Quantifying shortening of the fractured clavicle assuming clavicular symmetry is unreliable

Limitations in rotational correction: 3D displacement analysis of midshaft clavicle fractures with titanium elastic nails

To investigate the three-dimensional displacement of midshaft clavicular fractures after closed reduction and fixation with titanium elastic intramedullary nails. From January 2019 to January 2023, 74 patients with midshaft clavicle fractures (classified according to the AO/OTA system as groups A, B, and C) underwent closed reduction and titanium elastic nail fixation. Preoperative bilateral clavicular CT data and postoperative CT data of the affected clavicle were recorded and processed using Mimics software. Clavicle length, clavicle shortening, separation, and rotational displacement along the X/Y/Z axes were measured and recorded. Within-group comparisons showed a significant reduction in clavicle shortening and separation displacements, with a notable restoration of clavicle length postoperatively (p < 0.05). Except for Z-axis rotational displacement in Group A, no significant differences were observed in clavicle rotational displacement along the X/Y/Z axes between preoperative and postoperative measurements (p > 0.05). Between-group comparisons showed that preoperative separation displacement was significantly associated with AO/OTA classification (H = 6.427, p = 0.040), while no significant differences were observed in other displacements between preoperative and postoperative measurements across groups. Titanium elastic intramedullary nails effectively restore clavicular length and correct shortening and separation displacement in midshaft fractures, but do not significantly improve rotational displacement along the X/Y/Z axes.

Measurement of clavicular symmetry: A hint for midshaft clavicle fracture management

BACKGROUND

Clavicle fractures represent approximately 2.6∼4 % of all fractures. The management of midshaft clavicle fractures is a topic of debate. The evaluation of clavicular shortening relies on the assumption of clavicular symmetry.

OBJECTIVE

Our hypothesis posited that clavicles were not of identical length, challenging the assumption of clavicular symmetry.

METHODS

This retrospective study was conducted at a level 1 hospital between February 1, 2022, and February 28, 2022, with a total of 200 consistent thoracic CT scans from patients with suspected pneumonia reviewed. Bilateral clavicle lengths were measured using thoracic CT plain scans. Intraclass correlation coefficients (ICC) were examined. Linear and logistic regression were performed.

RESULTS

In a total number of 170 patients, the left clavicles were 1.96 mm longer than the right clavicles on average (95 % CI 1.25-2.68, p < 0.001). In 118 patients (69.4 %), the bilateral clavicle length difference was between 0-5 mm; In 45 patients (26.5 %), the difference was 5-10 mm, and in 7 patients (4.1 %), the difference was greater than 10 mm. Positive correlations were found between height (p = 0.002), male gender (p < 0.001), and the absolute difference, respectively.

CONCLUSION

Clavicle asymmetry is present with a positive correlation with male gender and height. Surgeons shall be aware of this asymmetry in managing midshaft clavicle fractures.

SHORTENING OF CLAVICLE FRACTURES: PHYSICAL VERSUS IMAGE EXAMINATIONS

Objective

Determine the reliability of three different methods of evaluating bone shortening in displaced midshaft clavicle fractures (DCMF).

Method

A cross-sectional analytical study evaluated bone shortening by metric tape (MT), radiography (X-ray), and computed tomography (CT). Twenty-six men had been evaluated and used clavícula not broken as control. The collection of data was of the blind type for three specialists. Differences and reliability were analyzed with the Friedman and Kappa tests and validated with the T-test (CI: 95%; significance index p<0.05; Software "R" version 3.2.2).

Results

The MT measurements (control) showed abnormal distribution and significant statistical difference concerning the imaging tests (p=0.000008). There was a similarity between X-ray and CT and Kappa agreement of 0.65. The fractured clavicles presented similar measurements between the three methods (p=0.059), and the T-tests proved that the similarity was caused by chance or possible measurement errors.

Conclusion

Measurement by metric tape showed a tendency to overestimate bone shortening. The CT showed more reliable results for the diagnosis; however, the X-ray was sufficient for decision-making by surgeons, and therefore, it is not possible to rule out the importance of this resource for DCMF. Level of Evidence IV; Case-Control Study.

Plate prebending using a three-dimensional-printed model affords effective anatomical reduction in clavicular shaft fractures

BACKGROUND

A precontoured plate rarely fits properly within the patient's clavicle and must be bent intraoperatively. This study aimed to determine whether anatomical reduction could be achieved using a plate bent before surgery.

METHODS

This study included 87 consecutive patients with displaced mid-shaft clavicle fractures who underwent plate fixation and were followed-up for a minimum of 1 year. After exclusions, 39 consecutive patients underwent fixation with a precontoured plate bent intraoperatively (intraoperative bending group), and 28 underwent fixation with the plate bent preoperatively (preoperative bending group). Using free software and a three-dimensional (3D) printer, ipsilateral clavicle 3D-printed models were constructed. Using plain radiographs, the distance between the edge of the lateral inferior cortex and the medial inferior cortex was measured. The angle between the line connecting the inferior cortex edge and the line passing through the flat portion of the superior cortex of the distal clavicle was measured.

