Treatment of clavicular fractures. Figure-of-eight bandage versus a simple sling

Comparable results of superior vs antero-inferior plating for the treatment of displaced midshaft clavicle fractures. A comparative study

BACKGROUND

Clavicle fractures represent up to 10 % of all fractures, affecting mainly a young population. Open reduction and internal plate fixation provide good results, but evidence on the best plate positioning is still unclear. Aim of this retrospective study was to compare superior and antero-inferior plating positioning in the surgical treatment of displaced midshaft clavicle fractures.

MATERIALS AND METHODS

104 patients aged > 18 years, treated surgically with plate fixation (51 superior, 53 antero-inferior) for a midshaft clavicle fracture from January 2010 to April 2021 were included. At the time of the visit, mean follow-up time was 6.6 ± 2.6 years. Shoulder function was evaluated with the use of Constant-Murley Score (CMS) and Disabilities of the Arm, Shoulder, and Hand (DASH) score. Return to sport, aesthetic satisfaction, operative time, radiological outcomes, rate of implant removal, and overall patient satisfaction were documented as well.

RESULTS

Mean CMS was 94.1 ± 10.0 points in the superior plating group and 93.4 ± 11.6 points in the antero-inferior plating group. DASH score: 4.6 ± 11.0 superior, 5.1 ± 10.5 antero-inferior. Return to sport: 8.2 ± 2.9 superior, 8.2 ± 3.0 antero-inferior. Aesthetic satisfaction: 8.9 ± 1.6 superior, 8.8 ± 2.1 antero-inferior. Overall satisfaction: 9.1 ± 1.5 superior, 8.9 ± 1.7 antero-inferior. The comparison between groups showed no statistically significant differences (p = n.s.) for all outcome measures. Operative time: 101.6 ± 27.3 min superior, 113.0 ± 31.6 min antero-inferior (p = 0.05). Radiological follow-up documented one non-union and one mal-union in the antero-inferior plating group. Overall, 63 patients underwent plate removal: 58.8 % in the superior plating group and 62.3 % in the antero-inferior plating group (p = n.s.). Main reason for plate removal was pain/discomfort.

CONCLUSIONS

Both superior and antero-inferior plating provided excellent clinical, functional, and radiological results for the treatment of displaced midshaft clavicle fractures, without significant differences between groups. The superior plating group showed a statistically shorter operative time. High rate of re-interventions with implant removal was documented in both groups.

LEVEL OF EVIDENCE

III.

Dual Versus Single Plate Fixation of Displaced Midshaft Clavicle Fractures: A Cost-Effectiveness Analysis

BACKGROUND

Prior studies have highlighted lower rates of reoperation if fixation of a displaced midshaft clavicle fracture is performed with dual plating (DP) compared with single plating (SP). Despite higher initial costs associated with the DP construct, the observed reduction in secondary surgeries compared with the SP construct may make it a more cost-effective treatment option. The objective of this study was to assess the cost-effectiveness of DP compared with SP in patients with operatively indicated displaced midshaft clavicle fractures.

METHODS

We developed a decision tree to model the occurrence of postoperative complications (acute hardware complications, wound healing issues, deep infection, nonunion, and symptomatic hardware) associated with secondary surgeries. Complication-specific risk estimates were pooled for both plating techniques using the available literature. The time horizon was 2 years, and the analysis was conducted from the health-care payer's perspective. The costs were estimated using direct medical costs, and the benefits were measured in quality-adjusted life-years (QALYs). We assumed that DP would be $300 more expensive than SP initially. We conducted probabilistic and 1-way sensitivity analyses.

RESULTS

The model predicted reoperation in 6% of patients in the DP arm compared with 14% of patients in the SP arm. In the base case analysis, DP increased QALYs by 0.005 and costs by $71 per patient, yielding an incremental cost-effectiveness ratio (ICER) of $13,242 per QALY gained. The sensitivity analysis demonstrated that the cost-effectiveness of DP was driven by the cost of the index surgery, risk of symptomatic hardware, and nonunion complications with SP and DP. At a willingness-to-pay threshold of $100,000 per QALY gained, 95% of simulations suggested that DP was cost-effective compared with SP.

CONCLUSIONS

When indicated, operative management of displaced midshaft clavicle fractures using DP was found to be cost-effective compared with SP. Despite its higher initial hardware costs, DP fixation appears to offset its added costs with greater health utility via lower rates of reoperation and improved patient quality of life.

LEVEL OF EVIDENCE

Economic and Decision Analysis Level II . See Instructions for Authors for a complete description of levels of evidence.

Dual Mini-Fragment Plate Fixation of Midshaft Clavicle Fractures Reduces Risk of Reoperation Compared With Single-Plate Fixation Techniques

BACKGROUND

Recent studies have highlighted dual plating as a method of reducing high rates of postoperative complication after operative management of displaced midshaft clavicular fractures. However, few studies have reliably characterized reoperation rates and magnitude of risk reduction achieved when using dual versus anterior and superior single-plate techniques.

