Verkürzungsfehlstellung des Schlüsselbeins nach diaphysären Klavikulafrakturen

Can Upstream Patient Education Improve Fracture Care in a Digital World? Use of a Decision Aid for the Treatment of Displaced Diaphyseal Clavicle Fractures

BACKGROUND

The increasing proportion of telemedicine and virtual care in orthopaedic surgery presents an opportunity for upstream delivery of patient facing tools, such as decision aids. Displaced diaphyseal clavicle fractures (DDCFs) are ideal for a targeted intervention because there is no superior treatment, and decisions are often dependent on patient's preference. A decision aid provided before consultation may educate a patient and minimize decisional conflict similarly to inperson consultation with an orthopaedic traumatologist.

METHODS

Patients with DDCF were enrolled into 2 groups. The usual care group participated in a discussion with a trauma fellowship-trained orthopaedic surgeon. Patients in the intervention group were administered a DDCF decision aid designed with the International Patient Decision Aid Standards. Primary comparisons were made based on a decisional conflict score. Secondary outcomes included treatment choice, pain score, QuickDASH, and opinion toward cosmetic appearance.

RESULTS

A total of 41 patients were enrolled. Decisional conflict scores were similar and low between the 2 groups: 11.8 (usual care) and 11.4 (decision aid). There were no differences in secondary outcomes between usual care and the decision aid.

DISCUSSION

Our decision aid for the management of DDCF produces a similarly low decisional conflict score to consultation with an orthopaedic trauma surgeon. This decision aid could be a useful resource for surgeons who infrequently treat this injury or whose practices are shifting toward telemedicine visits. Providing a decision aid before consultation may help incorporate patient's values and preferences into the decision-making process between surgery and nonoperative management.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Influence of radiographic projection and patient positioning on shortening of the fractured clavicle

Background

Radiographic measurements of shortening and vertical displacement in the fractured clavicle are subject to a variety of factors such as patient positioning and projection. The aims of this study were (1) to quantify differences in shortening and vertical displacement in varying patient positions and X-ray projections, (2) to identify the view and patient positioning indicating the largest amount of shortening and vertical displacement, and (3) to identify and quantify the inter- and intraobserver agreement.

Methods

A prospective clinical measurement study of 22 acute Robinson type 2B1 clavicle fractures was performed. Each patient underwent 8 consecutive standardized and calibrated X-rays in 1 setting.

Results

In the upright patient position, the difference of absolute shortening was 4.5 mm (95% confidence interval [CI]: 3.0-5.9, P < .0001) larger than in the supine patient position. For vertical displacement, the odds of being scored a category higher in the upright patient position were 4.7 (95% CI: 2.2-9.8) times as large as the odds of being scored a category higher in supine position. The odds of being scored a category higher on the caudocranial projection were 5.9 (95% CI: 2.8-12.6) times as large as the odds of being scored a category higher on the craniocaudal projection.

Conclusion

Absolute shortening, relative shortening, and vertical displacement were found to be the greatest in the upright patient positioning with the arm protracted orientation on a 15° caudocranial projection. No statistically significant differences were found for a change in position of the arm between neutral and protracted.

Does altering projection of the fractured clavicle change treatment strategy?

BACKGROUND

Shortening of the fractured clavicle is proposed and debated as an indicator for surgical intervention. There is no standardized or uniform method for imaging and measuring shortening. Different methods and techniques can lead to different measured outcomes. However, the question remains whether a difference in measured shortening using a different technique has any short-term clinical relevance in terms of treatment strategy. The aim of this study was to investigate whether a different projection of the same midshaft clavicular fracture would lead to a different choice in treatment strategy.

METHODS

Thirty-six AO-OTA (Arbeitsgemeinschaft für Osteosynthesefragen-Orthopaedic Trauma Association) 15A.1-15A.3 midshaft clavicular fractures were digitally reconstructed into radiographs using both 15° caudocranial and 15° craniocaudal projections. The 72 projections were rated in random order by 23 orthopedic trauma or upper-extremity surgeons on the need for either conservative or operative treatment.

RESULTS

On average, the raters altered their treatment strategy with a different projection of the same midshaft clavicular fracture 12.2 times among the 36 cases (33.9%), ranging from 5 times (13.9%) to 19 times (52.8%). A statistically significant increase in choice for surgical treatment was identified when using the 15° caudocranial projection (P = .01).

CONCLUSION

This study reveals the influence the projection of the midshaft clavicular fracture has on the surgeon's decision of treatment strategy. The decision changes from operative to nonoperative or vice versa in 33.9% of the cases.

