Treatment Of Midshaft Clavicle Fractures Research Articles

Intrinsic and extrinsic risk factors for nonunion after nonoperative treatment of midshaft clavicle fractures

BackgroundThe optimal treatment of midshaft clavicle fractures remains controversial. Nonunion is usually considered to be an uncommon complication following a nonoperatively treated clavicle fracture. HypothesisNot every midshaft clavicular fractures shares the same risk of developing nonunion after nonoperative treatment. The present study was performed to identify the intrinsic and extrinsic independent factors that are independently predictive of nonunion in patients with midshaft clavicular fractures after nonoperative treatment. Materials and methodsWe performed a retrospective study of a series of 804 patients (391 men and 413 women with a median age of 51.3 years) with a radiographically confirmed midshaft clavicle fracture, which was treated nonoperatively. There were 96 patients who underwent nonunion. Putative intrinsic (patient-related) and extrinsic (injured-related) risk factors associated with nonunion were determined with the use of bivariate and multivariate statistical analyses. ResultsBy bivariate analysis, the risk of nonunion was significantly increased by several intrinsic risk factors including age, sex, and smoking and extrinsic risk factors including displacement of the fracture and the presence of comminution (P<0.05 for all). On multivariate analysis, smoking (OR=4.16, 95% CI: 1.01–14.16), fracture displacement (OR=7.81, 95% CI: 2.27–25.38) and comminution of fracture (OR=3.86, 95% CI: 1.16–13.46) were identified as independent predictive factors. ConclusionThe risk factors for nonunion after nonoperative treatment of midshaft clavicle fractures are multifactorial. Smoking, fracture displacement and comminution of fracture are independent predictors for an individual likelihood of nonunion. Further studies are still required to evaluate these factors in the future. Level of evidenceLevel III, case-control study.

Surgical Treatment of Mid-Shaft Clavicle Fractures: Plate Fixation and Clinical Outcomes

Surgical Treatment of Mid-Shaft Clavicle Fractures: Plate Fixation and Clinical Outcomes

The Comparison of Results of Treatment of Midshaft Clavicle Fracture between Operative Treatment with Plate and Non-Operative Treatment.

Clavicle fractures are common and usually heal without complications. In this study, we evaluated the outcomes of non-operative versus operative management of displaced fractures. In a prospective clinical trial study, sixty-five patients with displaced clavicle mid-shaft fractures were non-randomly divided in two treatment groups. The first group underwent non-operative treatment with figure of 8 bandage (30 patients), and the other underwent operative treatment with plate fixation (35 patients). Figure of 8 bandage and 3.5 millimeter DCP plate with at least six cortical screws were used in non-operative and operative groups respectively. We followed up all patients at weeks 2, 6 and 12, and at month sixth. In addition to clinical examination and x-ray evaluation, we assessed satisfaction, DASH and Constant Shoulder Score for each individual. The average durations of union were 19.3 and 24.4 weeks in operative and non-operative groups respectively (P=0.006). Satisfaction with operative treatment was 74.3% and with non-operative treatment was 66.7%, showing no significant difference (P=0.500). The non-union rate was 5.7% in the operative group and 13.3% in the non-operative group (P=0.518). A significant difference between the two groups in terms of DASH and Constant Shoulder Scores after the six-month follow-up was not found (P=0.352). According to our results, we recommend operative treatment in mid-shaft clavicle fractures only when there is a definitive indication.

Functional and aesthetic results of orthopaedic treatment of midshaft fractures of the clavicle. A 22 years follow-up study

AimTo evaluate the functional results of the orthopaedic treatment of midshaft clavicle fractures with a minimum follow-up of 15 years. Materials and methodsA retrospective study was conducted on 40 patients, mean age 35 years (18–64) with a non-surgically treated clavicle fracture. The mean follow-up was more than 22 years (15–32). The clinical evaluation was performed with the Disability of Arm, Shoulder and Hand score (DASH), Constant Shoulder Score test (CSS), EVA score, and a subjective assessment of the final result. Fractures were classified according to Neer's criteria. The radiological evaluation was performed with an anteroposterior and 45° cephalic anteroposterior oblique X-ray. ResultsA mean DASH score 2.17 points (0–20.82), the mean CSS score was 98.2 (79–100), the mean EVA score was 0.42 (0–6), and 100% patients were satisfied, with good or excellent results. The control X-ray showed 39 healed fractures (97.5%) with a mean shortening of 6.4mm (0–20). ConclusionsThe presence of comminution and/or shortening of 15mm or more had the worst functional and radiographic results. Despite this, non-surgical treatment showed excellent functional and radiographic results, and a high personal satisfaction.

