Middle-third Clavicle Fractures Research Articles

ACOMPARATIVE STUDY OF THE FUNCTIONAL ANDRADIOLOGICAL OUTCOME OF DISPLACED MID SHAFT CLAVICLE FRACTURE MANAGED WITH INTRAMEDULLARY NAILING AND PLATING

Introduction: Clavicle fractures are common injuries in young, energetic people, especially those whoplaysportsinvolvingfrequentviolentcollisionsorhigh-speedfalls(e.g.,football,hockey),butinchildrenandtheelderlytheyareassociatedwithfallsandmakeupabout2.6%ofallfractures(1-3). The most common site of fracture in the clavicle occurs at the middle third and whichaccounts for almost 80% of all clavicle fractures. Withcarefulmanagement,Neerreportedanon-unionrateof0.1%(4),andRoweconfirmedthesefindingsin1968bydemonstratinganon-unionrateof0.8%inpatients.(6)Sincethen,though, other authors have been unable to show that conservative treatment can provideresults as favourable. (7-8). This could be as a result of the early series including childrenand teenagers, whose extraordinary capacity for bone healing may have thrown off theresults,aswellasthefactthatpatient-basedgradingmethodswerenotemployedtorecordtheoutcome in the initial series. Treating conservatively, Hill et al reported a non-union rate of 15% in correlation withinitial shortening greater than 2 cm. 31% of patients who were reviewed in the study ofHillet al werenot satisfied with treatment results.(10) Therefore, even if they mend without complications, displaced midshaft clavicle fracturescan result in significant, long-term morbidity. Thus, there is a trend towards surgicalfixation of clavicle fractures based on the unsatisfactory data obtained from conservativetreatment. For fixation of displaced clavicle fractures good results with high union rates and lowcomplicationrateshavebeenreportedfrommanytechniques. Similartootherlongbones,the clavicle is most effectivelytreated usingintra medullarytechniques. In order to reduce the number of delayed unions., non-union, symptomatic malunion andother complications, elastic stable intra medullary nailing (ESIN) is recommended for allsimpledisplaced midshaft claviclefractures Result: Patients who had their displaced middle-third clavicle fractures surgically fixed had alowerrateofnon-union andsymptomaticmalunion.Giventhatfunctionalratingswereidenticalinbothgroups, it isunclearwhetherthisimpact hasanyclinicalimportance. Overall,bothPFandIMFdemonstrated goodrecoveryrates.RecoverywasfasterinthePF group, with a 55% recovery rate at 6 weeks post procedure according to the DASHscore. Forearlyfunctionalrehabilitation fixationconstructismorerigidandbothobjectiveandsubjectiverecoveryis faster Conclusion: Wecan thereforedraw theconclusion fromourstudythat,when usedfor surgicalfixationof displaced mid-shaft clavicle fractures, pre-contoured plates offered better functionaloutcome and were associated with problems in fewer cases than titanium elastic nails. Upto 6 months, plating had better follow-up results than nailing, but after that, there were noappreciable differences in the prognosis of either operation. Accordingly, we advise usingpre-contoured locking plates for internal fixation of displaced mid shaft clavicle fractures.Low prevalence complications were not found due to the short sample size. For knowingthe prevalence of the more uncommon complications including wound dehiscence,symptomatic malunion, and refracture, a larger sample size will be necessary.Long termfollowsup arerequiredfor furtherresearch.

Assessing the Change in Operative Treatment Rates for Acute Midshaft Clavicle Fractures: Incorporation of Evidence-Based Surgery Results in Orthopaedic Practice.