HYPOTHESIS

There would be lower rates of reoperation among patients who underwent open reduction and internal fixation (ORIF) of displaced midshaft clavicular fractures via dual plating.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This was a retrospective analysis of patients who underwent ORIF for a displaced midshaft clavicular fracture between 2010 and 2021 at a level 1 trauma center with a minimum 12-month follow-up. Patients were separated into 3 cohorts based on fixation type: (1) orthogonal dual mini-fragment plate fixation, (2) superior plate fixation, and (3) anterior plate fixation. Data on patient characteristics, fracture pattern, and reoperations were documented. All-cause reoperation rates and hazard ratio (HR) estimates of dual, superior, and anterior plating were calculated using a multivariate multilevel mixed-effects parametric survival model. Significant confounders including high-risk fracture morphology and smoking status were controlled for in the final model.

RESULTS

A final cohort of 256 patients was identified with mean follow-up of 4.9 ± 3.8 years. In total, 101 patients underwent superior plating, 92 underwent anterior plating, and 63 underwent dual plating. Overall, 31 reoperations took place (18 in superior, 12 in anterior, 1 in dual plating) among 22 patients. Major contributors to reoperation included symptomatic hardware (n = 11), nonunion (n = 8), deep infection (n = 7), and wound dehiscence (n = 2). Superior plating revealed the highest reoperation rate of 0.031 per person-years, followed by anterior plating with 0.026 per person-years and dual plating with 0.005 per person-years. Overall, single plating (either anterior or superior placement) had a nearly 8-fold greater risk of reoperation than dual plating (HR, 7.62; 95% CI, 1.02-56.82; P = .048). Further broken down by technique, superior plating had an 8-fold greater risk of reoperation than dual plating (HR, 8.36; 95% CI, 1.10-63.86; P = .041), but anterior plating did not demonstrate a statistically significant difference compared with dual plating (HR, 6.79; 95% CI, 0.87-52.90; P = .068).

CONCLUSION

Dual-plate fixation represents an excellent treatment for displaced midshaft clavicular fractures, with low rates of nonunion and reoperation. When compared with single locked superior or anterior plate fixation, dual mini-fragment plate fixation has a nearly 8-fold lower risk of reoperation.

Evidence on treatment of clavicle fractures

Depending on the severity of the injury and the involvement of the soft tissue envelope, clavicle fractures can be treated operatively or non-operatively. In the past, displaced fractures of the clavicle shaft in adults have been treated non-operatively. However, the rate of nonunion following non-operative treatment seems to be higher than previously reported. In addition, publications reporting better functional outcomes following operative treatment are increasing. In recent years this has led to a paradigm shift towards an increase of operative fracture treatment. The aim of this review article was to summarize the currently available evidence on the treatment of clavicle fractures. Classifications, indications, and treatment options for different fracture patterns of the medial, midshaft, and lateral clavicles are presented and discussed.

Classification of Distal Clavicle Fractures and Indications for Conservative Treatment

Management of distal clavicle fractures depends on a clear understanding of the injury's proximity to the ligamentous attachments joining the clavicle and scapula. Various classification systems have been proposed to guide treatment. Despite this, controversy between operative and nonoperative management remains for certain fracture patterns. Patient-specific factors, concomitant injuries, fracture characteristics (displacement, shortening, and rotation) should all be considered when deciding on treatment. When nonoperative management is indicated, patients should be immobilized in a sling for 2 weeks, followed by gradual range of motion, and strengthening exercises.

Rescue Blankets as Multifunctional Rescue Equipment in Alpine and Wilderness Emergencies-A Narrative Review and Clinical Implications

The utilization of rescue blankets in pre-hospital emergency medicine exceeds protection from hypothermia and enhanced visibility by far. In this narrative review, we focus on emphasizing the alternative applications of these fascinating multifunctional tools in the pre-hospital setting. A literature search in PubMed^® and Web of Science^TM yielded 100 results (last update was on 8 July 2022), a total number of 26 of which were included in this narrative review. Nine articles assessing alternative functions of rescue blanket were further evaluated and described in more detail. In addition, we performed various experimental and observational trials to test the functionality of rescue practice in mountain emergency medicine. Newly fabricated rescue blankets proved to possess impressive robustness. We evaluated rescue blankets in their applicability to not only protect from hypothermia, but also as practical tools to treat catastrophic hemorrhage and bleeding limbs, to perform open pneumothorax chest seals in sucking chest wounds, to prevent damage to unprotected eyes on the glacier and as alternative instruments for transportation in the inaccessible areas. Rescue blankets are important rescue equipment in alpine and wilderness emergencies with multifunctional applications, and must be part of every personal medical kit.

Broad Arm Sling vs Figure of 8 Bandage: The Better Choice in Conservative Management of Middle Third Clavicle Fractures in Indian Population

BACKGROUND

A prospective randomised trial was conducted to compare the results of conservative management of middle-third clavicular fracture using the figure of 8 bandage and broad-arm sling.

METHODS

296 patients with middle-third clavicle fracture were included in the study conducted between March 2017 and January 2020. 152 patients were managed with figure of 8 bandage and 144 patients were managed with a broad arm sling. Results were evaluated based on clinical, radiological and functional outcomes. Visual analogue scale (VAS) for pain was used to evaluate the clinical outcomes, whereas radiological outcomes were assessed with non-union, malunion, clavicle shortening and time to union. Disability of Arm, Shoulder and Hand score (DASH), Constant score and Nottingham Clavicle Score were used to assess functional outcomes.