Intraobserver and Interobserver Agreement in the Classification and Treatment of Midshaft Clavicle Fractures

Background: With the recent emphasis on performing open reduction and internal fixation on midshaft clavicle fractures with complete displacement, comminution, and >2 cm of shortening, it is important to determine the reliability of orthopaedic surgeons to assess these variables on standard plain radiographs and to determine the agreement among orthopaedic surgeons in choosing the treatment. Purpose: To determine the intra- and interobserver reliability in the classification of midshaft clavicle fractures via standard plain radiographs and to determine the intra- and interobserver agreement in the treatment of these fractures. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: Charts of patients seen by the 2 senior authors from 2006 to 2011 were reviewed to identify patients treated for clavicle fractures (CPT codes 23500 and 23515). Anteroposterior and 30° cephalad radiographs were selected, representing midshaft clavicle fractures treated both operatively and nonoperatively. Thirty pairs of radiographs were included in the investigation. The radiographs were standardized for size to allow accurate measurements within a non-PACS (picture archiving and communications system) program, and a PDF document was created with all representative radiographs. Clinical scenarios were created for each set of radiographs, and the evaluators were asked to (1) measure the degree of shortening in millimeters, (2) determine the percentage displacement, (3) determine whether the fracture was comminuted, and (4) state whether they would treat the fracture operatively or nonoperatively. The radiographs, along with instructions on how to use the measuring tool with Adobe Reader, were distributed to 22 shoulder/sports medicine fellowship–trained orthopaedic surgeons, then reordered and redistributed approximately 3 months later. Sixteen surgeons completed 1 round of surveys, and 13 surgeons completed both rounds. Results: Interrater agreement was moderate for displacement of 0%-49% (κ = 0.71, P < .001) and >100% (κ = 0.73, P < .001), with minimal agreement for displacement of 50%-100% (κ = 0.39, P < .001). There was moderate interrater agreement for the presence/absence of comminution (κ = 0.75, P < .001). Interrater agreement was weak for shortening of 0-5.0 mm (κ = 0.58, P < .001) and >30.0 mm (κ = 0.51, P < .001), with minimal agreement for shortening of 5.1-10.0 mm (κ = 0.22, P < .001) and no agreement for the other 4 categories. Interrater analysis showed weak agreement on whether surgical treatment was recommended (κ = 0.40, P < .001). Intrarater agreement was strong for comminution (κ = 0.80, P < .0001), moderate for both displacement (κ = 0.76, P < .001) and operative treatment (κ = 0.64, P < .001), and minimal for shortening (κ = 0.38, P < .001). The following variables statistically predicted whether surgery was recommended (P < .001): (1) the odds of surgery were 2.26 if comminution was noted, holding displacement and the interaction between displacement and shortening constant, and (2) the odds of surgery were 3.37 if there is displacement of >100% compared with displacement of 0%-49%, holding comminution and shortening constant. Conclusion: Standard plain unilateral radiographs of the clavicle are insufficient to reliably determine the degree of shortening of clavicle fractures and the need for surgery among shoulder/sports medicine fellowship–trained orthopaedic surgeons. Consideration should be made to not use shortening as the sole determinant for whether to proceed with surgical intervention or to use other radiographic modalities to determine the amount of shortening.

Fracturas de clavícula tratadas conservadoramente tras 22 años de seguimiento: resultados funcionales y estéticos

AimTo evaluate the functional results of the orthopaedic treatment of midshaft clavicle fractures with a minimum follow-up of 15 years. Material and methodsA retrospective study was conducted on 40 patients, mean age 35 years (18-64) with a non-surgically treated clavicle fracture. The mean follow-up was more than 22 years (15-32). The clinical evaluation was performed with the Disability of Arm, Shoulder and Hand score (DASH), Constant Shoulder Score test (CSS), EVA score, and a subjective assessment of the final result. Fractures were classified according to Neer's criteria. The radiological evaluation was performed with an anteroposterior and 45° cefalic anteroposterior oblique X-Ray. ResultsA mean DASH score 2.17 points (0-20.82), the mean CSS score was 98.2 (79-100), the mean EVA score was 0.42 (0-6), and 100% patients were satisfied, with good or excellent results. The control X-Ray showed 39 healed fractures (97.5%) with a mean shortening of 6.4mm (0-20). ConclusionsThe presence of comminution and/or shortening of 15mm or more had the worst functional and radiographic results. Despite this, non-surgical treatment showed excellent functional and radiographic results, and a high personal satisfaction.