This retrospective cohort analysis used population-level administrative health data on the residents of British Columbia, Canada. Cases were identified by International Classification of Diseases, Ninth Revision (ICD-9) diagnostic codes and procedure fee codes. Adult patients (≥18 years) with closed middle-third clavicle fractures between 1997 and 2018 were included. Multivariable logistic regression modeling compared the proportion of clavicle fractures treated operatively before and after January 1, 2007, controlling for patient factors. The Pearson chi-square test compared the proportion of fractures treated operatively for malunion or nonunion in the cohorts. A total of 52,916 patients were included (mean age, 47.5 years; 65.6% male). More clavicle fractures were treated operatively from 2007 onward: 6.9% compared with 2.2% prior to 2007 (odds ratio [OR] = 3.35, 95% confidence interval [CI] = 3.03 to 3.70, p < 0.001). Male sex, moderate-to-high income, and younger age were associated with a greater proportion of operative fixation. The rate of surgery for clavicle malunion or nonunion also increased over this time period (to 4.1% from 3.4%, OR = 1.26, 95% CI = 1.15 to 1.38, p < 0.001). We found a significant change in surgeon practice regarding operative management of clavicle fractures following the publication of a Level-I RCT. With limited high-quality trials comparing operative and nonoperative management, it is important that clinicians, health-care institutions, and health-authority administrations determine what steps can be taken to increase responsiveness to new clinical studies and evidence-based guidelines. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Conservative treatment for brachial plexus injury after a displaced clavicle fracture: a case report and literature review

BackgroundA brachial plexus injury is a rare complication of clavicle fractures. Previous case reports only examined the surgical outcomes of brachial plexus injuries that occurred after a clavicle fracture and did not report on the outcomes of conservative treatment. In this report, we present the prognosis of a patient with an acute displaced clavicle fracture accompanied by a brachial plexus injury that was conservatively treated.Case presentationA 51-year-old man with a middle-third clavicle fracture due to a direct trauma after falling down the stairs. A brachial plexus injury experienced symptoms, including numbness occurred in the affected upper extremity, at 1 day after the injury. The patient’s motor power in the elbow, wrist, and hand decreased at 3 days after the injury. Magnetic resonance imaging (MRI) showed no loss of continuity in the brachial plexus, but showed nerve compression by displaced fracture fragments. Electromyography revealed brachial plexopathy. Conservative treatment, including a shoulder sling, was performed with satisfactory outcomes; the patient reported a 70% improvement at 6 months after the injury.ConclusionsA brachial plexus injury is a rare complication of clavicle fractures that can cause serious dysfunction of the upper extremities affected by the injury. Conservative treatment may be considered for acute nerve compression by displaced fracture fragments rather than extensive callus or granulation tissue formation to achieve a satisfactory recovery in young patients. MRI should typically be performed before making a treatment decision to examine the brachial plexus for any discontinuity or kinking.

Broad Arm Sling vs Figure of 8 Bandage: The Better Choice in Conservative Management of Middle Third Clavicle Fractures in Indian Population.

BackgroundA prospective randomised trial was conducted to compare the results of conservative management of middle-third clavicular fracture using the figure of 8 bandage and broad-arm sling.Methods296 patients with middle-third clavicle fracture were included in the study conducted between March 2017 and January 2020. 152 patients were managed with figure of 8 bandage and 144 patients were managed with a broad arm sling. Results were evaluated based on clinical, radiological and functional outcomes. Visual analogue scale (VAS) for pain was used to evaluate the clinical outcomes, whereas radiological outcomes were assessed with non-union, malunion, clavicle shortening and time to union. Disability of Arm, Shoulder and Hand score (DASH), Constant score and Nottingham Clavicle Score were used to assess functional outcomes.ResultsThe broad arm sling group showed a significantly better VAS score in the first 4 weeks. DASH score was significantly superior in the broad arm sling group in the initial 4 weeks, but with similar outcome thereafter. Constant scores showed a good outcome for both groups at the final follow-up, whereas the Nottingham Clavicle Score was significantly superior in the broad arm sling group at the 2 year follow-up. A satisfactory outcome was achieved with respect to the radiological parameters, without any significant difference between the 2 groups. Incidence of malunion was significantly higher in figure of 8 bandage group.ConclusionsBroad-arm sling proves to be a better modality of management for middle-third clavicular fractures in terms of ease of application, pain relief, incidence of malunion, and functional outcomes.

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.

