A new approach for plate fixation of midshaft clavicular fractures

Management of Displaced Midshaft Clavicle Fractures in Pediatrics and Adolescents: Operative vs Nonoperative Treatment

The purpose of the current review is to describe the management of displaced midshaft clavicle fractures in pediatric and adolescent patients. Midshaft clavicle fractures are relatively common in pediatric and adolescent patients. They most commonly occur from direct trauma and are often related to sports participation in adolescents. Recent literature in the management of adult midshaft clavicle fractures has supported operative management due to improved functional outcomes, decreased time to union, leading to early return to activity. A similar trend of increasing frequency in operative management has been seen in pediatric and adolescent patients with no consensus in the literature on optimal management. Nonoperative treatment consists of with a brief period of sling immobilization followed by range of motion. Operative management may be considered for open fractures, fractures with significant neurovascular compromise and soft tissue complications. Studies have shown comparable mid- to long-term functional and patient-reported outcomes after operative and nonoperative management of midshaft clavicle fractures in pediatric patients.

Operative management of midshaft clavicle fractures demonstrates better long-term outcomes: A systematic review and meta-analysis of randomised controlled trials

Introduction

Midshaft clavicular fractures are common amongst young adults. Conservative or surgical treatment for definitive fracture management has been widely debate, both with their pros and cons. Previous meta-analyses compared the clinical outcomes between conservative and surgical treatment options of midshaft clavicular fractures but failed to elucidate any difference in functional improvement. We postulate that functional improvement after fracture union plateaus and the clinical outcome after treatment varies at different time points. This meta-analysis will focus on the synthesis comparison of outcomes at early, short-term results (3 months), intermediate-term (6 to 12 months) and long-term (>24 months) clinical outcomes.

Methods

A systematic search was done on databases (Pubmed, Embase, Medline, Cochrane) in June 2021. Search keywords were: midshaft clavicular fractures and clinical trials. Clinical trials fulfilling the inclusion criteria were selected for comparison and the clinical outcomes of midshaft clavicular fractures using surgical and non-surgical interventions in terms of improvement in the Disabilities of the Arm, Shoulder and Hand (DASH) score, Constant-Murley Score (CMS), time to union and risk ratio of treatment related complications were analysed in correlation with post-treatment timeframe.

Results

Of the 3094 patients of mean age 36.7 years in the 31 selected studies, surgical intervention was associated with improved DASH score (standard-mean difference SMD -0.22, 95% CI -0.36 to -0.07, p = 0.003; mean difference MD -1.72, 95% CI -2.93 to -0.51, p = 0.005), CMS (SMD 0.44, 95% CI 0.17–0.72, p = 0.001; MD 3.64, 95% CI 1.09 to 6.19, p = 0.005), time to union (non-adjusted SMD -2.83, 95% CI -4.59 to -1.07, p = 0.002; adjusted SMD -0.69, 95% CI -0.97 to -0.41, p<0.001) and risk ratio of bone-related complications including bone non-union, malunion and implant failure (0.21, 95% CI 0.1 to 0.42; p<0.001). Subgroup analysis based on time period after treatment showed that surgical intervention was far superior in terms of improved DASH score at the intermediate-term results (6–12 months later, SMD -0.16, 95% CI -0.30 to -0.02, p = 0.02; and long term results (>24 months SMD -4.24, 95% CI -7.03 to -1.45, p = 0.003) and CMS (>24 months, SMD 1.03, 95% CI 0.39 to 1.68, p = 0.002; MD 5.77, 95% CI 1.63 to 9.91, p = 0.006). Surgical outcome is independent of fixation with plates or intra-medullary nails.

Conclusion

Surgical intervention was associated with better clinical outcomes compared with non-surgical approach for midshaft clavicular fractures in terms of improvement in functional scores DASH, CMS, time to union and fracture related complications, although not to the minimal clinically significant difference. Benefits in the long-term functional improvements are more pronounced.

Cost-Effectiveness of Operative Versus Non-Operative Treatment for Clavicle Fracture: a Systematic Literature Review

PURPOSE OF REVIEW

Operative and non-operative treatment of midshaft clavicle fractures seems to yield comparative functional results. Furthermore, it has been suggested that surgery is more expensive compared with non-operative treatment of clavicle fracture. Cost-effectiveness seems to be more important in trends of treatment decisions. The purpose of this study is to investigate the cost-effectiveness of clavicle fracture treatment.

