Treatment Of Clavicle Fractures Research Articles

Clavicle fractures: epidemiology, classification and treatment of 2 422 fractures in the Swedish Fracture Register; an observational study

BackgroundLarge multi-centre studies of clavicle fractures have so far been missing. The aim of this observational study was to describe the epidemiology, classification and treatment of clavicle fractures in the The Swedish Fracture Register (SFR) that collects national prospective data from large fracture populations.MethodsData were retrieved from the SFR on all clavicle fractures sustained by patients ≥ 15 years of age in 2013–2014 (n = 2 422) with regards to date of injury, cause of injury, fracture classification and treatment.ResultsSixty-eight per cent of the clavicle fractures occurred in males. The largest subgroup was males aged 15–24 years, representing 21% of clavicle fractures. At the ages of 65 years and above, females sustained more clavicle fractures than males. Same-level falls and bicycle accidents were the most common injury mechanisms. Displaced midshaft fractures constituted 43% of all fractures and were the most frequently operated fractures. Seventeen per cent of the patients underwent operative treatment within 30 days of the injury, where plate fixation was the choice of treatment in 94% of fractures.ConclusionThe largest patient group was young males. Displaced midshaft fractures were the most common type of clavicle fracture as well as the most frequently operated type of fracture.

Treatment of Clavicle Fracture with Anteroinferior Plating Technique

Treatment of Clavicle Fracture with Anteroinferior Plating Technique

Functional outcomes following non-operative versus operative treatment of clavicle fractures in adolescents

Functional outcomes following non-operative versus operative treatment of clavicle fractures in adolescents

Evaluation of minimally invasive fixation with ESIN in the management of displaced mid-shaft clavicle fractures: a case series with minimum of 2 years follow-up

<p class="abstract"><strong>Background:</strong> Over the last few years, operative treatment has become the standard for treatment of clavicle fractures. Both plating and intra-medullary pinning techniques are available for treating clavicle fractures. The aim of the study was to evaluate the role of minimally invasive technique using elastic stable intramedullary nailing (ESIN) in surgical treatment of displaced mid-shaft clavicle fractures<span lang="EN-IN">.</span></p><p class="abstract"><strong>Methods:</strong> It is a prospective case series study conducted at the Department of Orthopaedics of a tertiary care centre. 44 cases of acute displaced mid-shaft clavicle fractures with a mean age of 32.7 years were treated by intramedullary pinning with titanium elastic stable nails and were followed-up for a mean period of 30.6 months(range= 24-40 months). Functional outcomes were evaluated by using Constant Shoulder score. The results obtained were analysed using student’s t-test.<strong></strong></p><p class="abstract"><strong>Results:</strong> Union was achieved in all except one case which showed delayed union. 7 cases were complicated by telescoping (incidence= 15.9%) and 6 out of these 7 cases also had medial nail protrusion (incidence= 13.6%) simultaneously. 9 cases had shortening of less than 1cm and 2 had shortening of more than 1cm. No other complication was reported from any of the case. Mean constant shoulder scores improved from 15 to 85.6 (p value <0.001) after 12 months from surgery. However, no further improvement was seen after 12 months of surgery, with no statistical difference (p value= 0.789) between the mean scores at 12 (85.6) and 24 (85.7) months<span lang="EN-IN">. </span></p><p class="abstract"><strong>Conclusions:</strong> ESIN offers the advantages of treating displaced mid-shaft clavicle fractures with minimal incision and decreased surgery time with minimal intra-operative blood loss. The results were excellent in terms of functional outcomes. The complication rates were low and return to normal activity was quiet fast. ESIN is a minimally invasive technique with good cosmetic and functional results. This method should be seen as an alternative to plate fixation and non-operative treatment<span lang="EN-IN">.</span></p>

Trends in the Incidence of Clavicle Fractures and Surgical Repair in Sweden: 2001-2012.

