identified.

Poster 179: Fracture Morphology, Surgical Technique, and Obesity as Predictors of Major Postoperative Complications in Midshaft Clavicle Fractures

Objectives:Optimal management of midshaft clavicle fractures remains controversial. This study assessed demographic factors, injury patterns, and surgical technique as potential predictors of complications following open reduction internal fixation (ORIF) of midshaft clavicle fractures. We hypothesize that smoking, diabetes, obesity, and fracture pattern would be risks factors for surgical complications.Methods:Consecutive patients who presented to a single tertiary institution who underwent ORIF of midshaft clavicle fractures were identified retrospectively from 2007-2019. Patients who were lost to follow-up or had a follow-up period of 12 weeks or less, were excluded from analyses. Of the 354 eligible patients, 223 (63%) completed at least 12 weeks of follow-up.Demographics, injury data, surgery characteristics, and postoperative complications were recorded. Postoperative complications were obtained via chart review and separated into major (reoperation) and minor (no reoperation) complications based on reoperation status. Chi-squared statistics, Fisher’s Exact test, and multivariate logistic regression were utilized with significance level set to p<0.05.Results:223 patients (average 39.3 + 15.2 yo) were identified with average follow-up of 9.2 months Table 1. Overall complication incidence was 21.5% (95% [CI], 16.3% to 27.5%), minor complication incidence was 15.2% (95% [CI], 10.8% to 20.6%), major complication incidence was 6.3% (95% [CI], 3.5% to 10.3%), and incidence of non-union was 1.8% (95% [CI], 0.5% to 4.5%). Major complications requiring reoperation revealed 4 cases of non-union (28.6%), 4 instances of symptomatic hardware (28.6%), 3 incidents of deep infections (21.4%), 1 instance of acromioclavicular joint dislocation (7.1%), and 1 incident of broken hardware (7.1%).Smoking status, obesity, and fracture morphology were significant prognostic factors for overall complication risk while diabetes was not. Results from a multivariate analysis demonstrated a 2.4- and 3.2-times greater risk of overall post-operative complications among smokers and obese patients, respectively (p=0.013 and p=0.004, respectively). After adjusting for BMI and smoking status, the risk of post-operative complications among patients with a transverse fracture was 2.26 times greater compared to a patient with an oblique fracture (p = 0.035).Regarding major complications, obese patients were 3.5-times more likely to require reoperative intervention. Moreover, after adjusting for obesity status, transverse and z-type fractures had an 8.9- and 22.7-times greater risk for reoperation, relative to patients with oblique fractures respectively (p=0.04 and p=0.006, respectively. Finally, there were no reported major complications among patients with dual plating, and nonunion occurred exclusively among patients with transverse fractures. Conclusions:Fracture pattern, obesity, and smoking status were significant predictors of postoperative complications. However, only fracture morphology, BMI, and surgical technique were significant predictors of reoperative risk. Transverse and z-type fractures may require increased vigilance, especially among obese patients, with potential consideration for dual plating in these circumstances.Table 1.Baseline Characteristics

Functional and radiological outcomes of mid-shaft clavicle fracture managed by flexible intramedullary nailing

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Clavicle fracture is a common injury accounting for 2.6-5% of all injuries. The commonest site of fracture is the midshaft. Historically clavicle fractures were managed conservatively with figure-of-eight bandage resulting in higher non-union and symptomatic malunion rates. With the advent of operative fixation of these fractures the ideal surgical technique remains elusive. Flexible intramedullary nailing stands out as a minimally invasive and effective method with excellent outcomes for fixation of these fractures.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; A prospective study was carried out over 18 months. A total of 26 patients met the inclusion criteria and were operated with flexible intramedullary nailing. Regular follow up was done till 14 weeks. At each postoperative visit patients were evaluated for shoulder function using constant score and DASH score. Radiographs were taken at each visit to evaluate for fracture alignment and union.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; In this prospective study a total of 26 patients with closed midshaft clavicle fracture were managed using flexible intramedullary nail. Average time to radiological union was 7.5 weeks. Average disabilities of arm, shoulder and hand (DASH) score at 14 weeks was 13 and average constant score was 95 suggesting excellent functional outcome.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Flexible intramedullary nailing is a simple, minimally invasive surgical technique with excellent functional outcomes for management of midshaft clavicle fractures.&lt;/p&gt;