RECENT FINDINGS

Seven publications were selected, and 5 studies showed that operative treatment is more expensive than non-operative treatment. The mean overall cost per person in discounted prices was 10,230 USD for operative and 7923 USD for non-operative treatment. The mean absence from work ranged 8-193 and 24-69 days for operative and non-operative treatment, respectively. Studies varied in methods of assessing the cost-effectiveness of treatment modalities. Based on this literature review, routine operative treatment seems to be more expensive. In some cases, operative treatment might be more cost-effective. In all studies, direct and indirect costs of health care were calculated, but a great heterogeneity exists in the sources of cost data between countries. The cost-effectiveness of the treatment of clavicle fracture depends strongly on the cost of operative treatment and length of absence from work. Cost-effectiveness analysis could be a routine in RCT studies in the future.

Surgical approach for open reduction and internal fixation of clavicle fractures: a comparison of vertical and horizontal incisions

PURPOSE

This study was designed to compare the results of clavicle fracture open reduction internal fixation (ORIF) with standard horizontal incision versus vertical incision.

METHODS

ORIF surgery performed between October 2012 and August 2016 was included. The surgical approach was chosen according to surgeon preference as vertical or horizontal. Functional outcomes, fracture union, complications, scar appearance, skin irritation, and denervation around the scar were assessed at a minimum follow-up of three months.

RESULTS

Thirty-eight patients, age 39 ± 12 years, were operated upon, 22 through vertical incisions and 16 through horizontal incisions. There were no significant group differences in functional scores, fracture union, or complications. Two patients in the vertical incision group had a post-operative haematoma. The scar length was significantly shorter when a vertical incision was used (6.75 ± 1.25 cm vs 8.9 ± 2.3 cm, P = 0.001). The typical distribution of hypoesthetic skin area distal and lateral to the scar represented iatrogenic damage to the supraclavicular nerves and was found in 66% of patients. The mean hypoesthetic surface area was smaller in the vertical incision group (38 ± 29 cm² vs 48 ± 28 cm², P = non-significant).

CONCLUSION

Vertical incision results in shorter scars but may be associated with increased incidence of haematomas. Meticulous closure of the subcutaneous tissue is recommended.

Complications associated with plate fixation of acute midshaft clavicle fractures versus non-unions

An important consideration when counselling patients with midshaft clavicle fractures is whether operative treatment of non-union, if it develops after non-operative treatment, is associated with higher complication rate than acute fracture fixation. The aim of this study is to compare complications and re-operations after open reduction and plate fixation for acute midshaft clavicle fractures versus non-unions. The study was retrospective. There were 90 patients in the acute fixation group and 20 patients in the non-union group. The mean follow-up was 8 and 15 months, respectively, Logistic regression analysis was used to assess whether 'non-union surgery' was a predictor of complications and re-operations. Of 90 patients, 23 had complications in acute fixation group. Of 20, 7 developed 8 complications in the non-union group (p = 0.4). Of 90, 12 required re-operations in the acute fixation group compared to 5/20 requiring 7 re-operations in the non-union group (p = 0.19). When any complication or re-operation was considered, 'non-union surgery' was not significant predictor for complications (p = 0.78) or re-operations (p = 0.99). The complication and re-operation rates were not higher after non-union surgery compared to acute fracture fixation and were mostly related to persistent delayed or non-union, rather than operative complications. When counselling patients about treatment of midshaft clavicle fractures, a 'higher complication rate after surgery for non-union, should it happen' should not be an argument against non-operative treatment.

A Biomechanical and Clinical Comparison of Midshaft Clavicle Plate Fixation: Are 2 Screws as Good as 3 on Each Side of the Fracture?

Background:

The standard of care for plating displaced midshaft clavicle fractures has been 6 cortices of purchase on each side of the fracture. The use of locking plates and screws may afford equivalent biomechanical strength with fewer cortices of purchase on each side of the fracture.