Midshaft clavicle fractures: Current concepts

Clavicle fractures are common fractures and the optimal treatment strategy remains debatable. The present paper reviews the available literature and current concepts in the management of displaced and/or shortened midshaft clavicle fractures.

Operative treatment leads to improved short-term functional outcomes, increased patient satisfaction, an earlier return to sports and lower rates of non-union compared with conservative treatment. In terms of cost-effectiveness, operative treatment also seems to be advantageous.

However, operative treatment is associated with an increased risk of complications and re-operations, while long-term shoulder functional outcomes are similar.

The optimal treatment strategy should be one tailor-made to the patient and his/her specific needs and expectations by utilizing a shared decision-making model.

Cite this article: EFORT Open Rev 2018;3:374-380. DOI: 10.1302/2058-5241.3.170033

[Complications after intramedullary stabilization of clavicle fractures]

BACKGROUND

Operative treatment of clavicle fractures by intramedullary nailing with titanium elastic nailing (TEN) has been established as an alternative to plate osteosynthesis for many years. The main complication after TEN osteosynthesis is nail migration. The goal of this study was evaluation of predictors for medial nail migration and comparison with plate osteosynthesis.

MATERIAL AND METHODS

A retrospective analysis of electronic patient charts, surgical protocols and radiographs of all operatively treated clavicle shaft fractures between 2010-2014 (n = 141) was performed. When evaluating the patient charts and the surgical protocols special attention was paid to the fracture type, the duration of the operation, the need for an open reduction and the onset of complications as well as the duration until implant removal. Radiographs were analyzed concerning the implant location and an implant migration.

RESULTS

Surgery time (39 vs. 83 min) as well as the time to implant removal (226 vs. 495 days) were significantly reduced (p = 0.00), while complication (39% vs. 21.4%) as well as reoperation rates (15% vs. 7.1%; p = 0.033) were increased in TEN compared to plate osteosynthesis. The main complication was medial nail migration. The following predictors regarding medial migration could be identified: open or closed reduction (p = 0.021), multifragmentary fractures (p = 0.049), oblique fractures (p = 0.08) and TEN thickness (33% at 2 mm, 0% at 3 mm).

DISCUSSION

Advantages of TEN are a shorter surgery time as well as a shorter duration until implant removal. The TEN osteosynthesis led to a significantly increased complication rate, with nail migration representing the major reason. When predictors for medial TEN migration are considered, type B and C fractures can also be sufficiently treated by a large diameter TEN.

Quantifying shortening of the fractured clavicle assuming clavicular symmetry is unreliable

BACKGROUND

One of the more commonly used methods of determining the amount of shortening of the fractured clavicle is by comparing the length of the fractured side to the length of contralateral unfractured clavicle. A pre-existing natural asymmetry can make quantification of shortening using this method unreliable. The goal of this study is to assess the side-to-side variation in clavicle length in 100 uninjured, skeletally mature adults.

MATERIALS AND METHODS

To assess the side-to-side difference in clavicle length the length of both clavicles of 100 patients on thoracic computed tomography (CT) scans were measured. Patients without a history of pre-CT clavicular injury were included. The measurements were allocated into three groups based on the amount of asymmetry (< 5, ≥ 5-10 and > 10 mm). Dominant side and sex were analyzed to determine influence on the length of the clavicle.

RESULTS

In 30 patients (30%), an asymmetry of 5 mm or more was found. 2% of the patients had a side-to-side difference of more than 10 mm. The absolute side-to-side length difference (LD) was 3.74 mm (95% CI 3.15-4.32; p < 0.001). A significant association between clavicle length and dominant side or sex was found (p < 0.001).

CONCLUSION

These results show that by utilizing a treatment algorithm based upon clavicular symmetry has a potential for error and can lead over- or under-treatment of the fractured clavicle. A significant association between clavicle length and dominant side or sex was found (p < 0.001).

LEVEL OF EVIDENCE

2.

Reliability of measurements of the fractured clavicle: a systematic review

BACKGROUND

The objective of this systematic review was to evaluate the reliability and reproducibility of measurements of shortening in midshaft clavicle fractures (MSCF) using any available imaging technique.

METHODS

Electronic databases (PubMed, EMBASE, and Cochrane) were searched. The 4-point-scale COSMIN checklist was used to evaluate the methodological quality of studies.

RESULTS

Four studies on reliability of measurement of MSCF were identified. These studies were of fair and poor quality. The reported intrarater reliability varied between none to fair, and intrarater reliability was minimal.

CONCLUSION

No definite conclusions could be drawn. In order to optimize future studies and the realization of comparable results, more research is necessary to identify a standardized method of imaging and measuring. Level of Evidence III.