Is shortening of displaced midshaft clavicle fractures associated with inferior clinical outcomes following nonoperative management? A systematic review

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.

An Institutional Standardised Protocol for the Treatment of Acute Displaced Midshaft Clavicle Fractures (ADMCFs): Conservative or Surgical Management for Active Patients?

BACKGROUND AND OBJECTIVES

The treatment of acute displaced midshaft clavicle fractures (ADMCFs) is still under debate. The aim of this study was to verify the effectiveness of our institutional protocol by comparing the clinical and radiographic outcomes of two groups of patients with ADMCFs treated operatively and non-operatively.

MATERIALS AND METHODS

active patients with a traumatic, isolated non-pathological ADMCF with at least 1-year clinical and radiographic follow up were included. Surgical treatment was performed in the cases where the residual displacement was higher than 140% after the application of a figure-of-eight bandage (F8-B). All other cases were treated conservatively with a F8-B. A total of 134 patients were enrolled and divided into two groups: surgical and conservative groups, with 59 and 75 patients, respectively. Radiological and clinical parameters were evaluated.

RESULTS

Good clinical (Constant-Murley Score, the Quick Disability of the Arm, Shoulder and Hand score, and VAS satisfaction) and radiographic outcomes (initial and residual shortening, initial and residual displacement) were obtained for ADMCFs in both groups. Multivariate analysis showed that patients treated conservatively had better clinical outcomes compared to surgically treated patients (p < 0.001). Return to sports was longer in those treated with surgery. Initial shortening was found to impact clinical outcomes as well as initial displacement. None of the patients showed signs of non-union in both groups.

CONCLUSIONS

Very good mid-term clinical results can be obtained in adult patients with ADMCFs, conservatively or operatively managed, by applying our institutional treatment protocol based on objective radiographic parameters evaluated in the ER.

Closed midshaft clavicle fractures

Aims

The management of mid-shaft clavicle fractures (MSCFs) has evolved over the last three decades. Controversy exists over which specific fracture patterns to treat and when. This review aims to synthesize the literature in order to formulate an appropriate management algorithm for these injuries in both adolescents and adults.

Methods

This is a systematic review of clinical studies comparing the outcomes of operative and nonoperative treatments for MSCFs in the past 15 years. The literature was searched using, PubMed, Google scholar, OVID Medline, and Embase. All databases were searched with identical search terms: mid-shaft clavicle fractures (± fixation) (± nonoperative).

Results

Using the search criteria identified, 247 studies were deemed eligible. Following initial screening, 220 studies were excluded on the basis that they were duplicates and/or irrelevant to the research question being posed. A total of 27 full-text articles remained and were included in the final review. The majority of the meta-analyses draw the same conclusions, which are that operatively treated fractures have lower nonunion and malunion rates but that, in those fractures which unite (either operative or nonoperative), the functional outcomes are the same at six months.

Conclusion

With regard to the adolescent population, the existing body of evidence is insufficient to support the use of routine operative management. Regarding adult fractures, the key to identifying patients who benefit from operative management lies in the identification of risk factors for nonunion. We present an algorithm that can be used to guide both the patient and the surgeon in a joint decision-making process, in order to optimize patient satisfaction and outcomes. Cite this article: Bone Jt Open 2022;3(11):850–858.

Plate fixation of midshaft clavicle fractures for delayed union and non-union is a cost-effective intervention but functional deficits persist at long-term follow-up

BACKGROUND

The primary aim of this study was to compare the long-term functional outcome of midshaft clavicle fracture fixation for delayed (≥3 month) and non-union (≥6 month) compared to a matched cohort of patients that achieved union with non-operative management. The secondary aim was to assess cost-effectiveness of fixation.

METHODS

A consecutive series of patients over 10-years were retrospectively reviewed using the QuickDASH, Oxford Shoulder Score and EuroQol five-dimension summary index (EQ-5D). These patients were compared to a matched cohort that achieved union after non-operative management using propensity score matching.

RESULTS

Sixty patients (follow-up 79%, n = 60/76) at 4.1 years post-operative (1.1-10.0 years) had a QuickDASH of 16.5 (95% CI 11.6-21.5), Oxford Shoulder Score 41.5 (39.0-44.1) and EQ-5D 0.7621 (0.6822-0.8421). One in five patients were dissatisfied with their final outcome (n = 13/60). Functional outcome was inferior following fixation when compared to patients that united with non-operative management (QuickDASH 16.5 vs. 5.5, p < 0.001 and EQ-5D 0.7621 vs. 0.9073, p = 0.001). However, significant improvements were found when compared to pre-operative scores (QuickDASH p < 0.001 and EQ-5D p < 0.001). The cost per QALY for fixation was £5624.62 for the study cohort.