Clavicle fractures are common injuries causing substantial morbidity. Recent literature suggests that the incidence of surgically treated clavicle fractures has increased. However, it is unknown whether the increase is caused by more surgeons choosing operative over nonoperative treatment for the injury or an increase in the actual incidence of clavicle fractures. The aim of this study was to assess both the national incidence of clavicle fractures and the rate of surgical treatment of those fractures in Sweden. We assessed the incidence and trends of clavicle fractures and rates of surgery in Sweden. The validated Swedish Hospital Discharge Register offers a unique opportunity to assess both outpatient and inpatient visits and was used to conduct a national register-based study including all adults (≥18 years of age) with a diagnosis of clavicle fracture in Sweden between 2001 and 2012. A total of 44,609 clavicle fractures occurred in Sweden between 2001 and 2012. The incidence of clavicle fractures increased from 35.6 per 100,000 person-years in 2001 to 59.3 per 100,000 person-years in 2012. Interestingly, the highest incidence rates were observed in the oldest age groups. The increase in the rate of surgically treated clavicle fractures (705%) was greater than the increase in the actual fracture incidence (67%). Most (77%) of the surgically treated patients were men. Open reduction and plate fixation was the most common surgical procedure. Overall, the proportion of surgically treated clavicle fractures increased markedly. Although the incidence of clavicle fractures increased in Sweden between 2001 and 2012, the rate of surgical treatment of clavicle fractures increased much more than could be expected solely based on the increase in the fracture incidence. The observed changes in the rates of surgery require additional studies since there is still controversy regarding the indications for surgical treatment.

Factors Associated With Narcotic Use After Clavicle Fractures.

Clavicle fractures are common in adults. Recent studies have shown that operative treatment of clavicle fractures has benefits in many situations. However, there is controversy about the indications. Data on social outcomes are limited. A total of 434 patients with 436 clavicle fractures treated both operatively and nonoperatively at a level 1 trauma center were identified. Narcotic use was recorded 2, 4, 6, 8, 10, 12, 14, and 16 weeks after injury for both treatment groups. Other descriptive data included age, sex, laterality, hand dominance, rib fractures, smoking, alcohol use, employment, long bone or spine fracture, open clavicle fracture, and mechanism of injury. Logistic regression analysis was performed to determine the independent predictors of narcotic use after clavicle fracture. Open reduction and internal fixation was performed in 105 fractures (24%), and 329 fractures were managed nonoperatively. A total of 154 patients (35%) reported some narcotic use 2 weeks after injury, and 15% were still using narcotics 16 weeks after injury. Narcotic use decreased over time in patients treated with open reduction and internal fixation (10% vs 15% after nonoperative management). Patients treated with open reduction and internal fixation reported reduced narcotic use at 16 weeks (odds ratio [OR], 0.454; P=.070). Concurrent rib fracture (OR, 5.668; P<.001), smoking (OR, 3.095; P=.013), unemployment (OR, 5.429; P<.0005), and long bone or spine fracture (OR, 6.761; P<.001) were predictors of narcotic use. Further studies of the social, economic, and financial outcomes of clavicle fracture and osteosynthesis are warranted. [Orthopedics. 2016; 39(5):e917-e923.].

Treatment of clavicle fractures by Ilizarov technique

We treated 28 clavicle fractures with a mean age of 45 years (15-55) years with mini Ilizarov fixation from January 1999 to January 2015 at Bari-Ilizarov Orthopaedic Centre and NITOR, Dhaka. Out of 28 patients 20 were male and 8 female. We are presenting here the use of mini Ilizarov apparatus for fracture clavicle. Among the complications 2 wire track infections were observed from which all responded positively to local care. The mini Ilizarov apparatus and technique represents a useful method for the successful healing of fracture clavicle.

Overtreatment of displaced midshaft clavicle fractures

Background and purpose — The best treatment for displaced clavicle fractures has been debated for decades. Operative treatment has become more common. However, several randomized trials comparing non-operative and operative treatment have not shown any compelling evidence in favor of surgery. We identified the preferred treatment of displaced midshaft clavicle fractures at public hospitals in 3 countries in Scandinavia.Patients and methods — A purpose-made multiple-choice questionnaire in English was sent to all public hospitals in Denmark, Sweden, and Finland. This was addressed to the orthopedic surgeon responsible for treatment of clavicle fractures, and completed questionnaires were obtained from 85 of 118 hospitals.Results — In the 3 countries, 69 of the 85 hospitals that responded would treat displaced clavicle fractures operatively. Clear criteria for treatment allocation were used at 58 of the hospitals, with the remaining 27 using individual assessment in collaboration with the patient. Precontoured locking plates were mostly used, placed either superiorly (64/85) or anteriorly (10/85).Interpretation — Displaced midshaft clavicle fractures are mainly treated operatively in Sweden, Denmark, and Finland. This treatment is not supported by compelling evidence.