Surgical treatment of middle third fracture clavicle in adults by pre-contoured locked plate

Background: The clavicle is one of the bones that are most commonly fractured in the body. In adults, clavicle fractures represent 5–10 % of all fractures and 35 % of shoulder girdle fractures. Although most clavicular fractures may be treated nonoperatively, there is still a debate about the best therapy option for displaced mid-shaft clavicle fracture. Aim of the Study: To investigate the results of surgical fixation of displaced middle-third fracture clavicle by the anatomical pre-contoured locked plate in young adults. Materials and methods: This research involved 20 adult patients with a recent middle-third clavicle fracture. Results were assessed after 1 year according to the Disabilities of the Arm, Shoulder, Hand score (DASH). Results: The average age of the patients was 37 years old (25 - 52 years), all of them were males, All the fractures achieved union at 9 weeks (8-14 weeks ) postoperatively with no cases of implant failure, The average DASH score became15.3, 18 patients had no disabilities (90%), 1 patient had a mild disability (5%), 1 patient had a moderate disability (5%). 18 patients (90%) returned to their work within 3 months postoperatively, with no cases of deep infection with 1 case of superficial infection. Conclusion: Surgical treatment of displaced middle-third clavicle fracture in young adults by pre-contoured locked plates is an optimum procedure resulting in excellent functional outcomes, with a quicker return to the normal activities.

Placa superior vs. placa antero-inferior en fracturas del tercio medio de la clavícula. Estudio de Cohorte longitudinal

BackgroundClavicle fractures are frequent injuries of the shoulder, with an overall incidence of 2.6% of all fractures among the adult population and 35% of all shoulder injuries. This study aims to determine whether dorsal plating or anterior/inferior plating is a better surgical technique for treating middle-third clavicle fractures. MethodsA cohort study using inclusion criteria and involving a nine-month follow-up period was carried out. Different surgical technique outcomes were measured; Dash and Constant Score questionnaires, respectively, were used to assess the degree of satisfaction and functional outcome of patients. This study has the approval of the hospital's Ethics Committee. Results96 patients were selected; 44 underwent anterior-inferior plating and 52 superior plating. The following measured variables are revealed as protective factors for anterior-inferior plating: operative blood loss volume (RR 0.60), operative time (RR 0.52), union rate (RR 0.55), irritation due to material (RR 0.12), and request for material extraction (RR 0.25). Differences regarding functional outcomes and patient satisfaction degrees were also statistically significant. DiscussionAccording to literature, anterior-inferior proved to be safer than dorsal plating method and thus advisable, due to it reduces union time, retarded union rates, operative blood loss volume, and operative time; which results in better functional outcomes and greater patient satisfaction.Evidence level: III

Functional outcome of conservative versus surgical management in mid shaft clavicle fractures at tertiary care centre

Aim of the study: To evaluate the functional outcome of locking compression plate fixation and figure of eight clavicle brace in the treatment of displaced middle 1/3rd clavicle fracture.Materials and Methods: In our Prospective Study, we included 36 patients, both male and female patients with displaced middle-third clavicle fracture (Robinson type 2B1). Patients were randomly divided into two groups, based on treatment modalities as a conservative group and surgical management group, with 18 patients in each group. All patients will be followed up every week for 2 weeks after treatment, and then every 6 weeks, 3 months, 6 months and 1 year. Functional outcome were assessed with the help of Constant and Murley scoring system. Result: In our study, we found that the functional outcome of surgical patients was significantly improved. At the end of 12 months, in surgical group excellent and good outcome was achieved in 12 patients (75%) whereas in conservative group excellent and good outcome was obtained only in 3 patients (18%). The complications seen in the surgical group were 2 cases each of infection implant failure and four cases of nonunion in the conservative group. Conclusion: In this study, we observed that patients who were treated by surgical treatment with locking compression plating had a better functional outcome in terms of early range of movements and less shoulder stiffness and therefore early return to work when compared to the conservative group.

Operative Versus Nonoperative Outcomes of Middle-Third Clavicle Fractures: A Systematic Review and Meta-Analysis.