CONCLUSIONS

Clavicle fixation for delayed and non-union is a cost-effective intervention but outcomes are worse compared to patients that unite with non-operative management.

Management of Displaced Midshaft Clavicle Fractures with Figure-of-Eight Bandage: The Impact of Residual Shortening on Shoulder Function

The treatment of displaced midshaft clavicle fractures (MCFs) is still controversial. The aims of our study were to evaluate clinical and radiological outcomes and complications of patients with displaced MCFs managed nonoperatively and to identify potential predictive factors of worse clinical outcomes. Seventy-five patients with displaced MCFs were enrolled and treated nonoperatively with a figure-of-eight bandage (F8-B). Initial shortening (IS) and displacement (ID) of fragments were radiographically evaluated at the time of diagnosis and immediately after F8-B application by residual shortening (RS) and displacement (RD). The clavicle shortening ratio was evaluated clinically at last follow-up. Functional outcomes were assessed using Constant (CS), q-DASH, DASH work and DASH sport scores. Cosmetic outcomes and rate of complications were evaluated. Good to very good mid-term clinical results were achieved by using the institutional treatment protocol. Multiple regression identified RS as an independent predictor of shoulder function, while RD affects fracture healing. These findings support the efficacy of our institutional protocol and thus could be useful for orthopedic surgeons during the decision-making process.

Acute plate fixation of displaced midshaft clavicular fractures is not associated with earlier return of normal shoulder function when union is achieved

Aims

It is unclear whether acute plate fixation facilitates earlier return of normal shoulder function following a displaced mid-shaft clavicular fracture compared with nonoperative management when union occurs. The primary aim of this study was to establish whether acute plate fixation was associated with a greater return of normal shoulder function when compared with nonoperative management in patients who unite their fractures. The secondary aim was to investigate whether there were identifiable predictors associated with return of normal shoulder function in patients who achieve union with nonoperative management.

Methods

Patient data from a randomized controlled trial were used to compare acute plate fixation with nonoperative management of united fractures. Return of shoulder function was based on the age- and sex-matched Disabilities of the Arm, Shoulder and Hand (DASH) scores for the cohort. Independent predictors of an early recovery of normal shoulder function were investigated using a separate prospective series of consecutive nonoperative displaced mid-shaft clavicular fractures recruited over a two-year period (aged ≥ 16 years). Patient demographics and functional recovery were assessed over the six months post-injury using a standardized protocol.

Results

Data from the randomized controlled trial consisted of 86 patients who underwent operative fixation compared with 76 patients that united with nonoperative treatment. The recovery of normal shoulder function, as defined by a DASH score within the predicted 95% confidence interval for each respective patient, was similar between each group at six weeks (operative 26.7% vs nonoperative 25.0%, p = 0.800), three months (52.3% vs 44.2%, p = 0.768), and six months post-injury (86.0% vs 90.8%, p = 0.349). The mean DASH score and return to work were also comparable at each timepoint. In the prospective cohort, 86.5% (n = 173/200) achieved union by six months post-injury (follow-up rate 88.5%, n = 200/226). Regression analysis found that no specific patient, injury, or fracture predictor was associated with an early return of function at six or 12 weeks.

Conclusion

Return of normal shoulder function was comparable between acute plate fixation and nonoperative management when union was achieved. One in two patients will have recovery of normal shoulder function at three months, increasing to nine out of ten patients at six months following injury when union occurs, irrespective of initial treatment.

Cite this article: Bone Jt Open 2021;2(7):522–529.

Adolescent mid-shaft clavicular fracture displacement does not predict nonunion or inferior functional outcome at long-term follow-up

AIMS

The aim of this study was to define the complications and long-term outcome following adolescent mid-shaft clavicular fracture.

METHODS

We retrospectively reviewed a consecutive series of 677 adolescent fractures in 671 patients presenting to our region (age 13 to 17 years) over a ten-year period (2009 to 2019). Long-term patient-reported outcomes (abbreviated version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) score and EuroQol five-dimension three-level (EQ-5D-3L) quality of life score) were undertaken at a mean of 6.4 years (1.2 to 11.3) following injury in severely displaced mid-shaft fractures (Edinburgh 2B) and angulated mid-shaft fractures (Edinburgh 2A2) at a minimum of one year post-injury. The median patient age was 14.8 years (interquartile range (IQR) 14.0 to 15.7) and 89% were male (n = 594/671).