Operative management of midshaft clavicle fractures demonstrates better long-term outcomes: A systematic review and meta-analysis of randomised controlled trials

IntroductionMidshaft clavicular fractures are common amongst young adults. Conservative or surgical treatment for definitive fracture management has been widely debate, both with their pros and cons. Previous meta-analyses compared the clinical outcomes between conservative and surgical treatment options of midshaft clavicular fractures but failed to elucidate any difference in functional improvement. We postulate that functional improvement after fracture union plateaus and the clinical outcome after treatment varies at different time points. This meta-analysis will focus on the synthesis comparison of outcomes at early, short-term results (3 months), intermediate-term (6 to 12 months) and long-term (>24 months) clinical outcomes.MethodsA systematic search was done on databases (Pubmed, Embase, Medline, Cochrane) in June 2021. Search keywords were: midshaft clavicular fractures and clinical trials. Clinical trials fulfilling the inclusion criteria were selected for comparison and the clinical outcomes of midshaft clavicular fractures using surgical and non-surgical interventions in terms of improvement in the Disabilities of the Arm, Shoulder and Hand (DASH) score, Constant-Murley Score (CMS), time to union and risk ratio of treatment related complications were analysed in correlation with post-treatment timeframe.ResultsOf the 3094 patients of mean age 36.7 years in the 31 selected studies, surgical intervention was associated with improved DASH score (standard-mean difference SMD -0.22, 95% CI -0.36 to -0.07, p = 0.003; mean difference MD -1.72, 95% CI -2.93 to -0.51, p = 0.005), CMS (SMD 0.44, 95% CI 0.17–0.72, p = 0.001; MD 3.64, 95% CI 1.09 to 6.19, p = 0.005), time to union (non-adjusted SMD -2.83, 95% CI -4.59 to -1.07, p = 0.002; adjusted SMD -0.69, 95% CI -0.97 to -0.41, p<0.001) and risk ratio of bone-related complications including bone non-union, malunion and implant failure (0.21, 95% CI 0.1 to 0.42; p<0.001). Subgroup analysis based on time period after treatment showed that surgical intervention was far superior in terms of improved DASH score at the intermediate-term results (6–12 months later, SMD -0.16, 95% CI -0.30 to -0.02, p = 0.02; and long term results (>24 months SMD -4.24, 95% CI -7.03 to -1.45, p = 0.003) and CMS (>24 months, SMD 1.03, 95% CI 0.39 to 1.68, p = 0.002; MD 5.77, 95% CI 1.63 to 9.91, p = 0.006). Surgical outcome is independent of fixation with plates or intra-medullary nails.ConclusionSurgical intervention was associated with better clinical outcomes compared with non-surgical approach for midshaft clavicular fractures in terms of improvement in functional scores DASH, CMS, time to union and fracture related complications, although not to the minimal clinically significant difference. Benefits in the long-term functional improvements are more pronounced.

DO THE CHANGES OF SCAPULOTHORACIC ANGLE AFFECT WINGED SCAPULA DEVELOPMENT AND FUNCTIONAL SCORES DURING CLAVICLE FRACTURE TREATMENT?

ABSTRACTIntroduction:To compare surgical and conservative management of midshaft clavicle fractures according with scapulothoracic joint angle change, considering clinical, functional, and radiological outcomes.Methods:A total of 95 midshaft clavicle fracture patients aged between 18-70 years with a minimum follow-up duration of 12 months were included in this study. Patients were treated either conservatively (Group I) or surgically (Group 2). Plane deformities, scapulothoracic joint angle, shortness and isokinetic muscle strength were measured. Shoulder Pain, Disability Index (SPADI) and Short Form-36 (SF36) were assessed.Results:Scapulothoracic joint angles were higher in the conservative treatment group than in surgery group (p=0.036). Consequently, winged scapula was seen more commonly in the conservative treatment group than in the surgery group (p=0.001). Surgical treatment was associated with significantly better SF-36 physical scores and with SPADI pain and disability scores. However, the two groups did not differ in terms of isokinetic muscle strength. Negative anteroposterior plane deformity (p<0.001) and negative axial plane deformity (p=0.004) were more frequent in the conservative treatment group. Clavicle shortness was more common in the conservative treatment group.Conclusion:According to our findings scapulothoracic joint angle changes were seen in the conservative treatment group more than in the surgery group. Consequently, winged scapula was seen more commonly in the conservative treatment group than in the surgery group (p=0.001). Level of Evidence III; Retrospective comparative study .