Paper #20 - Patient factors influencing return to work and cumulative financial claims after clavicle fractures in workers compensation cases

Background: Workers compensation status is consistently cited as a predictor of poor outcome after orthopaedic procedures. This study analyzes a cohort of all workers compensation patients after surgical or non-operative treatment of clavicle fractures to identify factors that influence the time for return to work and total healthcare reimbursement claims, including a comparison of surgical and non-operative treatments. Operative treatment has been associated with faster time to boney union. We hypothesized that return to work for operative patients would be faster and the reimbursement claims for operative cases would be higher. Methods: The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes and Current Procedural Terminology (CPT) codes were used to retrospectively query the Workers' Compensation national database managed by University of Illinois, Chicago. Claims for clavicular fractures treated surgically and non-operatively were identified from 2003 to 2013. The outcomes of interest were the number of days for return to full work (RTW) following surgery and the total reimbursement for healthcare-related claims. The primary independent variable was treatment modality. Multivariate analysis was performed to control for relevant employee, employer and treatment covariates that were likely to confound associations. We used two-tailed hypothesis tests and P < .05 to indicate statistical significance. Averages are ± standard deviation. Results: There were 169 settled claims for clavicle fractures within the database. Only 20% (n = 34) of these claims related to surgical treatment, while 80% (n = 135) related to non-operative treatment. For claims with complete follow-up, the average time for RTW was 196 ± 287 days for surgical treatment, and 69 ± 94 days for non-operative treatment. The average healthcare claims reimbursed were $29,136 ± 26,998 for surgical management, compared to $8366 ± 14,758 for non-operative treatment. From multivariate RTW analysis, we did not find a significant difference between non-operative and surgical treatment groups in their time to RTW (P = .06) Claims from workers with one or more dependents (Reference Group [RG]: No dependents), from the West (RG: Midwest), from injuries related to athletics/Police/Firefighters (RG: Driving/flying/boating) were significant predicators of earlier RTW. Claims with a higher percentage of impairment, filing of a legal suit, and incident report only claims (RG: Employer's liability) were associated with later RTW. From multivariate reimbursement analysis, total healthcare reimbursement for claims with surgical treatment were 330% higher as compared to claims for non-operative treatment (P < .01). Claims with an associated legal suit, from working professionals (RG: Driving/Flying/Boating related injuries), from workers with at least 20 years of service (RG: < 10 years), and between 180 and 360 lost working days (RG: < 45 days) were predictors of higher healthcare claims. Injuries from pushing/pulling/lifting, and from falls (RG: Motor vehicle related injuries), and incident report only claims (RG: Employer's liability) were significant predictors of lower healthcare claim amount. Conclusion: Contrary to our hypothesis, the patients treated under workers compensation status for clavicle fractures return to work at roughly the same time whether they are treated surgically or non-operatively, when controlling for relevant covariates. Workers compensation patients treated with surgery accumulate significantly higher healthcare claims than those treated without surgery. Although many variables that independently influence return to work timing and cumulative health care claims in this study are non-modifiable, attempting to minimize legal suits may help expedite patients return to work. As the indications for operative treatment of clavicle fractures continues to be elucidated, non-operative treatment of fractures may help reduce overall financial burden in workers compensation patient population.