RESULTS

The majority of fractures were mid-shaft (n = 606) with angulation (Edinburgh 2A2, n = 241/606, 39.8%) or displacement (Edinburgh 2B1/2, n = 263/606, 43.4%). Only 7% of the displaced mid-shaft fractures underwent acute fixation (n = 18/263). The incidence of refracture over ten years following nonoperative management of mid-shaft fractures was 3.2% (n = 19/588) and all united without surgery. Fracture type, severity of angulation, or displacement were not associated with refracture. One nonunion occurred following nonoperative management in a displaced mid-shaft fracture (0.4%, n = 1/245). Of the angulated fractures, 61 had angulation > 30°, of which 68.9% (n = 42/61) completed outcome scores with a median QuickDASH of 0.0 (IQR 0.0 to 0.6), EQ-5D-3L 1.0 (1.0 to 1.0), and 98% satisfaction with shoulder function. For the displaced fractures, 127 had displacement beyond one cortical width of bone for which completed outcome scores were provided in 72.4% (n = 92/127). Of these 15 had undergone acute fixation. Following nonoperative treatment, the median QuickDASH was 0.0 (IQR 0.0 to 2.3), EQ-5D-3L 1.0 (1.0 to 1.0), and satisfaction with shoulder function was 95%. There were no significant differences in the patients' demography or functional outcomes between operative and nonoperative treatments.

CONCLUSION

Nonoperative management of adolescent mid-shaft clavicle fractures results in excellent functional outcomes at long-term follow-up. Nonunion is exceptionally rare following nonoperative management and the relative indications for surgical intervention in adults do not appear to be applicable to adolescents. Cite this article: Bone Joint J 2021;103-B(5):951-957.

Reliability of the radiographic views in supine position for evaluation of displaced midshaft clavicle fracture length

PURPOSE

To analyze the agreement of the displaced midshaft clavicle fracture length measurement between each of the supine radiographic position (chest anteroposterior (AP), both clavicle AP, and 20° cephalic tilt clavicle AP view) and computed tomography (CT) scan of the clavicle. Furthermore, the inter- and intraobserver reliability of each radiographic position was analyzed.

METHODS

Prospective cross-sectional study was performed with patients diagnosed with displaced midshaft clavicle fracture treated conservatively. Three views of radiographs and CT scan of clavicle were obtained in supine position after informed consent. The measurement of fractured clavicle length was done by three observers at the time and after 4 weeks interval.

RESULTS

Thirty-three patients (25 males and 8 females), with a mean age of 45, were recruited. The agreement between each of the radiographic measurement and CT scan was good. The interobserver reliability was moderate to good for radiographic measurement. The highest intraclass correlation coefficient (ICC) of 0.80-0.81 was shown between the 20° cephalic tilt and the CT scan, followed by the both clavicle AP (0.75-0.77) and the chest AP (0.69-0.75), respectively. There was an excellent intraobserver reliability for all of the radiographic measurement with the ICC 0.92-0.99.

CONCLUSION

The supine radiographs could be a useful option to measure the displaced midshaft clavicle fracture length. The recommended view was the 20° cephalic tilt clavicle AP view in supine position to best evaluate the fractured clavicle length.

Prospective evaluation of early functional recovery of displaced fractures of the middle third of the clavicle whether operated or not

INTRODUCTION

Several studies have analyzed the functional recovery after plate fixation of a displaced fracture of the middle third of the clavicle beyond the 6th week. The aim of this study was to assess the early functional recovery in the first 6 weeks, which has not yet been investigated.

HYPOTHESIS

Functional recovery in the first 6 weeks after surgical treatment is better than in the first 6 weeks of functional (non-operative) treatment.

METHODS

Any patient who had a closed displaced fracture of the middle third of the clavicle - Edinburgh types 2B1 or 2B2 - was informed of the treatment options within a week of their fracture: surgical fixation by anatomic plate or functional treatment. A QuickDASH score was filled out weekly for 6 weeks and at 3 and 6 months. Similarly, the Constant score was determined at 3 and 6 weeks and at 3 and 6 months. Any complications were documented and time to union was determined.