A systematic review of plate versus intramedullary fixation in the treatment of midshaft clavicle fractures

The best method of fixation for clavicle fractures is not known. The purpose of this review was to examine the evidence comparing plate and intramedullary fixation for midshaft clavicle fractures. A search of MEDLINE in September 2011 identified five papers that compared plate and intramedullary fixation, and fulfilled our eligibility criteria, consisting of; one randomised controlled trial, two quasi-randomised controlled trials, and two retrospective studies. Level of evidence was assessed using the Scottish Intercollegiate Guidelines Network guidance and the Cochrane Bone, Joint and Muscle Trauma Group's quality assessment tool. No attempt at meta-analysis was made due to the heterogeneity of the study populations and interventions. We found no difference between intramedullary fixation and plate fixation. There was a trend towards a lower complication rate with intramedullary fixation. On the basis of the available evidence, we would advocate both techniques for the treatment of midshaft clavicle fractures.

Reliability of Measurements of Clavicle Shaft Fracture Shortening in Adolescents

A relative indication for surgical treatment of midshaft clavicle fractures is shortening ≥2.0 cm. A standard method for determining shortening with routine clavicle radiographs has not been established. This study evaluated the interobserver and intraobserver reliability when measuring shortening of midshaft clavicle fractures in adolescents. We identified all clavicle radiographs of simple midshaft clavicle fractures in adolescents from 2006 to 2010. Thirty-two radiographs were chosen following a power analysis for 7 observers. Each film was measured twice by each evaluator using 2 separate methods. Method 1 was the evaluator's method of choice to determine shortening on the digital radiographs. Method 2 was standardized. Intraclass correlation coefficient and confidence intervals (CI) were calculated to determine interrater reliability, and average differences between the 2 time points with 95% CI were calculated to determine intrarater reliability. Interrater reliability for method 1 was 0.771 (95% CI, 0.655-0.865) and 0.743 (95% CI, 0.604-0.851) at the 2 time points for fair agreement. Interrater reliability for method 2 was 0.741 (95% CI, 0.629-0.842) and 0.685 (95% CI, 0.554-0.805) at the 2 time points, for fair and poor agreement, respectively. Neither method was statistically superior to the other. For method 1, the SD for the measurements averaged 3.1 mm. For method 2, the average SD was 3.0 mm. Intrarater reliability for method 1 was 2.62 mm average difference between the 2 time points (95% CI, 2.24-3.00), and for method 2 it was 3.34 mm average (95% CI, 2.88-3.80). Method 2 had a significantly greater difference at the 2 time points than method 1 (P=0.027). There is only fair agreement among observers when measuring the shortening of clavicle fractures in adolescents on digital clavicle radiographs by either method described. However, as the average difference among measurers was only 3 mm, this is unlikely to influence clinical decision making. A lack of standardization of measurement in previous studies on clavicle fracture treatment may not represent a significant problem. Level III diagnostic study.

Comparison between conservative and surgical treatment of midshaft clavicle fractures: Outcome of 151 cases

Midshaft clavicle fractures comprise up to 15% of all adult upper extremity fractures and account for 76% of all clavicle fractures. The treatment of choice remains controversial. The aim of our retrospective study was to compare the outcome of the surgical and conservative procedure in a trauma care unit (single center study). In a cohort of 151 (mean age 36,1y/male 115/female 36) cases, between 2005 and 2009, 70 patients (46.4%) were treated conservatively (mean age 40.8y) and 81 (53.6%) underwent either surgical treatment with a locking compression plate (n=73/mean age 40.3y) or an intramedullary nail system (n=8, mean age 27.1y). Mean follow up was 15 months. Nine patients (5.9%) were lost to follow-up, due to poor compliance. The clinical outcome was assessed by the Disability of Arm, Shoulder and Hand (DASH) score and the Constant shoulder score. The average DASH score was 7.3 and the Constant score measured 91.7 in the surgical group. The conservative group achieved a DASH score of 11.1 and a Constant score of 88.1. The clinical scores showed a significant superiority for the benefit of the surgical treatment for the DASH (p=0.037) and Constant score (p=0.036). Totally nine patients had a non-union in the conservative group and six a hardware failure in the surgical group which were revised. The treatment options for midshaft clavicle fractures have to be discussed carefully for each patient with regard to the non-union risk, function, cosmesis and revision surgery. Both therapeutic modalities demonstrated comparable efficacy. For active and younger patients we would favour a surgical treatment due to the short time of rehabilitation, the return to sport activities and the high non-union rate after conservative treatment.