RESULTS

Mean length differences between the ipsilateral and contralateral clavicle were smaller on both anteroposterior (AP; P=0.032) and axial images (P=0.029) in the preoperative bending group. The mean angular differences on both AP (P=0.045) and axial images (P=0.008) were smaller in the preoperative bending group. No significant differences were observed between the two groups in functional scores at the last follow-up.

CONCLUSIONS

Smaller differences in length and angle between the ipsilateral and contralateral clavicle, indicative of reduction, were observed in the preoperative bending group. Using the precontoured technique with low expense, the operation was performed more effectively as reflected by a shorter operation time. Level of evidence: III.

Less than 1.5cm shortening in clavicle midshaft fracture has long-term functional impact

INTRODUCTION

Mediolateral shortening is a risk in treatment of clavicle shaft fracture, and can lead to scapular dyskinesis and shoulder dysfunction. Many studies advocated surgical treatment if shortening exceeds 15mm.

HYPOTHESIS

Clavicle shaft shortening of less than 15mm has negative impact on shoulder function at more than 1 year's follow-up.

MATERIALS AND METHODS

A retrospective case-control comparative study was performed, with assessment by an independent observer. Clavicle length was measured on frontal radiographs showing both clavicles, and the ratio between the healthy and affected sides was calculated. Functional impact was assessed on Quick-DASH. Scapular dyskinesis was analyzed by global antepulsion on Kibler's classification. In total, 217 files were retrieved for a 6-year period. Clinical assessment was performed for 20 patients managed non-operatively and 20 patients managed by locking plate fixation, at a mean 37.5months' follow-up (range: 12-69months).

RESULTS

Mean Quick-DASH score was significantly higher in the non-operated group: 11.363 [0-50] versus 2.045 [0-11.36] (p=0.0092). Pearson ρ correlation between percentage shortening and Quick-DASH score was -0.3956 [95% CI: -0.6295; -0.0959] (p=0.012). Clavicle length ratio differed significantly between groups: operated group, +2.2% [-5.1%; +17%] for 0.34cm; non-operated group, -8.28% [-17.3%; -0.7%] for 1.38cm (p<0.0001). Shoulder dyskinesis was significantly more frequent non-operated patients: 10 versus 3 (p=0.018). A threshold of 1.3cm shortening was found for functional impact.

CONCLUSION

Restoring scapuloclavicular triangle length is an important aim in management of clavicular fracture. Surgery by locking plate fixation is therefore to be recommended in case of>8% radiological shortening (1.3cm) to avoid medium- and long-term complications in shoulder function.

LEVEL OF EVIDENCE

III; case-control study.

Measurement of Clavicular Symmetry in Healthy Subjects Using Tomographic Database of Public Hospitals

Objective  This study aimed to perform an imaging evaluation to prove the existence or not of symmetry between the clavicles of healthy subjects from Curitiba, Paraná, Brazil, and identify potential factors influencing the clavicular length. Method  The study analyzed chest computed tomography (CT) scans of 211 patients with no clavicular fracture or malformations (100 women and 111 men). We measured the greatest clavicular diagonal on both sides, and the software automatically generated the maximum distance in millimeters. Relative and absolute frequencies described qualitative variables and mean values; quantitative variables used a 95% confidence interval. Value comparisons employed the student's t-test, and correlations determinations used Pearson's correlation coefficient. The significance level adopted was 5%. Results  There was a significant difference between the clavicular length (right clavicle, 143.58 mm; left clavicle, 145.72 mm; p = 0.037), indicating asymmetry. On average, the left clavicle was 3.71 mm larger. Asymmetry was significant for both men and women (p < 0.001). The average difference was 4.13 mm for men and 3.23 mm for women. Seventy-three percent of the sample had < 5 mm of asymmetry, 23.7% had 5 to 10 mm, and 3.3% had > 10 mm of asymmetry. Conclusion  The studied population did not present clavicular symmetry. On average, the left clavicle was longer than the right clavicle, with differences of 3.71 mm in the general sample, 3.23 mm in women, and 4.13 mm in men. The only significant factor was gender since men presented longer clavicles and higher differences than women.

Revisiting the surgical indication of mid-shaft clavicle fractures: Clavicle asymmetry

OBJECTIVES

The aim of the study was to investigate whether clavicular symmetry was a valid assumption and to assess the factors that could predict clavicular asymmetry.

PATIENTS AND METHODS

Between January 2021 and April 2021, a total of 100 consecutive patients (61 males, 39 females; mean age: 63.6±15.5 years; range, 27 to 94 years) whose both clavicles were adequately seen on chest computed tomography (CT) were retrospectively analyzed. Clavicular lengths were measured on three-dimensional (3D) reconstruction of chest CTs by two independent orthopedic surgeons on two separate occasions. The longest distance passing the straight line between the most lateral part of the clavicle at the acromioclavicular joint and the most medial point of the clavicle on the sternoclavicular joint was given as the clavicle length after adjusting tilt of convertible 3D CTs. Clavicular length difference was calculated by subtracting the short clavicle's length from the long clavicle's length. Patients' age and sex were noted. The calculated clavicular length differences were assigned into three groups: ≤5 mm, >5 mm and ≤10 mm, and >10 mm.