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

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. 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 1year. Time taken for union, functional outcome, complications, and patient satisfaction were compared. 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. Displaced and comminuted mid-shaft clavicle fractures treated conservatively have more advantages when compared to surgically treated fractures.

Rates of readmission and reoperation after operative management of midshaft clavicle fractures in adolescents.

BACKGROUNDThe national rates of readmission and reoperation after open reduction internal fixation (ORIF) of midshaft clavicle fractures in adolescents is unknown.AIMTo determine rates of and risk factors for readmission and reoperation after ORIF of midshaft clavicle fractures in adolescents.METHODSThis retrospective study utilized data from the Healthcare Cost and Utilization Project State Inpatient Database for California and Florida and included 11728 patients 10–18 years of age that underwent ORIF of midshaft clavicle fracture between 2005 and 2012. Readmissions within ninety days, reoperations within two years, and differences in patient demographic factors were determined through descriptive, univariate, and multivariate analyses.RESULTSIn total, 3.29% (n = 11) of patients were readmitted within 90 d to a hospital at an average of 18.91 ± 18 d after discharge, while 15.87% (n = 53) of patients underwent a reoperation within two years at an average of 209.53 ± 151 d since the index surgery. The most common reason for readmission was a postoperative infection (n < 10). Reasons for reoperation included implant removal (n = 49) at an average time of 202.39 ± 138 d after surgery, and revision ORIF (n < 10) with an average time of 297 ± 289 d after index surgery. The odds of reoperation were higher for females (P < 0.01) and outpatients (P < 0.01), while the odds of reoperation were lower for patients who underwent surgery in California (P = 0.02).CONCLUSIONThere is a low rate of readmission and a high rate of reoperation after ORIF for midshaft clavicle fractures in adolescents. There are significant differences for reoperation based on patient sex, location, and hospital type.

Rates of Operative Management of Midshaft Clavicle Fracture in Adolescents Have Increased in Florida between 2005 and 2014.

Background: It is not known if the adult literature on midshaft clavicle fracture treatment with open reduction internal fixation (ORIF) has influenced injury management in adolescents. Purpose: We sought to longitudinally evaluate the rates of operative management of adolescent midshaft clavicle fractures in the state of Florida. Methods: We conducted a retrospective review of data from the following Healthcare Cost and Utilization Project databases: the State Inpatient Database, the State Ambulatory Surgery and Services Database, and the State Emergency Department Database. Patients in Florida ages 10 to 18 years with midshaft clavicle fractures between 2005 and 2014 were identified along with data on age, sex, race/ethnicity, insurance type, treatment, and income percentile. We reviewed the data to identify trends in the rates of operative management of midshaft clavicle fractures. We then compared the rates of operative management between the first 3 years and the most recent 3 years (2005-2007 vs 2012-2014). Various demographic and socioeconomic factors were compared between patients treated with and without surgery. Descriptive statistics as well as univariate and multivariate analyses were performed. Results: There were 4297 midshaft clavicle fractures in adolescents identified between 2005 and 2014, and 338 (7.8%) of these fractures underwent operative management. There was a significant increase in the rate of operative management; it increased from 4.3% (n = 59) of the 1373 clavicle fractures that occurred between 2005 and 2007 to 11.2% (n = 130) of the 1164 clavicle fractures that occurred between 2012 and 2014. Patients with commercial insurance and patients who were older were more likely to undergo ORIF. Patients with Medicaid were more likely to undergo ORIF between 2012 and 2014 compared with patients with Medicaid between 2005 and 2007. Conclusions: Operative management rates of adolescent midshaft clavicle fractures have significantly increased in Florida over a decade; additional research is needed to understand these findings.