Purpose:

To compare the biomechanical and clinical performance of 3- versus 2-screw constructs for plating displaced midshaft clavicle fractures.

Study Design:

Controlled laboratory study/cohort study; Level of evidence, 3.

Methods:

Lateral fragments of simulated midshaft fractures in 10 pairs of cadaveric clavicles were randomly assigned to plate fixation with either 3 nonlocking screws or 2 locking screws. Cyclic tensile loads were applied along the long axis of the clavicle. The constructs were then loaded to failure with pullout forces applied parallel to the long axis of the screws. Additionally, clinical outcomes of patients who had midshaft clavicle fractures that were surgically repaired were retrospectively identified and compared; 21 patients were treated with 3-screw constructs and 20 with 2-screw constructs.

Results:

Biomechanically, there were no significant differences for cyclic displacement, stiffness, yield load, or ultimate load between groups. Forces required for screw pullout were considerably higher than physiologic forces experienced by a healing clavicle in vivo. Clinically, there were no significant differences in American Shoulder and Elbow Surgeons, Constant, visual analog scale, and Single Assessment Numeric Evaluation scores; complications; or mean time to union. Additionally, we found that the plates used in the 2-screw group were consistently shorter.

Conclusion:

Plate fixation of displaced midshaft clavicle fractures with 4 cortices of purchase with 2 locking screws demonstrated no significant differences biomechanically when compared with fixation with 6 cortices of purchase and 3 nonlocking screws. Clinically, there were no significant differences in outcomes or complications seen in patients receiving 2- or 3-screw constructs.

Clinical Relevance:

Clinical benefits of using the 3-screw construct for plate fixation include decreased surgical exposure, morbidity, and cost, and the use of shorter and noncontoured straight plates eliminates the extra time and technical difficulty associated with matching longer contoured plates to the complex morphology of the clavicle.

Intrapleural Penetration of a Clavicle Fracture: An Indication for Operative Fixation

INTRODUCTION

Clavicle fractures are common injuries treated by orthopedic surgeons, with most injuries managed nonoperatively. Operative fixation of clavicle fractures is indicated in specific clinical scenarios such as open injuries, ipsilateral shoulder trauma, or fractures with associated neurovasculature compromise. Operative fixation is not widely accepted for closed injuries and is typically reserved for instances of failed closed treatment with resultant nonunion or delayed union. Among the complications associated with clavicle fractures, pneumothorax has not been commonly reported. We report a case of a severely displaced clavicle fracture requiring operative repair through plate fixation to achieve union of the fracture as well as resolve the pneumothorax.

CASE REPORT

A 22-year-old intoxicated male with no past medical history was admitted to the trauma bay in stable condition after being involved in a motor vehicle accident. On the primary survey, the patient was noted to be tachypneic with decreased breath sounds over his right hemithorax. Radiographic studies of his chest demonstrated a right proximal third clavicle fracture with inferior displacement with associated partial pneumothorax; the patient was also noted to have a right femoral shaft fracture. Neurovascular examinations of his extremities were normal. A chest thoracostomy tube was inserted and placed under suction. Computerized tomography studies later revealed that the fractured clavicle had penetrated the pleura and caused the partial lung collapse. The patient was initially placed in a sling and underwent intramedullary nailing of his femur on the day of presentation. Given the severe displacement of his clavicle fracture into the lung tissue resulting in pneumothorax, there was significant concern for nonunion and lack of resolution of the pneumothorax. 2 days after stabilization of his right femur fracture, the patient underwent open reduction with internal fixation of his right clavicle. Follow-up radiographs showed a healed clavicle fracture and resolved pneumothorax.

CONCLUSION

Closed clavicle fractures typically heal uneventfully. Low energy, minimally displaced clavicle fractures can be managed nonoperatively, but high energy, significantly displaced injuries may require operative repair. Specifically, if these injuries result in pneumothorax, physicians shoulder consider operative repair for both treatment of the bony defect as well resulting pneumothorax.

Anterior inferior plating versus superior plating for clavicle fracture: a meta-analysis

Background

The position of plate fixation for clavicle fracture remains controversial. Our objective was to perform a comprehensive review of the literature and quantify the surgical parameters and clinical indexes between the anterior inferior plating and superior plating for clavicle fracture.