Biomechanical comparison of the Locking Compression superior anterior clavicle plate with seven and ten hole reconstruction plates in midshaft clavicle fracture stabilisation

The purpose of this study was to characterise the biomechanical properties of the seven hole superior anterior clavicle LCP (locking compression plate) and to compare these with the properties of commonly applied implants used for the stabilisation of clavicular midshaft fractures such as the locking 7- and ten hole reconstruction plate. Twenty-four synthetic clavicles were used. A transverse midshaft fracture was induced. The clavicles were fixed with angle stable clavicle LCPs, seven hole and ten hole reconstruction plates (n = 8 each). Twenty cycles of axial compression and torsion were performed for each sample, which was followed by 1,000 cycles of three point bending and ultimately bending to failure. Axial, torsional and cantilever bending stiffness were calculated from the data recorded. The clavicle LCP showed the highest overall stiffness compared to the seven and ten hole reconstruction plate. Significantly higher stiffness values were found for axial compression and external rotation. In the load-to-failure tests, the ten hole reconstruction plate especially showed early signs of plastic deformation, which might account for early plate insufficiency so frequently observed clinically. The results indicate that the clavicle LCP, as compared to the reconstruction plates, leads to superior biomechanical stability in the treatment of midshaft clavicle fractures.

Comparing the effect of operative and nonoperative treatment in adult mid-shaft clavicular fracture by Meta-analysis

Objective To systematically summarize and compare results and related advantages of different methods in the management of adult mid-shaft clavicle fractures. Methods The data of adult midshaft clavicle fracture from 1989 to 2009 was retrieved. The database were included Cochrane Database,med & Ovid Medline, OTA, AAOS, High Wire Press, Springer Link, CBM, CNKI, WANFANG DATA and with hand-search journals in related fields. Internalizing randomized controlled trials and retrospective cohort studies which compared the operative and nonoperative treatment for adult mid-shaft clavicle fracture. Evaluating the quality of included studies and using the Rvaman 4.2 for Meta-Analysis. Results 5053 literatures had been reviewed. After screening, there were 8 studies brought into the review that included 519 patients.There were 5 studies which took union rate as observed indicator. The results had statistically significant (P＜0.00001). A total of 4 studies used malunion rate as indicator, the results had statistically significant (P ＜0.0001). A total of 4 researches selected satisfaction of patient as indicator, the results had statistically significant(P＜0.00001). A total of 5 studies selected symptoms of nerve stimulation as indicator, the results had statistically significant (P＜0.0001). A total of 4 studies selected residual pain as indicator, the results had no significant statistically difference (P=0.56). A total of 2 studies selected barriers of joint activities as indicator, the results had no significant statistically difference (P=0.25). A total of 2 researches used refracture as indicator, the results had no significant statistically difference (P＞O.05). Conclusion This study evaluation results shows that operation can be used as the first choice of treatment of adult midshaft clavicle fractures. Key words: Clavicle; Fractures, bone; Clinical protocols; Meta-analysis

A retrospective study of the association between shortening of the clavicle after fracture and the clinical outcome in 136 patients

Background and purpose The purpose of this retrospective study was to examine the association between shortening of the clavicle after a united midshaft fracture and clinical outcome. Second, the purpose was to compare the results obtained by conservative treatment with either a figure-of-eight bandage or a simple sling. Materials and methods This study included 136 patients with a united, conservatively treated, midshaft clavicle fracture. Mean age was 35 years (range 15–70 years); mean follow-up time was 55 months (range 24–83 months). The shortening of the clavicle was measured on a radiograph including one antero-posterior view of both clavicles on a single film and defined as the difference between the injured and the contralateral clavicle. The clinical outcome was measured using the Constant–Murley Score. Results The mean difference in the Constant–Murley Score between the injured and the contralateral shoulder was 7.3, P < 0.001 (95% confidence interval (CI) 5.6; 9.1). Mean shortening of the injured shoulder was 11.6 mm, P < 0.001 (95% CI 10.2; 13.0). A shortening of more than 20 mm was not associated with a poorer clinical outcome. The results obtained by conservative treatment with either a figure-of-eight bandage or a simple sling showed no difference in shortening or in the Constant–Murley Score. Conclusions We found that conservative treatment of midshaft clavicle fractures resulted in final shortening and mild reduction of shoulder function. A shortening of 20 mm or more was not associated with a poorer clinical outcome. The figure-of-eight bandage and a simple sling were equal treatments of midshaft clavicle fractures.