Middle third clavicle fractures have long been managed conservatively with immobilization. Some patients, especially those with completely displaced or shortened clavicle fractures are now thought to have increased risk of nonunion or symptomatic malunion. The authors performed a meta-analysis to study the incidence of nonunion and symptomatic malunion and test the hypothesis that surgical fixation of these fractures significantly lowers the risk of these complications. A search was performed in the PubMed, Embase, and Cochrane Library databases for randomized clinical trials and quasi-experimental trials that compare outcomes of operative and nonoperative management for clavicle fractures that are fully (100%) displaced or have greater than 2 cm of shortening. Pooled patient data were used to construct forest plots for the meta-analysis. Eleven studies including 497 patients who were treated and 457 patients treated conservatively were analyzed. Patients managed operatively had significantly lower relative risk of developing nonunion [0.17 (95% confidence interval 0.08-0.33)] and symptomatic malunion [0.13 (95% confidence interval 0.05-0.37)]. Plate fixation significantly reduced the risk of nonunion, but intramedullary nail fixation did not. There was no difference in Constant-Murley or DASH scores between the 2 treatment groups or in the rate of secondary operative procedures. Patients who undergo operative fixation of displaced middle-third clavicle fractures have a lower incidence of nonunion and symptomatic malunion. The clinical significance of this effect is uncertain, as functional scores were similar in both groups. Further research into the risk factors for nonunion and symptomatic malunion will be necessary to determine which patients benefit from operative fixation. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Acute Surgery vs. Non-union Surgery of Displaced Midshaft Clavicle Fractures: A Case-control Study.

IntroductionThere is a lack of information about the results of surgical treatment and complications in midshaft clavicle fracture non-unions. Our hypothesis was that there is no difference in functional outcomes between the surgical treatment of an acute displaced middle-third clavicle fracture and the surgical treatment of a chronic symptomatic non-union of a displaced middle-third clavicle fracture.MethodsThis was a case-control study. Fourteen cases were considered with a displaced midshaft clavicle fracture, initially treated non-surgically, but which developed symptomatic non-union and required surgical treatment. The control group was a cohort of 18 patients with a displaced midshaft clavicle fracture, who had surgical treatment in an acute setting (<3 weeks). Our cases had a median follow-up of 77 months and were retrospectively analyzed. All those in the control group had a 12-month prospective follow-up evaluation. The variables measured were Constant score, time to discharge to work, and bone union rate.ResultsThe median Constant score at final follow-up for surgically treated non-unions was 87.5 (control group 84.5, p > 0.05). The median time to complete return to work was 3.2 months in the control group and 9.7 months in the case group (p=0.001). Hundred percent of those patients who were initially treated with surgery had bone union without other treatment. Two out of 14 cases required a second surgery with a plate and bone graft to achieve bone union.ConclusionSymptoms from displaced midshaft clavicular fracture non-unions are due to related pain and dysfunctional deficits that result from displacement and shortening. According to our study, patients with a displaced midshaft clavicle fracture non-union who needed surgery achieved similar functional results as compared to patients treated in an acute setting for a displaced midshaft clavicle fracture. The median time to discharge and return to work was more than doubled in the non-union surgery group.

Minimally invasive plate osteosynthesis (MIPO) in AO/OTA type B displaced clavicle fractures.

Open reduction and plate fixation is known to reduce chances of malunion and symptomatic nonunion in displaced middle-third clavicle fractures. However, this treatment modality is also associated with several complications, such as hardware irritation, numbness around the surgical scar, infection, nonunion and implant failure. The minimally invasive plate osteosynthesis (MIPO) technique may reduce these complications. To study clinical, radiological and functional outcomes of MIPO in AO/OTA type B displaced clavicle fractures and report any complications. A total of 22 patients underwent internal fixation of acute displaced AO/OTA type B clavicle fractures from Jan 2014 to Dec 2015 by MIPO using locking compression plates. Patients were followed up at a regular interval and assessed clinically and radiologically. The clavicle length difference was measured. Functional assessment was done at the end of 2year using constant shoulder score (CSS) and disability of the arm, shoulder and hand score (Quick DASH) and complications if any were noted. All fractures united at a mean of 12.5weeks. One (4.5%) patient had numbness around the surgical scar. None of the patients had wound-related complications. In four patients, hardware irritation was noted. The difference in clavicle length was not significant. All patients had excellent CSS and Quick DASH score at the final follow-up. Internal fixation of displaced AO/OTA type B clavicle fractures by MIPO showed high fracture union rates and good functional outcomes.