Methods

PubMed, EMBASE, and the Cochrane Library were searched for randomized and non-randomized studies that compared the anterior inferior plating with the superior plating for clavicle fracture. The relative risk or standardized mean difference with 95% confidence interval was calculated using either a fixed- or random-effects model.

Results

Four randomized controlled trials and eight observational studies were identified to compare the surgical parameters and clinical indexes. For the surgical parameters, the anterior inferior plating group was better than the superior plating group in operation time and blood loss (P < 0.05). Furthermore, in terms of clinical indexes, the anterior inferior plating was superior to the superior plating in reducing the union time, and the two kinds of plate fixation methods were comparable in constant score, and the rate of infection, nonunion, and complications (P > 0.05).

Conclusions

Based on the current evidence, the anterior inferior plating may reduce the blood loss, the operation and union time, but no differences were observed in constant score, and the rate of infection, nonunion, and complications between the two groups. Given that some of the studies have low quality, more randomized controlled trails with high quality should be conduct to further verify the findings.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-017-1517-1) contains supplementary material, which is available to authorized users.

Anteroinferior versus superior plating of clavicular fractures

BACKGROUND

Open reduction and plate fixation has gained recognition as an effective treatment for certain types of clavicular fractures. However, 88% of cases report some implant-related problems. To determine the optimal plate position, the aim of the present study was to compare implant-related irritation and proportion of plate removal in patients with clavicular fractures undergoing plate fixation by an anteroinferior or superior approach.

METHODS

Retrospectively collected data of 39 patients who underwent anteroinferior plating for displaced midshaft clavicular fractures were compared with prospectively collected data of 60 patients who were treated with superior plate fixation as part of a multicenter randomized controlled trial. Electronic medical records were reviewed for reports of complications, in particular, implant-related irritation and implant removal during follow-up. In addition, all patients were contacted in June 2014 to obtain additional information. The primary outcome parameter was implant-related irritation.

RESULTS

Univariate and multivariate regression analysis showed plate position was not significantly associated with implant-related irritation. Higher rates of asymptomatic patients with the plate still in place were observed in the anteroinferior group (46% vs 22%, P = .01). Almost an equal percentage of implant removals was seen in both groups because of implant irritation (36% vs 37%, P = .938).

CONCLUSIONS

The present study found the surgical approach of clavicular plating was not associated with implant-related irritation. Future studies are needed to determine whether there is an optimal approach for clavicle plating.

Locking plate osteosynthesis of clavicle fractures: complication and reoperation rates in one hundred and five consecutive cases

PURPOSE

Locking plate osteosynthesis has become the preferred method for operative treatment of clavicle fractures. The method offers stable fixation, and would theoretically be associated with a low rate of fracture-related complications and reoperations. However, this remains to be explored in a large cohort, and our purpose was to assess the overall rates of complications and reoperations following locking plate osteosynthesis of mid-shaft clavicle fractures.

METHODS

We identified all locking plate osteosynthesis of mid-shaft clavicle fractures operated upon in our department from January 2008 to November 2010 (n = 114). Nine patients did not attend the follow-up at our institution. The study group of 105 fractures (104 patients, 86 males) had a median age of 36 years (14-75 years). Follow-up ranged from 0.5 to 3.5 years. No patients were allowed to load the upper extremity for six weeks. By studying patient files and radiographic material, we assessed complications and reoperations.

RESULTS

Overall, there were 31 cases (30 %) of plate removals for discomfort. There were five cases (5 %) of failure of osteosynthesis: two occurred early after approximately six weeks and three late after ten to 13 months postoperatively.

CONCLUSION

The overall rate of failure of osteosynthesis is low (5 %). The burden of plate removals in approximately one third of patients should be included in the preoperative information.