Operative Versus Nonoperative Treatment of Z-Type Comminuted Clavicle Fractures in Adolescents: A Substratified Cohort Analysis

Purpose: There has been a recent shift towards operative management of mid-shaft clavicle fractures in adults and adolescents. This has been largely based on studies in the adult population that showed reduced rates of nonunion, symptomatic malunion and better short-term functional outcomes. For injuries with a comminuted “Z-type” fracture pattern, characterized by vertical positioning of a segmental fragment, it is commonly accepted to treat surgically due to concerns about healing and bony prominence. The purpose of this study was to assess the clinical, radiographic, and patient-reported outcome measures (PROs) in adolescents with comminuted Z-type mid-shaft clavicle fractures by comparing an operative and nonoperative cohort.&#x0D; Methods: Patients aged 10 to 18 years treated for a diaphyseal clavicle fracture between August 2013 and February 2016 at one of eight geographically diverse pediatric centers were screened and enrolled at the time of injury. Inclusion criteria were a comminuted Z-type fragment ≥1cm in size, with &gt;35 degrees of angulation relative to the long axis of the clavicle, and &gt;100% fracture displacement at time of presentation. Clinical course, complications, validated PROs, quality of life metrics, and satisfaction scores were analyzed and compared between the operative (Op) and nonoperative (NonOp) cohorts.&#x0D; Results: Eighty-two patients (37 NonOp, 45 Op) were included, 60 (73%) of whom provided 2-year PROs with similar response rates between treatment cohorts. There were no significant differences in demographics or fracture characteristics in the two cohorts other than fracture shortening being greater in the operative cohort (mean 29mm) compared to the nonoperative cohort (mean 23mm, p=0.01). This confounder was controlled for in both regression analysis and propensity score matching. There was no statistically significant difference in the rates of nonunion (none), delayed union (Op 2%, NonOp 0%, p=1.0), symptomatic malunion (Op 0%, NonOp 3%, p=0.4), refracture (Op 4%, NonOp 3%, p=1.0), unexpected surgery (Op 11% vs. NonOp 5%, p=0.45), or clinically significant complications (Op 16%, NonOp 5%, p=0.17) between cohorts. There were no differences in PROs (Table 1), even when controlling for fracture shortening.&#x0D; Conclusions: Z-type mid-shaft clavicle fractures are one of the most severe fracture patterns seen in adolescent shoulders. Yet, in this comparative investigation of 2-year PROs and complications, surgery appears to offer no benefit over nonoperative management. &#x0D; Significance: The comparable natural histories between this study’s operative and nonoperative cohorts are critical for surgeons and their adolescent patients to understand when deciding appropriate management, particularly when reviewing what are often very concerning appearing initial radiographs.

Surgical management of midshaft clavicle fracture by titanium elastic nailing system

Introduction: Midclavicular fractures accounts for about 76% of all clavicular fractures and are common clinically. Recent studies have revealed a previously unrecognized incidence of non-union and malunion after conservative treatment of more severe midclavicular fractures. Our aim was to evaluate the clinical outcomes of midclavicular fractures treated with titanium elastic nails. Methods: A hospital based prospective study conducted between April 2018 to April 2020 at VIMS bellary. 30 patients with displaced midshaft clavicle fracture between 18 to 50 years were assessed clinically and confirmed radiologically were operated with intramedullary nailing with titanium elastic nail (TEN). Mean operative time, postoperative complications, duration of union was recorded. The outcomes were evaluated with radiographic assessment and the disabilities of the arm, shoulder, and hand (DASH) score. Results: Closed operation with TENS was undertaken in 28 cases, and mini open technique was performed in 2 cases. Satisfactory reduction was achieved in all patients, who were followed up for a mean of 10 months. The mean union time was 11.2 weeks. TENS led to a significantly shorter time to union, especially for simple fractures. In TENS group, all patients got fracture union, of which 4 cases had medial skin irritation due to implant prominence. No severe complication occurred in any patient. TENS removal done at 10 months after surgery, no re-fracture and non union was found in any our patient. Average DASH score was 3.0023. Conclusion: Intramedullary fixation with TENS might be a effective and safe treatment for displaced midshaft clavicular fractures with few complications, satisfactory clinical therapeutic effects, good functional recovery and cosmetic appearance. Keyowords: Displaced midshaft clavicular fractures; Minimally invasive treatment; Titanium elastic nail; DASH score.