Выбор технологии остеосинтеза нестабильных переломов ключицы

Background Review of the effectiveness of different methods used to repair clavicle injury allows for identifying rational aspects of treatment factors that would directly reflect key pathogenetic mechanisms. A greater part of surgical treatment options have been reported to lead to faster recovery of the patients’ structural and functional stereotypes in majority of the cases. Purpose Improve outcomes of surgical treatment of middle-third clavicle fractures. Material and methods Experimental bench tests of various osteosynthesis technologies using original interlocking intramedullary nail for clavicle fracture and a clinical study of 104 patients with middle-third clavicle fractures were carried out. Original IM nail was applied to repair clavicle fracture in index group (n = 48) and the fractures were plated in control group (n = 56). The DASH questionnaire was used to evaluate results of surgical intervention at 3, 6 and 12 months. Results Original IM nail and plate with angular stability showed comparable characteristics in stability. Original compression interlocking intramedullary nail offered to treat middle-third clavicle fractures showed improvements in outcomes of the patients. Discussion The algorithm developed for diagnosis, treatment and rehabilitation of clavicle fractures showed better results of treatment providing easier social reintegration into everyday life. Clinical findings demonstrated significantly improved DASH scores and lower complications rate in index group (p = 0.038).

Comparison of plate osteosynthesis versus non-operative management for mid-shaft clavicle fractures—A prospective study

IntroductionTreatment for mid-shaft clavicle fractures has recently seen a paradigm shift towards surgical management. The aim of the study was to compare clinical and functional outcome between plate osteosynthesis and conservative line of management in middle-third clavicle fractures. Material and methodsA prospective randomized study was conducted on 69 patients with closed displaced clavicle fractures between May 2014 and May 2016. Patients with medial or lateral third clavicle fractures, polytrauma and compound fractures were excluded from the study. Patients treated with plating were in group A (n = 36) while those treated with arm pouch were in group B (n = 33). ResultsThe mean age of the patient in group A was 32.4 ± 43 and group B was 31.7 ± 26 years. 48 (69.9%) females were involved in the study. History of fall was the most common mechanism of injury affecting 51 (73.9%) patients. All the patients were type 2 B as per the Robinson classification system. The average operative duration was 78.3 ± 12.4 min. Union was seen at 15.6 ± 0.8 in group A and 22.8 ± 0.4 in group B (p < 0.0001). Two (6%) of the patients in group B had non-union. One (2.7%) patient in group A had mal-union. Two (5.5%) patients had plate prominence. One (2.7%) patient had superficial infection. The Constant and Murley scoring at 24 months was 89.42 and 76.24 in group A and group B respectively. ConclusionPlating for displaced mid-shaft clavicle fractures is can lead to better functional and radiological outcomes with minimal complications as compared to the conservative modality of treatment.

Open Reduction and Internal Fixation of a Middle-Third Clavicle Fracture with a Superior Plate.

Open reduction and internal fixation has become a reliable technique to treat complex middle-third clavicle fractures (AO/OTA B-15). Nonoperative treatment of these fractures may result in higher rates of symptomatic malunion, nonunion, dissatisfaction with cosmetic appearance, and even dysfunction and muscular weakness. Risk factors such as substantial displacement or comminution, far lateral fractures, fractures in the elderly, open fractures, or those occurring in polytrauma scenarios are appropriate indications for surgery. The aim of the procedure is to reconstitute the initial curvature and length of the clavicle, restore a normal connection from the arm to the axial skeleton, and provide stable fixation of the proximal and distal fragments, to allow an immediate full range of motion during rehabilitation. The procedure includes the following steps. Step 1: Place the patient in a beach-chair, semi-sitting position.Step 2: Make a transverse skin incision along the anteroinferior aspect of the clavicle.Step 3: Expose the fracture site, identify and prepare the fragments unless they are comminuted, and preserve soft-tissue attachments to the extent possible.Step 4: Reduce the fragments by direct or indirect manipulation, and maintain the reduction with clamps, Kirschner wires, or mini-fragment plates. Consider bridging comminuted zones to allow secondary fracture-healing.Step 5: Apply a contoured plate to the superior or anterior surface of the clavicle, and obtain at least 6 cortices of fixation on each side with strategic nonlocking and locking screws. The working length of the plate is more important than the number of screws or cortices.Step 6: Obtain a single intraoperative anteroposterior radiograph of the clavicle.Step 7: Separately close the wound in layers (deltotrapezial fascia, platysma, and skin). Apply sterile dressings and a sling. The patient is discharged home on the same day if the injury is isolated, and a full range of motion of the affected shoulder is allowed immediately. The patient is expected to regain full function and strength of the arm once healing occurs.