RESULTS

The broad arm sling group showed a significantly better VAS score in the first 4 weeks. DASH score was significantly superior in the broad arm sling group in the initial 4 weeks, but with similar outcome thereafter. Constant scores showed a good outcome for both groups at the final follow-up, whereas the Nottingham Clavicle Score was significantly superior in the broad arm sling group at the 2 year follow-up. A satisfactory outcome was achieved with respect to the radiological parameters, without any significant difference between the 2 groups. Incidence of malunion was significantly higher in figure of 8 bandage group.

CONCLUSIONS

Broad-arm sling proves to be a better modality of management for middle-third clavicular fractures in terms of ease of application, pain relief, incidence of malunion, and functional outcomes.

Pediatric Clavicle Fractures and Congenital Pseudarthrosis Unraveled

Clavicle fractures are commonly seen in the pediatric and adolescent populations. In contrast, congenital pseudarthrosis of the clavicle is rare. Although both conditions may present with similar signs and symptoms, especially in the very young, clear differences exist. Clavicle fractures are often caused by trauma and are tender on palpation, while pseudarthrosis often presents with a painless protuberance on the clavicle, which becomes more prominent as the child grows. Its presence may only become apparent after trauma, as it is usually asymptomatic. The diagnosis is confirmed on plain radiography, which shows typical features to distinguish both entities. Both clavicle fractures and congenital pseudarthrosis are generally treated conservatively with a high success rate. Operative treatment for a fracture can be indicated in the case of an open fracture, severely displaced fracture, floating shoulder, neurovascular complications or polytrauma. Congenital pseudarthrosis requires operative treatment if the patient experiences progressive pain, functional limitation and late-onset thoracic outlet symptoms, but most operations are performed due to esthetic complaints.

Are there any differences between the shoulder-arm sling and figure-of-eight bandage in the conservative treatment of paediatric clavicle fractures?

PURPOSE

Clavicle fractures are treated conservatively in the paediatric age group, except in rare types of fractures. We investigated whether there was a difference between using shoulder-arm sling and figure-of-eight bandage in this age group.

METHODS

This study was designed as a retrospective study. In all, 41 children among 53 who underwent conservative treatment with a shoulder-arm sling or figure-of-eight bandage between 2014 and 2019 were included in the study and divided into two groups. Treatment results were compared clinically with respect to pain intensity, muscle strength and radiological examinations.

RESULTS

Group A comprised 20 children with a figure-of-eight bandage and group B comprised 21 children with shoulder sling. According to the Robinson classification, ten fractures were displaced in group A and 12 in group B (p = 0.647). The mean time until the first appointment after the index visit that started the management course was 25.5 days (21 to 31) in group A and 24 days (20 to 30) in group B (p = 0.129). Fracture healing was observed in all patients at the first follow-up and the treatment was discontinued. There was no difference between the groups in the muscle strength examination and shoulder joint range of movement examination at the first-year follow-up (p = 1.00).

CONCLUSION

In the paediatric age group, there was no significant difference between shoulder-arm sling and figure-of-eight bandage in the conservative treatment of clavicle fractures. Since the shoulder-arm sling is more suitable for treatment, it may be the primary preference.

LEVEL OF EVIDENCE

Level III (retrospective comparative study).

Osteossíntese minimamente invasiva com placa para fraturas de clavícula

Objective  To analyze the radiological, clinical, and functional outcomes of clavicle fractures treated with the minimally-invasive plate osteosynthesis (MIPO) technique.

Methods  From June 2018 to July 2019, 17 cases of clavicular fractures were managed using the MIPO technique under C-arm fluoroscopy. The functional outcomes were assessed using the Constant-Murley score and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. The clinical results of union, the complications, the operative time, the hospital stay, as well as infection, were analyzed.

Results  The mean follow-up time was of 10.41 ± 1.75 months (range: 8 to 14 months). There were 11 male and 6 female patients, with a mean age of 39.05 ± 10.76 years (range: 22 to 57 years). All fractures united on the mean time of 15.35 ± 3.08 weeks (range: 12 to 20 weeks). The mean operative time was of 98.11 ± 13.83 minutes (range: 70 to 130 minutes), and the mean length of the hospital stay was of 4.7 ± 1.12 days (range: 3 to 7 days). The mean Constant-Murley score was of 74.82 ± 6.36 in 4 ^th postoperstive month, and of 92.35 ± 5.48 in the 8 ^th postoperative month, which was statistically significant. The mean DASH score was of 9.94 ± 1.55 in the 4 ^th postoperative month, and of 5.29 ± 1.85 in the 8 ^th postoperative month, which was also statistically significant. One patient had superficial skin infection at the site of the incision.

Conclusions  The MIPO technique is an alternative method for the fixation of clavicle fractures, but it is technically more demanding, and requires well-equipped operating room facilities.

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.

Anteroinferior versus superior plating techniques for displaced midshaft clavicle fractures: A retrospective single centre cohort study from Northern Nigeria

BACKGROUND

Clavicle fractures are common injuries accounting for up to 5% of all fractures in adults. Most clavicle fractures heal well with nonoperative treatment, some however, require surgical intervention especially when they are displaced. While plating remains the most popular and most successful method of clavicle fixation; the optimal position of the plate is yet to be agreed upon.

PURPOSES

The purpose of this study was to compare the functional outcomes of displaced clavicle fractures fixed with superior and anteroinferior plating techniques.