Patient factors influencing return to work and cumulative financial claims after clavicle fractures in workers' compensation cases

This study analyzed workers' compensation patients after surgical or nonoperative treatment of clavicle fractures to identify factors that influence the time for return to work and total health care reimbursement claims. We hypothesized that return to work for operative patients would be faster. The International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes and Current Procedural Terminology codes were used to retrospectively query the Workers' Compensation national database. The outcomes of interest were the number of days for return to full work after surgery and total reimbursement for health care-related claims. The primary independent variable was treatment modality. There were 169 claims for clavicle fractures within the database (surgical, n = 34; nonoperative, n = 135). The average health care claims reimbursed were $29,136 ± $26,998 for surgical management compared with $8366 ± $14,758 for nonoperative management (P < .001). We did not find a statistically significant difference between surgical (196 ± 287 days) and nonoperative (69 ± 94 days) treatment groups in their time to return to work (P = .06); however, there was high variability in both groups. Litigation was an independent predictor of prolonged return to work (P = .007) and higher health care costs (P = .003). Workers' compensation patients treated for clavicle fractures return to work at roughly the same time whether they are treated surgically or nonoperatively, with surgery being roughly 3 times more expensive. There was a substantial amount of variability in return to work timing by subjects in both groups. Litigation was a predictor of longer return to work timing and higher health care costs.

Plating versus intramedullary fixation for mid-shaft clavicle fractures: a systemic review and meta-analysis.

Background. Plate fixation and intramedullary fixation are the most commonly used surgical treatment options for mid-shaft clavicle fractures; the latter method has demonstrated better performance in some studies.Objectives. Our aim was to critically review and summarize the literature comparing the outcomes of mid-shaft clavicle fracture treatment with plate fixation or intramedullary fixation to identify the better approach.Search Methods. Potential academic articles were identified from the Cochrane Library, MEDLINE (1966-2015.5), PubMed (1966-2015.5), EMBASE (1980-2015.5) and ScienceDirect (1966-2015.5). Gray studies were identified from the references of the included literature.Selection Criteria. Randomized controlled trials (RCTs) and non-RCTs comparing plate fixation and intramedullary fixation for mid-shaft clavicle fracture were included.Data Collection and Analysis. Two reviewers performed independent data abstraction. The I2 statistic was used to assess heterogeneity. A fixed- or random-effects model was used for the meta-analysis.Results. Six RCTs and nine non-RCTs were retrieved, including 513 patients in the intramedullary fixation group and 521 patients in the plating group. No significant differences in terms of the union rate and shoulder function were found between the groups. Patients in the intramedullary fixation group had a shorter operative time, less blood loss, smaller wound size, and shorter union time than those in the plating group. With respect to complications, significant differences were identified for all complications and major complications (wound infection, nonunion, implant failures, transient brachial plexopathy, and pain after 6 months). Similar secondary complications (symptomatic hardware, hardware irritation, prominence, numbness, hypertrophic callus) were observed in both groups.Conclusions. Intramedullary fixation may be superior to plate fixation in the treatment of mid-shaft clavicle fractures, with similar performance in terms of the union rate and shoulder function, better operative parameters and fewer complications.

Functional Outcomes Following Nonoperative Versus Operative Treatment of Clavicle Fractures in Adolescents

Functional Outcomes Following Nonoperative Versus Operative Treatment of Clavicle Fractures in Adolescents

A biomechanical comparison of four different fixation methods for midshaft clavicle fractures.

Clavicle fractures may occur in all age groups, and 70%-80% of clavicle fractures occur in the midshaft. Many methods for treating midshaft clavicular fractures have been reported and remain controversial. To provide some guidance for clinical treatment, 30 artificial polymethyl methacrylate models of the clavicle were sewn obliquely at the midshaft to simulate the most common type of clavicular fractures, and the fracture models were divided into five groups randomly and were fixed as follows: the reconstruction plates were placed at the superior position of the fracture model (R-S group), the reconstruction plates were placed at the anteroinferior position of the fracture model (R-AI group), the locking plates were placed at the superior position (L-S group), the locking plates were placed at the anteroinferior position (L-AI group); and the control models were unfixed (control group). The strain gauges were attached to the bone surface near the fracture fragments, and then, the biomechanical properties of the specimens were measured using the compression test, torsion test and three-point bending test. The results showed that plate fixation can provide a stable construct to help with fracture healing and is the preferred method in the treatment of clavicle fractures. The locking plate provides the best biomechanical stability when placed at the anteroinferior position, and this surgical method can reduce the operation time and postoperative complications; thus, it would be a better choice in clinical practice.