A retrospective study on surgical management of clavicle midshaft fractures by locking plate in tertiary care center

Aim: The aim of this study was to analyze the outcome by surgical management of clavicle midshaft fractures by locking plate. Materials and Methods: This is a retrospective study of thirty patients who were operated for midshaft clavicular fractures and treated surgically with locking compression plate and screws between January 2012 and June 2016 in Chirayu Medical College and Hospital Bhopal. The case files of these patients were retrieved from the Medical Record Department and data were analyzed. Results: Thirty cases of clavicle midshaft fractures were treated with precontoured locking plate. Average hospital stay was 7 days. The average time for 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 18 patients (60.0%) and good in 12 patients (40%). There was no major complication, two (6.66%) patients had superficial skin infection, and one (3.33%) had nonunion. Conclusion: This study shows stable fixation with locking compression plate and screws for displaced middle-third clavicle fracture gives immediate relief of pain, prevents the development of shoulder stiffness, and helps in early rehabilitation.

Biomechanical analysis of intramedullary vs. superior plate fixation of transverse midshaft clavicle fractures

Middle-third clavicle fractures represent 2% to 4% of all skeletal trauma in the United States. Treatment options include intramedullary (IM) as well as plate and screw (PS) constructs. The purpose of this study was to analyze the biomechanical stability of a specific IM system compared with nonlocking PS fixation under low-threshold physiologic load. Twenty fourth-generation Sawbones (Pacific Research Laboratories, Vashon, WA, USA) with a simulated middle-third fracture pattern were repaired with either an IM device (n = 10) or superiorly positioned nonlocking PS construct (n = 10). Loads were modeled to simulate physiologic load. Combined axial compression and torsion forces were sequentially increased until failure. Data were analyzed on the basis of loss of rotational stability using 3 criteria: early (10°), clinical (30°), and terminal (120°). No significant difference was noted between constructs in early loss of rotational stability (P > .05). The PS group was significantly more rotationally stable than the IM group on the basis of clinical and terminal criteria (P < .05 for both). All test constructs failed in rotational stability. When tested under physiologic load, fixation failure occurred from loss of rotational stability. No statistical difference was seen between groups under early physiologic loads. However, during load to failure, the PS group was statistically more rotationally stable than the IM group. Given the clavicle's function as a bony strut for the upper extremity and the biomechanical results demonstrated, rotational stability should be carefully considered during surgical planning and postoperative advancement of activity in patients undergoing operative fixation of middle-third clavicle fractures. Basic Science Study; Biomechanics.

Scapular dyskinesis following displaced fractures of the middle clavicle

To evaluate the rate of scapular dyskinesis and resulting patient outcomes after treatment of displaced midshaft clavicle fractures. Skeletally mature patients with isolated, displaced midshaft clavicle fractures treated with or without surgery over a 16-month period were recruited. The minimum length of follow-up at study examination was 12 months. Patient outcomes were documented using the SICK (scapular malposition, inferomedial border prominence, coracoid pain and malposition, and dyskinesis of scapular movement) Scapula Rating Scale, the Simple Shoulder Test, 3 visual analog scales (VAS) for pain, and shoulder range-of-motion and strength measurements. Of the 32 eligible patients, 24 (75%) were successfully recruited. The mean participant age was 46 ± 17 years, with a mean length of follow-up at study evaluation of 1.7 ± 1 years. Surgical fixation was performed in 12 patients (50%). Scapular dyskinesis was present in 37.5% of patients (n = 9). Patients with scapular dyskinesis had worse SICK scapula scores (5.8 ± 2.2 vs 3.1 ± 2.4, P = .01), worse Simple Shoulder Test scores (10.5 ± 1.6 vs 11.7 ± 0.8, P = .029), higher maximum VAS pain scores (4.1 ± 3.1 vs 0.97 ± 1.2, P = .002), and worse average VAS pain scores in the week before the examination (2.7 ± 2.5 vs 0.2 ± 0.4, P < .001) compared with patients without scapular dyskinesis. Range of motion and abduction strength were similar between the groups. Scapular dyskinesis developed in 1 patient treated with surgery (8% [1 of 12]) compared with 8 patients treated nonoperatively (67% [8 of 12]) (P = .009). Scapular dyskinesis is common after displaced middle-third clavicle fractures, and these patients have more pain and worse functional outcomes compared with patients without scapular dyskinesis. Surgical treatment may reduce a patient's risk of scapular dyskinesis developing and improve short-term outcomes.