PATIENTS AND METHODS

This retrospective cohort study of 69 patients (45 males and 24 females) was carried out between January 2014 and December 2018 at a government orthopaedic hospital in north-western part of Nigeria. The study involved all consecutive patients who sustained a displaced mid-shaft clavicle fracture and had open reduction and internal fixation (ORIF) with either superior plating (SP) or anterior-inferior plating (AIP) and were followed up for at least one year. Data analyzed include: age, sex, laterality, mode of injury, the time from initial injury to surgery, type of plate used, position of the plate, union rate, functional outcome and peri-operative complications.

RESULTS

Fourty-two patients had SP and twenty seven patients had AIP. Fourty one (97.6%) patients had fracture union in SP group while all the twenty seven patients (100%) in the AIP group had fracture union. The mean QuickDASH scores was 3.2 ± 4.6 and 3.6 ± 4.7 in AIP and SP groups respectively. There was no significant difference in the union rates and functional outcome between the two groups.

CONCLUSION

Both superior and anteroinferior plating techniques are safe and effective in the surgical management of displaced mid-clavicle fractures.

LEVEL OF EVIDENCE

Level 3, retrospective cohort study.

Displaced mid-shaft clavicular fractures: state of the art for athletes and young active people

INTRODUCTION

Fractures ofthe clavicle are frequent injuries (between 4 and 10% of adult fractures) and mid-shaft diaphyseal fractures represent more than 80% of clavicle fractures. In a recent study from the USA in 2019, an incidence of 22.4 fractures per year per 100,000 people was reported. Multiple injury mechanisms are recognised, with sport accounting for 50 to 85% of these injuries. There is little or no consensus as to the optimal treatment but in recent years multiple studies have suggested operative management should be favoured in athletes and young active patients.

OBJECTIVES

These are (1) to present the anatomy and the anatomical-pathology of the fractures of the clavicle as well as the mechanisms of injury, (2), (3) to describe non-operative and operative treatment methods, (4) to review the literature around different treatment modalities and (5) to attempt to describe the best treatment for athletes.

METHODS

To collect and analyse the most recent articles of the literature regarding the management of displaced mid-shaft fractures of the clavicle for athletes and young active people.

RESULTS

Looking at studies of the general population, the results tend to favour surgical treatment with a smaller incidence of non-union and faster return to function. These results are mirrored in the athlete population where several studies have shown excellent anatomic restoration and functional recovery after plate fixation.

CONCLUSION

Based on this analysis, with the exception of patients who refuse operative management after an informed discussion, the treatment of choice in displaced clavicle fractures in athletes seems to be operative treatment with a plate and screws. However, prospective randomised studies comparing non-surgical treatment and plate osteosynthesis are missing and it is not possible to state that the latter is the best treatment.

The emergency medicine management of clavicle fractures

BACKGROUND

Clavicle fractures are common. An emergency physician needs to understand the diagnostic classifications of clavicle fractures, have a plan for immobilization, identify associated injuries, understand the difference between treating pediatric and adult patients, and have an approach to multimodal pain control. It is also important to understand when expert orthopedic consultation or referral is indicated.

OBJECTIVE OF THE REVIEW

To provide an evidence-based review of clavicle fracture management in the emergency department.

DISCUSSION

Clavicle fractures account for up to 4% of all fractures evaluated in the emergency department. They can be separated into midshaft, distal, and proximal fractures. They are also classified in terms of their degree of displacement, comminution and shortening. Emergent referral is indicated for open fractures, posteriorly displaced proximal fractures, and those with emergent associated injuries. Urgent referral is warranted for fractures with greater than 100% displacement, fractures with >2 cm of shortening, comminuted fractures, unstable distal fractures, and floating shoulder. Nondisplaced or minimally displaced fractures with no instability or associated neurovascular injury are managed non-operatively with a sling. Pediatric fractures are generally managed conservatively, with adolescents older than 9 years-old for girls and 12 years-old for boys being treated using algorithms that are similar to adults.

CONCLUSIONS

When encountering a patient with a clavicle fracture in the emergency department the fracture pattern will help determine whether emergent consultation or urgent referral is indicated. Most patients can be discharged safely with sling immobilization and appropriate outpatient follow-up.

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.

Clavicle fractures

Clavicle fractures account for approximately 2-5% of all fractures in adults and 10-15% in children. There is a bimodal distribution, with two peaks occurring in patients <25 years of age as a result of direct trauma and in those >55 years of age secondary to a fall onto an outstretched arm. Approximately two-thirds of all clavicle fractures occur in men. This article provides an overview of the presentation, assessment and management of clavicle fractures for both core surgical trainees and acute care common stem/emergency medicine trainees.

Comparison of radiological and clinical outcomes, complications, and implant removals in anatomically pre-contoured clavicle plates versus reconstruction plates - a propensity score matched retrospective cohort study of 106 patients

Background

Plate fixation is frequently used to treat displaced midshaft clavicular fractures, however the ideal plate choice remains subject to discussion; reconstruction locking compression plates (RLCPs) are cheaper and can be easily contoured, whereas anatomically pre-contoured locking compression plates (ALCPs) are thought to provide better stability and therefore lower rates of mechanical failure.

To compare the incidence of mechanical failures, functional and radiological outcomes in patients with midshaft clavicular fractures treated with ALCPs versus RLCPs.