RESULTS

Sixty-five fractures in 65 patients were followed for 6 months. Twenty-six patients chose surgical treatment (S) and 39 chose functional treatment (F). The Constant and QuickDASH scores were significantly better in the S group from the 2nd to the 6th week. At 3 weeks, we found a Constant score of 57.7 in group F versus 74.9 in group S (p<0.01) and a QuickDASH of 55.9 in group F versus 27.4 in group S (p<0.001). At 6 weeks, the Constant score was 71.3 versus 86.1 (p<0.001) and the QuickDASH was 28.3 versus 10.6 (p<0.01), respectively. At 3 and 6 months, the recovery was comparable in both groups for these two scores. Return to work was earlier in the S group (34.3 versus 59.7 days; p<0.05).

DISCUSSION

This is the first study reporting the functional results during the first 6 weeks after a displaced fracture of the middle third of the clavicle in adults. Further studies should be conducted to better identify target patients for whom fracture fixation may be beneficial.

CONCLUSION

This study supports open reduction and internal fixation with an anatomical plate of displaced fractures of the middle third of the clavicle since the functional recovery is better in the first 6 weeks.

LEVEL OF EVIDENCE

III; prospective case-control study.

Variation in management of humeral and clavicular shaft fractures amongst fellowship trained orthopedic traumatologists

Background

There exists a wide variety of opinions on the appropriate management of diaphyseal humeral and clavicular fractures amongst orthopedic surgeons.

The purpose of this study is to determine if there is a preference amongst orthopedic traumatologists on treatment of diaphyseal humerus and clavicle fractures with respect to various patient populations.

Methods

A 6-question survey was created using Surveymonkey.com and distributed via the Orthopedic Trauma Association (OTA) website to fellowship trained orthopedic surgery traumatologists to survey the preferred management of a simple oblique middle 1/3rd diaphyseal humerus fracture and a middle 1/3rd displaced diaphyseal clavicle fracture in the following 3 clinical settings: a healthy laborer, an older patient with co-morbidities, and if the surgeon themselves sustained the injury. The ratio of operative to non-operative management was calculated for all 6 questions. A chi-square value was performed to determine if the results are clinically significant based on the clinical scenario.

Results

There was 56 responses to the survey that were included in the analysis. Overall, there was a statistically significant trend towards surgical management of the surgeon’s own diaphyseal humerus fractures (55%) compared to that of healthy patients (41%) and those with medical comorbidities (21%) (p = 0.02) A similar trend was noted for operative management for diaphyseal clavicle fractures by the surgeon on their own fractures (43%) compared to that of healthy patients (38%) and those with medical comorbidities (18%) (p = 0.02).

Conclusion

While there are an increasing number of relative indications for treatment of diaphyseal humerus shaft and clavicle fractures, the results of this survey indicate that fellow-ship-trained orthopedic trauma surgeons prefer surgical management of simple humerus and clavicular fractures in young, healthy patients as well as in themselves.

Plating and cortical bone grafting of clavicular nonunions: clinical outcome and its relation to clavicular length restoration

Background

The goal of this study was to evaluate whether plating and cortical bone grafting of shortened clavicular nonunions would restore clavicular length and enable bone healing. The association between the clavicular length difference (CLD) between sides and long-term functional outcome was also explored.

Methods

For this retrospective 2-center study, patients who underwent plate fixation with cortical bone grafting of a clavicular nonunion were assessed after ≥2 years. The CLD and bone union were assessed using radiography and navigation ultrasound. The functional outcome was determined by the Constant score, Simple Shoulder Test score, and Subjective Shoulder Value, as well as local pain (0-10 numeric rating scale).

Results

Between 2 and 13 years after surgery, 25 patients (mean age, 53 years; 13 female patients) were examined. The median CLD was 0 mm (range, –17 to 13 mm) on ultrasound measurements and 2 mm (range, –32 to 9 mm) on radiographs. At follow-up, the median Constant score, Simple Shoulder Test score, Subjective Shoulder Value, and pain level were 82 points (range, 38-95 points), 12 points (range, 3-12 points), 95% (range, 60%-100%), and 0 (range, 0-8), respectively. There was no correlation between the CLD and all functional outcome scores. Bone union was achieved in all patients. After plate removal, 4 refractures occurred, 3 of which required revision.

Conclusions

Plate fixation with cortical bone grafting of clavicular nonunions is associated with restoration of clavicular length and a high rate of bone union. There is, however, a considerable risk of refracture following plate removal. There was no association between the CLD and clinical outcome.