Iatrogenic Supraclavicular Nerve Injuries in Surgical Treatment of Clavicle Fractures

Iatrogenic Supraclavicular Nerve Injuries in Surgical Treatment of Clavicle Fractures

Iatrogenic Supraclavicular Nerve Injuries in Surgical Treatment of Clavicle Fractures

Incidence and pattern of disturbed sensitivity in the zone of surgical intervention was studied in 24 patients with clavicle fractures. Traumatic damage of supraclavicular nerve (not related to surgery) was observed only in 1 case. Disturbance of sensitivity in the zone of surgical intervention was noted in 21 (87.5%) patients. Mean area of anesthesia made up 44.5±29.3 cm2 (from 8.0 to 125.5 cm2). That complication developed at both horizontal and vertical surgical approaches. Intraoperatively supraclavicular nerves were visualized and preserved in 6 patients however disturbed sensitivity in early postoperative period was observed in 4 cases. Preventive isolation of supraclavicular nerves does not always ensure the preservation of sensitivity in early postoperative period.

Intramedullary clavicle fixation with single large fragmentary screw.

The treatment of clavicle fractures has historically been nonoperative, but several studies have recently shown the merits of operative management for specific fractures patterns. We developed a novel technique utilizing a 6.5-mm cannulated screw for fixation of displaced midshaft clavicle fractures. We present 15 consecutive patients treated with this technique between 2007 and 2012. All patients were male, and all 15 suffered a traumatic injury involving a fall directly onto the affected side. Mean time from injury to surgery was 12 days (range 3-24 days). Decision for surgery was based on the displacement and shortening of the fracture, either at least 20 mm of shortening or displacement with no bony apposition. After surgery, all patients were placed in an abduction brace for 6 weeks. No motion was allowed for the first 3 weeks, followed by passive shoulder motion below 90° of forward flexion under the supervision of a therapist for the next 3 weeks. All 15 patients progressed to union at an average of 5.7 months (range 3-12). Three patients had superficial wound infections. Hardware removal was performed in 6 of the 15 patients at an average of 12 months (range 5-24). All patients regained full range of motion and strength in comparison with contralateral extremity. This novel technique limits soft tissue stripping. It has the advantages of using an implant familiar to most orthopedists and available in most hospital settings. We believe this technique is ideally suited for transverse fractures patterns, less than 14 days old, in males greater than 180 cm with clavicles large enough to accommodate a 6.5-mm screw.

Clavicle fractures: pins, plates, and drilling down: commentary on an article by Fernando Brandao Andrade-Silva, MD, PhD, et al.: "single, superiorly placed reconstruction plate compared with flexible intramedullary nailing for midshaft clavicular fractures. a prospective, randomized controlled trial".

The fact that the clavicle is the most commonly fractured bone in the human body would seem to ensure a level of study sufficient to render treatment formulaic. Indeed, this was largely the case after Neer1 reported on thousands of clavicle fractures, with nonunion rates of 0.1% for midshaft fractures with nonoperative treatment. That report guided generations of clavicle treatment until questions were posed with regard to the lack of outcomes reported and the heterogeneity of the patients included in the study. Recent large prospective studies2,3 have yielded diametrically opposite conclusions with regard to the outcomes of operative and nonoperative treatment. Andrade-Silva et al. examine the technique aspect of this issue with a well-constructed, prospective, randomized study evaluating the outcomes of two types of clavicle fixation—reconstruction plate fixation and elastic stable intramedullary nailing. Previous studies4,5 have shown improved outcomes when comparing elastic stable intramedullary nailing with plating. Andrade-Silva et al. seek to clarify whether this association holds up under continued scrutiny. The authors report patient outcomes measured with the Disabilities of the Arm, Shoulder and Hand (DASH) and Constant-Murley scores. The improvements in both groups (the group receiving fixation involving elastic stable intramedullary nailing, referred to in the study as the nail group, and the group receiving fixation involving reconstruction plates, referred to in the study as the plate group) were similar and differences were not significant. The mean six-month DASH score was 9.9 points in the plate group and 8.5 points in the nail group (p = 0.329). …

Complications in the treatment of adolescent clavicle fractures.