Rates of Operative Management of Midshaft Clavicle Fracture in Adolescents

Purpose: Treatment of midshaft clavicle fractures in adolescents remains controversial. The adult literature suggests more favorable outcomes with open reduction internal fixation (ORIF), and it is unknown how this has influenced the management in the adolescent population over the past decade. The purpose of this study was to longitudinally evaluate the rates of operative management of midshaft clavicle fractures in adolescent patients. Methods: The Healthcare Cost and Utilization Project State Inpatient Database, State Ambulatory Surgery and Services Database, and State Emergency Department Database were evaluated for the years 2005–2015. Patients 10–18 years-old with a midshaft clavicle fracture, who underwent operative or nonoperative management, were identified using diagnosis and procedure codes. Data regarding age, sex, race, insurance type, and income percentile were also collected. The overall number of fractures managed operatively and nonoperatively were compared. Throughout the study period, factors associated with operative and non-operative management were analyzed. Descriptive statistics as well as univariate and multivariate analyses were performed. Results: There were 4,815 adolescent midshaft clavicle fractures identified between 2005 and 2015, and 375 (7.8%) of these fractures underwent operative management. There was a significant increase in the rate of operative management from 4.26% (n = 62) between 2005 and 2008 to 12.13% (n=141) between 2012 and 2015 (p<0.001). This increase was seen across all racial groups (p<0.05). Patients undergoing operative management were significantly older [16.0±1.7 vs. 14.1±2.3 years-old, p<0.001], were more likely to have Medicaid insurance (p<0.001), and were more likely to be in the bottom 75th percentile for income. Conclusion: The rate of adolescent midshaft clavicle fractures treated operatively has significantly increased over the past decade, and there are several demographic and socioeconomic differences between patients treated with and without surgery. Additional outcomes research is needed to justify this trend in adolescent patients with midshaft clavicle fractures in the bottom 75th percentile income brackets. Additional studies are needed to understand and validate the increased rates in operative management of midshaft clavicle fractures in adolescents.

Intermediate-Term Outcomes Following Operative and Nonoperative Management of Midshaft Clavicle Fractures in Children and Adolescents: Internal Fixation May Improve Outcomes.

Background:Although multiple prospective comparative studies exist for adults with midshaft clavicle fractures, few comparative studies exist in older children and adolescents. This study compares intermediate-term functional, pain, radiographic, and complication outcomes in children and adolescents with midshaft clavicle fractures treated operatively or nonoperatively.Methods:Children and adolescents who were 10 to 18 years of age with midshaft clavicle fractures treated from 2006 to 2017 were identified through electronic picture archiving and communication system (PACS) radiographic and chart review. Closed injuries with a minimum of 1 year from the time of the injury were included. Patients completed patient-reported outcome measures and a focused questionnaire. The primary outcome was the abbreviated Disabilities of the Arm, Shoulder and Hand Questionnaire (QuickDASH) score; the secondary outcomes included the University of California Los Angeles (UCLA) Activity Scale, Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference (PI) and PROMIS Physical Function (PF) Upper Extremity (UE), Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS), Numeric Rating Scale (NRS) for Pain, and rates of implant removal, nonunion, and refracture. Univariate comparisons between the operatively treated group and the nonoperatively treated group were performed.Results:In this study, 302 patients were identified; of these, 79 patients (43 operatively treated and 36 nonoperatively treated) or their parent or legal guardian consented and the patients completed the study protocol. The mean age (and standard deviation) at the time of the injury was 16.0 ± 1.7 years for the operatively treated group and 13.5 ± 1.8 years for the nonoperatively treated group (p < 0.001). The median follow-up was 3.8 years. The patient-reported outcome scores were similar (p > 0.05 for all comparisons) between the operatively treated group and the nonoperatively treated group, even for patients at or near skeletal maturity and those with shortening of ≥15 mm or ≥100% translation. There were no nonunions. The refracture rate was 5% (2 of 43) for the operatively treated group and 3% (1 of 36) for the nonoperatively treated group (p = 1.00). There were 19% (8 of 43) who underwent implant removal. Responders were similar to nonresponders, other than female patients (p < 0.001) and surgically treated patients (p = 0.049) being more likely to respond.Conclusions:In the subset of this cohort who responded and completed the study, both operatively and nonoperatively treated patients had excellent functional and pain outcomes, similar refracture rates, and no nonunions. Even in widely displaced and translated fractures, and in those at or near skeletal maturity, outcomes were similar. Operative management should potentially be reserved for special circumstances. A prospective comparative study of older adolescents (female patients who are 14 to 18 years of age and male patients who are 16 to 20 years of age) with displaced midshaft clavicle fractures is warranted.Level of Evidence:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.