Methods

A propensity score matched retrospective cohort study was conducted across two centers. One hundred and six consecutively recruited patients with displaced midshaft clavicular fractures, who were treated with plate fixation and had a minimum follow-up of 6 months, were matched on gender, age, fracture grading, energy of injury, and fracture location. The resulting groups included 53 ALCP-treated fractures and 53 matched controls treated with RLCPs.

Results

During a mean follow-up of 20.5 months, there were no implant deformities in the ALCP group whereas the RLCP group had 6 patients (11.3%, p = 0.012) with implant deformities (5 occurrences of plate bending with fracture union, and 1 plate breakage with nonunion). Despite the higher rate of plate deformities in the RLCP group, there were no statistically significant differences in number of patients recovering full shoulder range of motion (ALCP 90.6%, RLCP 88.7%, p = 0.751), incidence of rest pain (ALCP 13.2%, RLCP 9.4%, p = 0.542), or implant removals (ALCP 49.1%, RLCP 56.6%, p = 0.439).

Conclusion

ALCPs may be superior to RLCPs in terms of implant stability but appear to produce similar clinical results.

Current Concepts for Classification and Treatment of Distal Clavicle Fractures

Distal clavicle fractures are less common than mid-shaft fractures in adults and there is no consensus on the best classification system or the ideal treatment approach considering that high nonunion rates have been reported. Although there are numerous treatment options for distal clavicle fractures, a gold standard treatment has not yet been established. Each surgical technique has its pros and cons. In this review article, we provide an overview of classification systems and treatment methods for distal clavicle fractures.

An evaluation of treatment options for medial, midshaft, and distal clavicle fractures: a systematic review and meta-analysis

Background

The majority of clavicle fractures are midshaft injuries, although fractures of the distal or medial fragment also occur. The aim of this study was to review the current evidence on these injuries to help inform future treatment plans.

Methods

We searched for studies comparing interventions for medial, midshaft, or distal clavicle fractures; however, we did not identify any comparative studies on medial fractures and performed a secondary search on this topic. We conducted Bayesian network meta-analyses, although this was not feasible with studies on medial fractures and we described their results qualitatively.

Results

For midshaft fractures, we found statistically significant improvements in function and time to radiographic union with plating, an elastic stable intramedullary nail (ESIN), and the Sonoma CRx intramedullary nail over nonoperative treatments. Both plating and an ESIN also showed significantly lower risks of nonunion and malunion relative to nonoperative methods. For distal fractures, a locking plate (LP) with or without coracoclavicular (CC) suturing yielded significantly better outcomes over K-wires with or without tension bands, CC suturing alone, an LP with a CC screw, a hook plate, and a sling. For medial fractures, plating may result in more favorable functional and union-related outcomes, although implant irritation may occur. In addition, K-wires, tension bands, and a screw with sutures demonstrated success when plating was technically not feasible in a few cases, whereas treatment with a sling may result in reduced function and a higher risk of complications relative to surgery.

Conclusion

This study can provide guidance on the management of medial, midshaft, and distal clavicle fractures. The current evidence suggests that plating, an ESIN, and a CRx intramedullary nail are all good options for midshaft fractures; an LP with or without CC suturing should be preferred for distal fractures; and plating is also acceptable for medial fractures, provided that the patient is deemed suitable for surgery and has the adequate bone stock and sufficiently sized medial fragment necessary to implant the device. Patient preferences for certain outcomes should be considered, which may result in different treatment recommendations.

Minimally invasive plate osteosynthesis (MIPO) in AO/OTA type B displaced clavicle fractures

INTRODUCTION

Open reduction and plate fixation is known to reduce chances of malunion and symptomatic nonunion in displaced middle-third clavicle fractures. However, this treatment modality is also associated with several complications, such as hardware irritation, numbness around the surgical scar, infection, nonunion and implant failure. The minimally invasive plate osteosynthesis (MIPO) technique may reduce these complications.

OBJECTIVE

To study clinical, radiological and functional outcomes of MIPO in AO/OTA type B displaced clavicle fractures and report any complications.

MATERIALS AND METHODS

A total of 22 patients underwent internal fixation of acute displaced AO/OTA type B clavicle fractures from Jan 2014 to Dec 2015 by MIPO using locking compression plates. Patients were followed up at a regular interval and assessed clinically and radiologically. The clavicle length difference was measured. Functional assessment was done at the end of 2 year using constant shoulder score (CSS) and disability of the arm, shoulder and hand score (Quick DASH) and complications if any were noted.

RESULTS

All fractures united at a mean of 12.5 weeks. One (4.5%) patient had numbness around the surgical scar. None of the patients had wound-related complications. In four patients, hardware irritation was noted. The difference in clavicle length was not significant. All patients had excellent CSS and Quick DASH score at the final follow-up.

CONCLUSION

Internal fixation of displaced AO/OTA type B clavicle fractures by MIPO showed high fracture union rates and good functional outcomes.

Operative Versus Nonoperative Treatment of Pediatric and Adolescent Clavicular Fractures: A Systematic Review and Critical Analysis

BACKGROUND

The optimal treatment of displaced middle-third clavicular fractures in pediatric and adolescent patients remains controversial. Furthermore, risk factors for the failure of nonoperative treatment have not been clearly defined. Therefore, we designed a systematic review and critical analysis to assess appropriate Grades of Recommendation for evidence-based treatment of middle-third clavicular fractures in the pediatric and adolescent populations.