Klavikulaschaftfrakturen

The objective of this systematic review was to summarize the current evidence on efficacy and safety of the various treatment options for midshaft clavicle fractures, taking into account fracture type and other variables. A search for systematic reviews and controlled studies published between 1998 and 2009 was carried out. There is moderate evidence that operative treatment for midshaft clavicle fractures results in a lower rate of fracture non-union and improved patient-oriented outcome compared to non-operative treatment. However, because union rates are generally high and there are complications which are unique to surgical intervention, risks have to be considered and weighed before a decision on treatment is made. The most important risk factors for non-union are major displacement and fracture comminution. Of all surgical procedures the best evidence of efficacy is presently available for plate fixation and elastic stable intramedullary nailing. This paper presents an algorithm derived from the current evidence which may be useful for therapy decision-making in the clinical routine.

Operative Versus Nonoperative Treatment of Midshaft Clavicle Fractures in Adolescents

Midshaft clavicle fractures in adolescents have traditionally been treated nonoperatively. Recent studies in the adult literature have shown a higher prevalence of symptomatic malunion, nonunion, and poor functional outcome after nonoperative treatment of displaced fractures. The purpose of this study was to compare operative versus nonoperative treatment of displaced clavicle fractures in adolescents. Adolescents who sustained closed midshaft clavicle fractures between 2000 and 2008 were identified in our institutional trauma registry. Medical records were reviewed for patient demographics, injury characteristics, treatment, and outcomes. Forty-two consecutive patients (mean age 15.4 y) with 43 closed midshaft clavicle fractures were identified. Twenty-five patients were treated nonoperatively with a sling or figure-of-8 brace. Seventeen patients were treated operatively with acute plate fixation for fractures displaced more than 2 centimeters. The average shortening at injury was 12.5 mm in the nonoperative group and 27.5 mm in the operative group (P=0.003). The mean time to radiographic union for displaced fractures was 8.7 weeks in the nonoperative group and 7.4 weeks in the operative group (P=0.02). There were no nonunions in either group. All complications in the operative group were related to local hardware prominence. The mean time to return to activities was 16 weeks in the nonoperative group and 12 weeks in the operative group. Symptomatic malunion, with a mean fracture shortening of 26 mm, developed in 5 patients in the nonoperative group. Four of these patients elected corrective osteotomy with internal fixation and all went on to union with resolution of their symptoms. Plate fixation of displaced midshaft clavicle fracture reliably restores length and alignment. It resulted in shorter time to union with low complication rates. Symptomatic malunion in adolescents may be more common than earlier thought after significantly displaced fractures. Corrective osteotomy with plate fixation can restore clavicle anatomy and eliminate symptoms associated with malunion. Therapeutic level III.

Treatment of mid-shaft clavicle fractures: A comparative study

We retrospectively evaluated 51 patients (17 in each of three groups) with mid shaft clavicle fractures. Group 1 underwent intramedullary stabilization using clavicle pins. Group 2 underwent open reduction and internal fixation using plates and group 3 underwent non operative treatment with a sling. Group1 patients progressed to union within 8 to 12 weeks. In Group 2, six patients had scar related pain and two had prominent metal work and discomfort and in group 3, three patients developed non union and one had symptomatic malunion. Our results suggest that the displaced and shortened midshaft clavicle fractures require operative fixation and the techniques of clavicle pinning resulted in less complications, short hospital stay and good functional outcome.

The use of anatomic pre-contoured plates in the treatment of mid-shaft clavicle fractures

The use of anatomic pre-contoured plates in the treatment of mid-shaft clavicle fractures

Percutaneous Pinning of Displaced Midshaft Clavicle Fractures

ABSTRACTFractures of the clavicle are common and seen across all age groups. The traditional treatment of midshaft clavicle fractures has been conservative. Although minimally displaced fractures do well, recent outcome studies have shown higher incidences of fracture malunion, nonunion, and patient