A patient with clavicle fracture and recurrent scapular winging with spontaneous resolutions

Injury to the long thoracic nerve with resulting serratus anterior palsy is a typical cause of medial scapular winging. We report a case of a 70-year-old female with scapular winging in the setting of a mildly comminuted midshaft clavicle fracture. The winging persisted for three months after the fracture, which became a nonunion. The winging spontaneously resolved prior to open reduction and internal fixation of the nonunion. The winging recurred after this surgery. The recurrence was attributed to transient irritation and/or inflammatory neuropathy of the brachial plexus caused by the surgical manipulation. This second episode of winging again spontaneously resolved. There are few reported cases of scapular winging in the setting of a clavicle fracture and only one case of recurrent scapular winging. In that case, which was in the setting of an acromioclavicular joint separation, the second episode of winging required long-term use of a brace. By contrast, our patient did not require bracing because the recurrent winging spontaneously resolved, making this a novel case. This case is important because it illustrates that recurrent scapular winging can occur, and spontaneously resolve, in the setting of a mid-shaft clavicle fracture after subsequent reconstruction of a fracture nonunion.

The outcome of surgical fixation of mid shaft clavicle fractures; looking at patient satisfaction and comparing surgical approaches

INTRODUCTION

Clavicle fractures represent 2.5% of fractures in adults and almost 44% of shoulder injuries. The treatment is usually non-surgical with good results; however, significantly displaced fractures can be associated with high non-union rate and therefore many would advocate surgical fixation. This is traditionally carried out by direct approach over the clavicle but an infraclavicular approach has also been used for clavicular fixation. The aim of this study was to identify the main indications for surgical intervention at our unit and patient satisfaction following surgery. We also wanted to compare the direct and the infraclavicular surgical approaches in relation to the outcome of surgical intervention.

MATERIALS AND METHODS

Retrospective study looking at all the clavicle fractures managed surgically over 5 years at our department. Information relating to surgical indication, surgical approach, complications, outcome, patient satisfaction, and oxford shoulder score were collected.

RESULTS

A total of 35 patients were identified, the majority were males (n = 25) and most (n = 29) were working at the time of injury. The commonest indication for surgery was displacement with shortening (n = 16). The infraclavicular approach was used in the majority of patients (n = 21), the rest (n = 14) had direct incision. Evidence of radiological and union was achieved in all patients after an average of 13 (8-24) weeks. There were no major complications but minor complications were reported in 28% and 19% of cases with direct and infraclavicular approaches, respectively. Plates were removed from six symptomatic patients; infraclavicular (n = 2) and direct approach (n = 4). Four asymptomatic plates were removed on patients' requests. All patients returned to work (after an average 2.6 months), had good oxford shoulder score between 12-20, regardless of the surgical approach used. All patients except one would recommend it to a friend.

CONCLUSION

Our study showed excellent surgical outcome for displaced clavicle fractures supported by the high union rate, good oxford shoulder score, high return to work rate, and good patient's satisfaction. The number of minor complications and symptomatic metal work removal was less in the infraclavicular approach.

Comparison of dynamic and locked compression plates for treating midshaft clavicle fractures

The purpose of this study was to compare the parameters of perioperative course and cost-effectiveness for patients with midshaft clavicle fractures treated by dynamic compression plates or locked compression plates.This retrospective, case-controlled study involved 54 patients with midshaft clavicle fractures who received dynamic compression plates (n=21) or locked compression plates (n=33) between January 2002 and December 2008. Indications for surgery included displacement or shortening >2 cm, comminuted fractures, and skin tenting. Patients with previous malunion, nonunion, multiple injuries of the shoulder girdle, or open fractures were excluded. Preoperative demographics showed no statistically significant differences between the 2 groups. Eighteen patients with dynamic compression plates and 28 patients with locked compression plates with postoperative follow-up >1 year were included for comparison. Statistical analyses for operative time, blood loss, complication rate, hospital stay, and union rate demonstrated no statistically significant difference between the 2 groups. The only statistically significant difference was a higher rate of plate removal requests in the dynamic compression plate group. Considering medical expenditure, locked compression plates cost 6 times more than dynamic compression plates in the authors' institution (US $600 vs $100, respectively).Other than more plate removal requests in the dynamic compression plate group and greater expense in the locked compression plate group, dynamic compression plates and locked compression plates achieved satisfactory operative outcomes in treating midshaft clavicle fractures, with no statistically significant difference between perioperative course and eventual fracture union observed between the 2 groups.