RESULTS

The mean right and left clavicle lengths were 13.9±1.3 cm and 14.1±1.2 cm, respectively (p<0.001). A total of 29 patients (29%) had >5 mm clavicle asymmetry and six patients (6%) had more than 10 mm clavicular length difference. Age, sex, and clavicular length were not associated with the clavicular length difference.

CONCLUSION

Our study results showed that 29% of the patients had >5 mm clavicular length asymmetry. The clavicular symmetry may not be a valid assumption in the decision making for the surgical treatment of mid-shaft clavicle fractures; thus, this assumption may lead to maltreatment. More factors that can predict clavicle asymmetry should be investigated in future studies.

Three-dimensional reconstruction and virtual reposition of fragments compared to two dimensional measurements of midshaft clavicle fracture shortening

Background

Midshaft clavicle fracture shortening measurement is a reported key element for indication to surgical management and reporting of clinical trials. Determination of pre-fracture clavicle length for shortening measurement remains an unresolved issue. The purpose of the study was to assess accuracy of a novel technique of three-dimensional reconstruction and virtual reposition of bone fragments (3D-VR) for determination of pre-fracture clavicle length and measurement of shortening.

Methods

Accuracy of 3D-VR measurements was assessed using 5 synthetic bone clavicle fracture models. Measurements were compared between caliper and 3D-VR technique measurements. Correlation between 3D-VR and 2D measurements on standard radiographs was assessed on a cohort of 20 midshaft fractures. Four different methods for 2D measurements were assessed.

Results

Mean difference between caliper measurements and 3D-VR was 0.74 mm (95CI = − 2.51;3.98) (p = 0.56) on synthetic fracture models. Mean differences between 3D-VR and standard radiograph shortening measurement methods were 11.95 mm (95CI = 7.44;16.46) for method 1 (Jeray et al.) and 9.28 mm (95CI = 4.77;13.79) for method 2 (Smekal et al.) (p < 0.05). Differences were − 1.02 mm (95CI = − 5.53;3.48) for method 3 (Silva et al.) and − 2.04 mm (95CI = − 6.55;2.47) for method 4 (own method). Interobserver correlation ranged between 0.85 and 0.99. A false positive threshold of 20 mm was measured by the two observers in 25% of the case according to method of method 1, 30–35% with method 2, 15% with method 3 et al. and 5–10% with the method 4.

Conclusion

3D VR is accurate in measuring midshaft clavicle fracture length and shortening. Two dimensional measurements may be used for approximation of clavicular shortening.

Current concepts in the treatment of midshaft clavicle fractures in adults

Midshaft clavicle fractures are the most common fracture of the clavicle accounting for 80% of all clavicle fractures. Traditionally, midshaft clavicle fractures are treated with conservative treatment even when prominent displacement is observed; however, recent studies revealed that nonunion or malunion rate may be higher with conservative treatment. Moreover, recent studies have shown better functional results and patient satisfaction with surgical treatment. This review article provides a review of clavicle anatomy, describes the current clavicle fracture classification system, and outlines various treatment options including current surgical options for clavicle fracture in adults.

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.

S-shaped titanium endomedullary nail reduces telescoping of comminuted midshaft clavicular fractures

BACKGROUND

The surgical treatment of displaced midshaft clavicular fractures (DMCF) is clinically relevant and a much discussed topic. The axial stability of DMCF after intramedullary nailing (IMN) is still a matter of debate.

OBJECTIVE

Our objective was to present a modification of IMN of DMCF with S-shaped titanium endomedullary nail (TEN) and determine fracture telescoping from day one after surgery to the time of fracture healing.

METHOD

In a prospective analytic cohort study over a 6-year period (2012-2017) at a Level II trauma care centre, a total of 128 patients with DMCF were included and classified according to the AO/OTA classification system. Group I was AO/OTA type 15.2A/15.2B (N = 68) and group II was AO/OTA type 15.2C (N = 60). After a modified open stabilization technique of each DMCF with IMN (S-shaped TEN), the dynamics of radiological assessed telescoping until union and rate of surgical adverse events were measured. Significance was assumed for p < 0.05.

RESULTS

One day after surgery, fractured clavicles were lengthened slightly in both groups compared to the unfractured clavicules (group I: 1.2%; group II: 0.9%). After osseus consolidation, the fractured clavicules were significantly shortened in both groups (group I: - 2.9%; group II: - 3.6%). Measurement of the clavicular shortening at one day postsurgically and at consolidation revealed a mean telescoping of - 3.99% in group I and of - 4.6% in group II. The difference between the two groups was not significant (P = 0.522). The overall rate of major surgical adverse events was 2.3%.

CONCLUSION

The proposed operative technique of IMN (stabilization of the DMCF with a long, S-shaped, tight-fitting TEN) provides enough axial stability to prevent significant telescoping of the comminuted fractures. The rate of nonunion is low and the overall rate of major adverse events is similar to the reported events after plate fixation in the literature.