Is intramedullary nailing more effective than non-operative treatment in adults with displaced middle-third clavicle fractures?

BackgroundClavicle fractures are common, accounting for 5–12 % of all fractures. Traditionally, displaced middle-third clavicle fractures have been managed non-operatively but the associated displacement often leads to mal-union with shortening, cosmetic deformity and occasionally non-union, with clinicians looking towards alternative operative methods such as intramedullary nailing (IMN). However, such methods have their own complications. In order to ascertain the effectiveness of IMN in the management of middle-third clavicle fractures compared with non-operative treatment, analysis of recent evidence is required and this review aims to achieve that, focusing on relevant, contemporary randomised-control trials.Materials and methodsEssential search-terms identified from the research question were used to formulate a search strategy. A systematic search of multiple databases was then performed from 1966 until present and appropriate papers for appraisal identified.ResultsThirteen papers were identified, with 10 excluded using appropriate eligibility criteria. The remaining papers were then critically appraised. With regards shoulder function, all papers demonstrated an association between IMN and a significantly (P < 0.05) superior shoulder function score, but no consensus with regards to complication rates. However, all have identified limitations; therefore, their overall findings must be considered conservatively.ConclusionsFurther, high-quality research, ideally in the form of well-designed, multi-centre RCTs is required to allow acceptable implementation of IMN of middle-third clavicle fractures into widespread practice. However, early results demonstrate that in young patients with displaced middle-third clavicle fractures, who are motivated to return to work, IMN provides superior functional results and should be considered. However, the importance of considering each patient individually as to their suitability for each management option, before coming to an informed decision with the patient rather than having a blanket approach to MTCF is essential.Level of EvidenceLevel 1.

Outcomes from surgical treatment of middle-third clavicle fractures non-union in adults: A series of 21 cases

IntroductionThe aim of our study was to evaluate the results of surgical treatment of clavicle non-union after failure of conservative treatment. Our hypothesis was that stable fixation with bone graft derived from local bone stock (fracture site) or the iliac crest was essential to achieve bone union. Material and methodsTwenty-one patients with a symptomatic middle-third clavicle non-union after failure of initial conservative treatment were included in the study. Delay between the initial fracture and surgery for non-union was 27months (6–144). In five cases, the non-union was hypertrophic and bone graft was obtained locally from the callus. In 16 patients, the non-union was atrophic. Bone was harvested from the iliac crest as cortico-cancellous graft (7 patients) and cancellous graft (8 patients). One patient refused bone grafting. A 3.5-mm plate with non-locking screws was placed anterior in 12 and superior in 9 patients. ResultsAt 41months average follow-up (minimum of 12months), 20 patients were available for review. Bone healing was obtained initially in 15 cases. Six complications required a revision procedure: 3 for infection and 3 for mechanical failure. At last follow-up, 19 patients were satisfied with the surgery. Average Constant score was 84±26 points (7–100), and Quick DASH score 17±22 points (0–91). Radiographic bone healing was obtained in 19 of the cases. ConclusionTreatment of middle-third clavicle non-union after initial failure of conservative treatment with stable fixation and bone graft is a reliable, well-suited and effective treatment. Our hypothesis was verified. Preoperative evaluation of appearance of the non-union X-rays can be used to determine the type of bone graft needed, but the final decision is often taken during surgery. Level of evidenceLevel IV.

Treatment of Middle-Third Clavicle Fractures Using Anterior Plating With a Dynamic Compression Plate (DCP)

Significantly displaced midshaft clavicle fractures can be managed operatively to restore anatomy and allow early mobilization. Several techniques have described using precontoured anatomically designed plates placed on the superior surface of the bone or reconstruction plates contoured by the surgeon placed either superiorly or anteriorly. We describe the use of the dynamic compression plate placed anteriorly on the clavicle in treating these fractures and discuss the relative advantages of this technique. We have a case series of 8 patients over a 2-year period, who were followed up and all went on to successful fracture union.