This study evaluated the complications associated with the treatment of clavicle fractures in adolescents. All cases of clavicle fractures were identified during an 8-year period between January 2005 and January 2013. During the study period, 153 clavicle fractures occurred in patients between the ages of 14 and 17 years who were treated at the authors' center. Medical records and radiographs were reviewed to determine injury mechanism, fracture pattern, treatment, and complications. Injury severity was assessed as high, medium, and low. Patients with medial or distal metaphyseal fractures and intra-articular fractures were excluded. Of the 153 clavicle fractures, 23 (15.0%) were treated surgically. Compared with the fractures treated nonsurgically, the surgical fractures had greater shortening (mean, 2.0 vs 0.9 cm; P<.001) and were more likely to be comminuted (65.2% vs 23.1%; P<.001). Complications occurred in 21.7% of fractures treated surgically, including refracture (n=2), implant removal for prominence (n=2), and nonunion with implant failure (n=1). One complication was associated with intramedullary nailing, whereas the other 4 complications occurred in clavicles treated with plate fixation. In the non-surgical group, no patients sustained a refracture or malunion who required delayed surgical intervention. Pediatric fellowship-trained orthopedic surgeons treated 78 displaced fractures, resulting in 8 (10.3%) surgeries. Nonpediatric orthopedic specialists treated 46 displaced fractures, 15 (32.6%) of which were treated surgically (P=.0035).

Outcomes of operative versus nonoperative treatment of displaced pediatric clavicle fractures.

Current literature proposes relative and absolute indications for surgical treatment of clavicle fractures in adults. However, few studies have evaluated these fractures in children. The current study examined short- and long-term outcomes of pediatric patients with displaced clavicle fractures. Outcomes assessed included radiographic healing, full active range of motion, and return to activity. The authors' hypothesis was that open reduction and internal fixation of displaced clavicle fractures would lead to better outcomes than nonoperative treatment. The authors retrospectively reviewed the charts of pediatric patients treated for clavicle fractures between January 2001 and October 2011. The nonoperative group included 32 patients, and the operative group included 46 patients. Mean time to return to activity was 12.24 weeks in the nonoperative group and 12.70 weeks in the operative group (P=.67). Mean time to full active range of motion was 7.85 weeks in the nonoperative group and 8.74 weeks in the operative group (P=.24). Mean time to radiographic evidence of healing was 12.02 weeks in the nonoperative group and 11.90 weeks in the operative group (P=.90). Average Disabilities of the Arm, Shoulder and Hand (DASH) score was 0.04 in the nonoperative group (range, 0-0.08) and 1.17 in the operative group (range, 0-8.3), with no significant difference between groups. No significant difference between operative treatment and nonoperative treatment was found in any of the authors' outcome measures. Thus, the authors propose that unless the patient's injury is an absolute indication for surgery, conservative management provides equivalent immediate and long-term clinical results.

Surgical treatment of clavicle fractures in the adolescent athlete.

Context:Current literature has clearly shown that the indications for surgical treatment of clavicle fractures in adults are expanding. Although clavicle fractures in children and adolescents have traditionally been treated nonoperatively, surgical treatment of displaced clavicle fractures may be indicated for adolescent athletes.Evidence Acquisition:A review of relevant articles published between 1970 and 2013 was completed using MEDLINE and the terms clavicle fracture and adolescent athlete.Study Design:Clinical review.Level of Evidence:Level 3.Results:Excellent outcomes and rapid return to competition can be achieved with surgical management of displaced clavicle fractures in the adolescent athlete with high functional demands similar to those of their adult counterparts. Complications include hardware irritation, screw loosening, pin migration, peri-incisional numbness, and refracture. Athletes and families must be counseled regarding complications and potential need for secondary surgery to remove hardware.Conclusion:The adolescent athlete with a displaced, shortened, or comminuted clavicle fracture presents a unique, controversial dilemma for the surgeon. Earlier return to competition can be achieved with surgical management to restore length and alignment and may prevent malunion, nonunion, and poor outcomes.