Systematic review of the complications of plate fixation of clavicle fractures

BACKGROUND

The number of displaced midshaft clavicle fractures treated surgically is increasing and plate fixation is often the treatment modality of choice. The study quality and scientific levels of evidence at which possible complications of this treatment are presented vary greatly in literature.

PURPOSES

The purpose of this systematic review is to assess the prevalence of complications concerning plate fixation of dislocated midshaft clavicle fractures.

METHODS

A computer-based search was carried out using EMBASE and PUBMED/MEDLINE. Studies included for review reported complications after plate fixation alone or in comparison to either treatment with intramedullary pin fixation and/or nonoperative treatment. Two quality assessment tools were used to assess the methodological quality of the studies. Included studies were ranked according to their levels of evidence.

RESULTS

After study selection and reading of the full texts, 11 studies were eligible for final quality assessment. Nonunion and malunion rates were less than 10% in all analysed studies but one. The vast majority of complications seem to be implant related, with irritation or failure of the plate being consistently reported on in almost every study, on average ranging from 9 to 64%.

CONCLUSION

The quantity of relevant high evidence studies is low. With low nonunion and malunion rates, plate fixation can be a safe treatment option for acute dislocated midshaft clavicle fractures, but complications related to the implant material requiring a second operation are frequent. Future prospective trials are needed to analyse the influence of various plate types and plate position on implant-related complications.

[Locking, multidimensional plate osteosynthesis of midshaft clavicle fracture]

BACKGROUND

The goal of this consecutive, retrospective clinical follow-up study was to analyse the quality of treatment with a multidimensional, anatomical locking plate osteosynthesis after comminuted clavicle shaft fracture (Robinson 2B).

PATIENTS AND METHODS

Of 38 operated patients, 35 were examined after locking plate osteosynthesis, with a median follow-up of 32 months (11-65). Four patients had suffered a 2B1 Robinson fracture and 31 patients a 2B2 Robinson fracture. The clinical and functional results were determined based on the standard clinical examination of the shoulder, the Constant and DASH scores, an analogue visual scale and a patient survey.

RESULTS

The clinical examination yielded a mean DASH score of 1.25, a mean Constant score of 98 and a mean VAS score on the visual analogue scale of 0.4 (with a range of 0-6). Neither nonunion nor implant failure was observed. We did, however, have one case of infection of the soft tissue.

CONCLUSION

The treatment of comminuted shaft fractures of the clavicle by means of a multidimensional locking plate is a safe treatment option that includes early functional postoperative care with free range of motion.

The comminuted midshaft clavicle fracture: a biomechanical evaluation of plating methods

BACKGROUND

The optimal plate location and fixation method for midshaft fractures of the clavicle remains undetermined. The objective of this study was to develop a realistic biomechanical model with which to compare superior with inferior-medial plate placement, and the failure resistance of locked and against non-locked constructs.

METHODS

We estimated implant loads for operated patients in early rehabilitation utilising 3-D mathematical model of the shoulder. During simulation of upper limb motion associated with eating, the fracture opened in an inferior and frontal direction. The peak X, Y, and Z loads from the simulation were reproduced using a materials testing machine. A one centimetre transverse osteectomy was created at the midshaft of forty composite clavicles. Each specimen was then fixed with either (1) non-locked superior plating (n=10), (2) locked superior plating (n=10), (3) non-locked inferior-medial plating (n=10), or (4) locked inferior-medial plating (n=10). Specimens were loaded at 20 N/s in four-point bending for 50 cycles to the peak X, Y, Z moment obtained from the computational model (-3.50, 2.46, and -1.00 N m), then loaded to failure at 20 N/s.

FINDINGS

Inferior-medial unlocked plates were significantly stiffer than superior locked plates (P=0.046).

INTERPRETATION

Operative fixation of midshaft clavicle fractures is controversial, though becoming more widely accepted. Few biomechanical data are available to assist surgical decision-making. Inferior plates may be better equipped to resist the in vivo loads experienced by the clavicle during early rehabilitation after internal fixation, particularly during the shoulder flexion motions associated with eating.

Superior versus anteroinferior plating of the clavicle revisited: a mechanical study

OBJECTIVES

This study was designed to compare bone-implant stiffness of two fixation techniques on a sawbone model of a clavicle fracture.