METHODS

We performed a systematic review following a search of the PubMed, Embase, and Cochrane databases that was conducted in May 2017. The search terms were clavicle, clavic*, and fracture. Our specific PubMed search was ("clavicle"[MeSH] OR clavic*) AND ("fracture"[MeSH] OR fracture*). The results were filtered for English language and subjects ≤18 years of age. There was no chronological limit on the results. The results were then assessed for relevance via a stepwise approach by first screening titles, then abstracts, and, finally, full text. The levels of evidence were determined for studies that met the inclusion criteria. The findings were summarized, and Grades of Recommendation were assigned by consensus.

RESULTS

Our search returned 3,615 studies. Of these, 215 were potentially relevant. Studies that did not meet our inclusion criteria were removed by consensus. One hundred and nineteen full-text articles were then assessed. Of these, 19 met the inclusion criteria. Overall, patients with both operative and nonoperative treatment of displaced middle-third clavicular fractures have good functional outcomes, with Grade-B supporting evidence. There is Grade-B evidence that operative treatment results in a high complication rate. Both plating and nailing have a high likelihood of requiring implant removal, with Grade-B evidence. There is conflicting evidence regarding the effect of both nonoperative and operative treatment on patient cosmesis following displaced fractures. There is Grade-B evidence that nonunions of pediatric clavicular fractures are exceptionally rare, regardless of treatment strategy. Nonoperatively treated displaced fractures have conflicting evidence regarding any adverse effect displacement may have on functional status.

CONCLUSIONS

Existing literature does not clearly delineate appropriate indications for nonoperative care or relative indications for operative intervention. Further studies are needed to guide treatment and promote better informed consent.

LEVEL OF EVIDENCE

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

Surgical versus conservative interventions for treating fractures of the middle third of the clavicle

BACKGROUND

Clavicle fractures are common, accounting for 2.6% to 4% of all fractures. Eighty per cent of clavicle fractures are located in the middle third of the clavicle. Although treatment of these fractures is usually non-surgical, displaced clavicle fractures may be considered for surgical treatment because of their greater risk of non-union. This is an update of a Cochrane Review first published in 2013.

OBJECTIVES

To assess the effects (benefits and harms) of surgical versus conservative interventions for treating middle third clavicle fractures.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Specialised Register, CENTRAL, MEDLINE, Embase, LILACS, trials registries and reference lists updated to December 2017. We did not apply any language or publication restrictions.

SELECTION CRITERIA

We considered randomised and quasi-randomised controlled trials evaluating surgical versus conservative interventions for treating fractures in the middle third of the clavicle. The primary outcomes were shoulder function or disability, pain and treatment failure, defined as the number of participants who had been given a non-routine secondary surgical intervention (excluding hardware removal), for symptomatic non-union, malunion or other complications.

DATA COLLECTION AND ANALYSIS

At least two review authors selected eligible studies, independently assessed risk of bias and cross-checked data. Where appropriate, we pooled results of comparable studies.

MAIN RESULTS

We included 14 studies involving 1469 participants with acute middle third clavicle fractures. All studies included adults, with the overall range from 17 to 70 years. Of the studies that reported gender, men were over-represented. Ten studies compared plate fixation with sling or figure-of-eight bandage, or both, and four studies compared intramedullary fixation with wearing either a sling or a figure-of-eight bandage. Almost all studies had design features that carry a high risk of bias, thus limiting the strength of their findings.Low-quality evidence from 10 studies (838 participants), showed that, compared with conservative treatment, surgical treatment of acute middle third clavicle fractures may not improve upper arm function at follow-up of one year or longer: standardised mean difference (SMD) 0.33, 95% confidence interval (CI) -0.02 to 0.67. We downgraded the quality of the evidence because of risk of bias and high statistical heterogeneity (I² = 83%). This corresponds to a mean improvement of 2.3 points in favour of surgery (0.14 points worse to 4.69 points better), on the 100-point Constant score; this does not represent a clinically important difference. There may be no difference in pain measured using a visual analogue scale (0 to 100 mm; higher scores mean worse pain) between treatments (mean difference (MD) -0.60 mm, 95% CI -3.51 to 2.31; 277 participants, 3 studies; low-quality evidence reflecting risk of bias and imprecision). Surgery may reduce the risk of treatment failure, that is, number of participants who had non-routine secondary surgical intervention (excluding hardware removal), for symptomatic non-union, malunion or other complication (risk ratio (RR) 0.32, 95% CI 0.20 to 0.50; 1197 participants, 12 studies; low-quality evidence, downgraded for risk of bias and imprecision). The main source of treatment failure was mechanical failure (3.4%) in the surgery group and symptomatic non-union (11.6%) in the conservative-treatment group.We are uncertain whether surgery results in fewer people having one or more cosmetic problems, such as deformities, which were more common after conservative treatment, or hardware prominence or scarring, which only occurred in the surgery group (RR 0.55, 95% CI 0.31 to 0.98; 1130 participants, 11 studies; I² = 63%; very low-quality evidence downgraded for risk of bias, imprecision and inconsistency). We are uncertain whether there is any difference between surgery and conservative treatment in the risk of incurring an adverse outcome that includes local infection, dehiscence, symptomatic malunion, discomfort leading to implant removal, skin and nerve problems: RR 1.34, 95% CI 0.68 to 2.64; 1317 participants, 14 studies; I² = 72%; very low-quality evidence, downgraded for risk of bias, imprecision and inconsistency). Hardware removal for discomfort was a common adverse outcome in the surgery group (10.2%) while symptomatic malunion was more common in the conservative-treatment group (11.3% versus 1.2% in the surgery group). Infection occurred only in the surgery group (3.2%). There may be no between-group difference in quality of life at one year (SF-12 or SF-36 physical component scores: 0 to 100 scale, where 100 is the best score): MD 0.30 (95% CI -1.95 to 2.56, 321 participants, 2 studies; low-quality evidence downgraded for risk of bias and imprecision).