METHODS

Twenty-four preosteotomized synthetic left clavicles (Sawbones Worldwide, Vashon, WA) were divided into four groups based on type of fixation: standard 3.5-mm pelvic reconstruction plate in the superior position; standard 3.5-mm pelvic reconstruction plate in an anteroinferior position; 3.5-mm locking pelvic reconstruction plate in a superior position; and a 3.5-mm locking pelvic reconstruction plate in an anteroinferior position. Three nondestructive cyclic mechanical tests were performed in random order: axial, torsion, and four-point bend.

RESULTS

No significant difference was found in axial (P = 0.61) or torsional stiffness (internal rotation, P = 0.46 or external rotation, P = 0.49) among all groups. No significant difference occurred in bending rigidity (four-point bending test) with type of plate (P = 0.41), but when the plate was placed anteroinferiorly, bending rigidity was significantly higher (P < 0.001) than in the superior position.

CONCLUSION

Placing the plate anteroinferiorly on the clavicle provides a more stable construct in terms of bending rigidity with no detriment in axial and torsional stiffness compared with placing the plate superiorly. We believe that anteroinferior plating is preferred as a result of the increase in bending rigidity together with other advantages, including avoidance of neurovascular compromise, the use of longer screws, and decreased hardware prominence.

Malunion after midshaft clavicle fractures in adults

This is an overview of the current literature on malunion after midshaft clavicle fracture. Anatomy, trauma mechanism, classification, incidence, symptoms, prevention, and treatment options are all discussed. The conclusion is that clavicle malunion is a distinct clinical entity that can be treated successfully.

Treatment of midshaft clavicular delayed and non-unions with anteroinferior locking compression plating

INTRODUCTION

Pain and impaired shoulder function are the predominant symptoms of midshaft clavicle non-unions. Obtaining consolidation and improvement of shoulder function is often successfully achieved with osteosynthesis and bone grafting. Most data in the literature pertain to plate osteosynthesis, placing the plate on the subcutaneous superior aspect of the clavicle. Although union rates are generally high, most patients require hardware removal as the plate is prominent under the skin causing pain and cosmetic problems.

MATERIALS AND METHODS

In the current retrospective study, we followed a cohort of 21 consecutive cases (20 patients) with a midshaft clavicular delayed or non-union, treated with anteroinferior plating using a 3.5 mm locking compression plate (LCP) for a mean of 30 months.

RESULTS

We operated on 10 males and 10 females with a mean age of 48.2 years (range 16-65). There was one early plate failure that needed revision. Two patients required hardware removal because of prominence of the plate. All but two patients were satisfied with the final cosmetic result. The average DASH score at follow up was 22.8.

DISCUSSION AND CONCLUSIONS

Anteroinferior plating with a 3.5 mm LCP is a reliable and reproducible treatment of midshaft clavicular delayed and non-union regarding consolidation, function, cosmesis and reduction of second surgery.

Shaft fractures of the clavicle: current concepts

Fractures of the clavicle are common and have been typically addressed to nonoperative treatment. Favorable results, which predominantly were achieved in the young and adolescents, were supposed to be usual in midshaft clavicular fractures. However, in the presence of comminution or complete displacement, especially when occurring in females or elderly patients, there is a marked risk of nonunion, malunion, and poor outcome. Thus, many authors prefer primary surgical stabilization, when risk factors add up. Plate fixation and intramedullary stabilization seem to be equally favored. Though, indications for operative management remain controversial. Further prospective randomized comparative clinical trials are necessary for a well-founded risk-benefit analysis.

Clavicle fractures

Clavicular fractures represent 2.6—5% of all fractures, with middle third fractures being the commonest. The shape of the clavicle bone is such that it has a flat medial and lateral expanses, linked by a thin, tubular middle. This central transitional area represents a weak link in clavicular structure, which is not protected by or reinforced with muscle or ligamentous attachments, therefore rendering it prone to fracture. Due to the subcutaneous position of the clavicle, there is an inherent susceptibility to direct injury. These fractures are easy to diagnose due to the presence of swelling and bruising present. Radiographical examination should include an anteroposterior and a 45° caudal tilt view. Optimal treatment in undisplaced or minimally displaced fractures is with a sling. In displaced or comminuted fractures the risk of non-union and poor functional outcome may be markedly higher and may be best treated with surgical fixation.