AUTHORS' CONCLUSIONS

There is low-quality evidence that surgical treatment has no additional benefits in terms of function, pain and quality of life compared with conservative treatment, but may result in fewer treatment failures overall. Very low-quality evidence means that we are very uncertain of the findings of a slightly better cosmetic result after surgery and of no difference between surgical and conservative treatment in the risk of adverse events. For both composite outcomes, there is a need to consider the balance of risks between the individual outcomes; for example, surgical adverse events, including wound infection or dehiscence and hardware irritation, against risk of adverse events that may be more commonly associated with conservative treatment such as symptomatic malunion and shoulder stiffness.Treatment options must be chosen on an individual patient basis, after careful consideration of the relative benefits and harms of each intervention and of patient preferences.

Cost-Effectiveness of Operative Versus Nonoperative Treatment of Displaced Midshaft Clavicle Fractures: A Decision Analysis

BACKGROUND

While previous studies have shown higher union rates and a quicker return to work with operative treatment of substantially displaced clavicle fractures, there is disagreement whether operative treatment results in improved clinical outcomes. Patients who undergo operative treatment sometimes require additional surgery for implant removal. Nonoperative treatment may fail so that delayed surgical intervention is ultimately required. The duration for which the clinical benefits of operative treatment remain superior to those of nonoperative treatment has not been well established in the literature. Considering these uncertainties, surgeons are faced with a difficult decision regarding whether operative treatment of a midshaft clavicle fracture will be cost-effective. The purpose of this study was to identify the most cost-effective strategy by considering these uncertain parameters with use of decision-analysis techniques.

METHODS

An expected-value decision tree was built to estimate the quality-adjusted life years (QALYs) and costs for operative and nonoperative treatment of substantially displaced midshaft clavicle fractures. Values for parameters in the decision model were derived from the literature. Medical costs were obtained from the Medicare database. A Markov model was used to calculate the QALYs for the duration of life expectancy. The decision model was used to analyze the duration for which the clinical results of operative treatment were superior to those of nonoperative treatment during the first 5 years after the operation and during a lifetime. Sensitivity analysis was performed to determine which parameters have the most influence on cost-effectiveness.

RESULTS

Operative treatment was more cost-effective than nonoperative treatment in 54% and 68% of the Monte Carlo trials in the 5-year and lifetime analyses, respectively. The cost per QALY with operative management was <$38,000 and <$8,000 in the 5-year and lifetime analyses, respectively. This is below the willingness-to-pay threshold of $50,000 per QALY. For operative treatment to remain cost-effective, its clinical benefits must persist for at least 3 years.

CONCLUSIONS

Operative treatment is more cost-effective than nonoperative treatment for substantially displaced midshaft clavicle fractures. The clinical benefits derived with operative treatment must persist for at least 3 years for operative treatment to remain cost-effective. This research should not be used to conclude that all clavicle fractures should be treated surgically. It is best that such a decision is made through a patient-surgeon shared decision-making process.

LEVEL OF EVIDENCE

Economic and Decision Analysis Level II. See Instructions for Authors for a complete description of levels of evidence.

Management of Midshaft Clavicle Fractures in Adults

Fractures of the clavicle are common injuries that occur across all age groups but are most frequently seen in the young, active patient population. Among the different types of clavicle fractures, those occurring in the middle third of the clavicular shaft are the most common. Historically, most of these fractures were treated by closed means even when notable displacement was present. Recently, there has been a renewed interest in assessing the best treatment option for these patients. Although nonsurgical treatment is a reliable method for treating many of these fractures, more recent data suggest that fractures with notable displacement (>2 cm of shortening or >100% displacement) and/or comminution have better short-term outcomes and lower rates of nonunion with surgical management. Current surgical options include superior plating, anterior-inferior plating, dual plating, and intramedullary nail fixation.

Are commercially-available precontoured anatomical clavicle plating systems offering the purported superior optimum fitting to the clavicle? A cadaveric analysis and review of literature

PURPOSE

The indication for operative treatment of displaced midshaft clavicle fractures remains controversial. However, if plate fixation is considered, implant prominence and skin irritation are the most common causes for re-operation. Low profile implants as well as closely contouring plates to the individual anatomy may reduce these complications. The aim of this study was to compare the fitting accuracy and implant prominence of 3.5mm pelvic reconstruction plates (PRP) with pre-contoured anatomical clavicle plates (PACP) for midshaft clavicle fractures.