Fractures of the clavicle

Undisplaced fractures of both the diaphysis and the lateral end of the clavicle have a high rate of union, and the functional outcomes are good after nonoperative treatment. Nonoperative treatment of displaced shaft fractures may be associated with a higher rate of nonunion and functional deficits than previously reported. However, it remains difficult to predict which patients will have these complications. Since a satisfactory functional outcome may be obtained after operative treatment of a clavicular nonunion or malunion, there is currently considerable debate about the benefits of primary operative treatment of these injuries. Displaced lateral-end fractures have a higher risk of nonunion after nonoperative treatment than do shaft fractures. However, nonunion is difficult to predict and may be asymptomatic in elderly individuals. The results of operative treatment are more unpredictable than they are for shaft fractures.

Management of acute clavicle fractures

It has been believed since the time of Hippocrates that clavicle fractures require little more than benign neglect by clinicians. Although many patients who have clavicle injuries do achieve adequate healing and functional recovery without surgical interventions, good outcomes, especially with displaced fractures, are not universal. Recent literature suggests that a subset of midclavicular injuries may warrant primary surgical treatment to minimize the incidence of nonunion and/or symptomatic malunion. Furthermore, certain types of clavicular injuries result in suboptimal outcomes when managed nonoperatively. This article is based on the currently available clinical evidence on the evolving management of acute clavicle fractures.

Acute midshaft clavicular fracture

Clavicular fractures represent 2.6% to 5% of all fractures, and middle third fractures account for 69% to 82% of fractures of the clavicle. The junction of the outer and middle third is the thinnest part of the bone and is the only area not protected by or reinforced with muscle and ligamentous attachments. These anatomic features make it prone to fracture, particularly with a fall on the point of the shoulder, which results in an axial load to the clavicle. Optimal treatment of nondisplaced or minimally displaced midshaft fracture is with a sling or figure-of-8 dressing; the nonunion rate is very low. However, when midshaft clavicular fractures are completely displaced or comminuted, and when they occur in elderly patients or females, the risk of nonunion, cosmetic deformity, and poor outcome may be markedly higher. Thus, some surgeons propose surgical stabilization of a complex midshaft clavicular fracture with either plate-and-screw fixation or intramedullary devices. Further randomized, prospective trials are needed to provide better data on which to base treatment decisions.

Open clavicle fractures and associated injuries

OBJECTIVES

To describe the associated injuries, demographic distribution, and management of patients sustaining open clavicle fractures.

DESIGN

Retrospective case series.

SETTING

A single level-1 trauma center.

PATIENTS

Twenty patients with open clavicle fractures were identified from a prospectively collected orthopaedic trauma registry.

INTERVENTION

All patients were managed with surgical irrigation and debridement with or without internal fixation.

RESULTS

Thirteen patients (65%) had a closed head injury. Fifteen patients (75%) had a significant associated pulmonary injury. In that group, there were 10 patients who had a pneumothorax (7 bilateral). Additionally, 12 patients had rib fractures and 11 had documented pulmonary contusions or effusions. Seven patients (35%) had a cervical or thoracic spine fracture or dislocation. Eight patients (40%) had concomitant scapula fractures. Six patients (30%) had additional ipsilateral upper extremity injuries remote from the shoulder girdle. One patient had a scapulothoracic dissociation. Eleven patients (55%) sustained significant facial trauma including fractures (5 patients), lacerations, and hematomas. Fourteen patients (70%) were treated with open reduction internal fixation. Fifteen patients (75%) were followed to healing (mean: 111 wk, median: 56 wk, range: 13 to 333 wk). There were no other complications related to the operative fixations. There were no known infections or nonunions.

CONCLUSIONS

Open clavicle fractures are a rare injury. Patients often have associated pulmonary and cranial injuries. Ipsilateral upper extremity and shoulder girdle injuries are common, whereas concomitant neurologic and vascular injuries are infrequent. The majority of patients have rapid and uneventful healing of their fractures after surgical treatment.