METHODS

Three-dimensional data of the largest, median and smallest male and female clavicle of an existing database of 89 cadaveric clavicles were included for analysis. A three-dimensional model of a commercially available PACP was used for digitally positioning of the plate on the segmented clavicles. Three-dimensional printouts of each clavicle were produced and the 3.5mm reconstruction plates were manually bent and positioned by the senior author. Computed tomography scans and three-dimensional reconstructions were then obtained to digitally compare the fitting accuracy and implant prominence.

RESULTS

Pelvic reconstruction plates offered superior fitting accuracy and lower implant prominence compared to PACP. The largest difference in implant prominence was observed in large sized female clavicles and measured 3.6mm.

CONCLUSION

Both, the less costly PRP plates and commercially available PACP for midshaft fractures of the clavicle demonstrated a clinically acceptable fitting accuracy. The manually bent pelvic-reconstruction plates demonstrated reduced implant prominence with superior fitting. Hypothetically this might contribute to a reduced rate of reoperation.

LEVEL OF EVIDENCE

Level IV cadaveric study.

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

Preferences of orthopedic surgeons for treating midshaft clavicle fracture in adults

Objective

To determine the current clinical practice in Latin America for treating midshaft clavicle fractures, including surgical and non-surgical approaches.

Methods

A cross-sectional study using a descriptive questionnaire. Shoulder and elbow surgeons from the Brazilian Society of Shoulder and Elbow Surgery and from the Latin American Society of Shoulder and Elbow were contacted and asked to complete a short questionnaire (SurveyMonkey^®) on the management of midshaft fractures of the clavicle. Incomplete or inconsistent answers were excluded.

Results

The type of radiographic classification preferably used was related to description of fracture morphology, according to 41% of participants. Allman classification ranked second and was used by 24.1% of participants. As to indications for surgical treatment, only the indications with shortening and imminence of skin exposure were statistically significant. Conservative treatment was chosen in cortical contact. Regarding immobilization method, the simple sling was preferred, and treatment lasted from 4 to 6 weeks. Although the result was not statistically significant, the blocked plate was the preferred option in surgical cases.

Conclusion

The treatment of midshaft clavicle fractures in Latin America is in accordance with the current literature.

Treatment of Displaced Midshaft Clavicle Fractures: Figure-of-Eight Harness Versus Anterior Plate Osteosynthesis: A Randomized Controlled Trial

BACKGROUND

Most midshaft clavicle fractures affect the economically active population, which is negatively impacted by transient limb impairment during the treatment. There is still debate about the advantages and disadvantages of surgical treatment for these fractures.

METHODS

In this prospective randomized controlled trial, 117 patients were allocated to 1 of 2 groups: nonsurgical treatment with a figure-of-eight harness or surgical treatment with anteroinferior plate osteosynthesis. The primary outcome was upper-limb limitation measured with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire at 6 months. Other outcomes included pain, radiographic findings, satisfaction with the cosmetic result, complications, and time to return to previous work and activities. Participants were assessed at 6 weeks, 6 months, and 1 year after the intervention.

RESULTS

No difference between the 2 groups was detected in the DASH score at any time point (p = 0.398, 0.403, and 0.877 at 6 weeks, 6 months, and 1 year, respectively), pain levels measured with a visual analogue scale (VAS), time to return to previous activities, or dissatisfaction with the cosmetic result. Seven patients (14.9%) developed nonunion after nonsurgical treatment, a nonunion rate that was significantly higher than that in the surgical group, in which all fractures had healed (p = 0.004). The patients in the nonsurgical group had radiographic evidence of greater clavicle shortening (p < 0.001) and more of the patients in that group answered "yes" when asked if their clavicle felt short (p < 0.001) and if they felt bone prominence (p < 0.001). More patients answered "yes" when asked if they felt paresthesia in the surgical group (7; 13.7%) than in the nonsurgical group (1; 2.1%) (p = 0.036).

CONCLUSIONS

This study did not demonstrate a difference in limb function between patients who underwent surgical treatment and those nonsurgically treated for a dislocated midshaft clavicle fracture. Meanwhile, surgical treatment decreased the likelihood of nonunion.

LEVEL OF EVIDENCE

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

Management of Simple Clavicle Fractures by Primary Care Physicians

The clavicle is the most commonly fractured bone. Children with simple fractures are often referred to orthopedic surgeons by primary care physician to ensure adequate care. The objective of this study was to show that simple clavicle fractures have excellent outcomes and are within the scope of primary care physician's practice. We performed a retrospective chart review of 16 adolescents with simple clavicle fractures treated with a sling. Primary outcomes were bony union, pain, and function. The patients with simple clavicle fractures had excellent outcomes with no complications or complaints of pain or restriction of their activities of daily living. The outcomes are similar whether treated by an orthopedic surgeon or a primary care physician. The cost to society and the patient is less when the primary care physician manages the fracture. Therefore, primary care physicians should manage simple clavicle fractures.

The virtual fracture clinic: Reducing unnecessary review of clavicle fractures

INTRODUCTION

We re-designed the outpatient management of trauma at our institution to eliminate appointments if there would be no change in management or information provision. All cases referred by the Emergency Department (ED) were reviewed at a Virtual Fracture Clinic (VFC) by an orthopaedic consultant and telephoned afterwards by a senior nurse. If face-to-face review was required, it was arranged at a specialist shoulder clinic.

AIMS

The primary aim of this study was to evaluate the proportion of clavicle fractures that could be discharged without physical review. The secondary aim was to assess the patient reported functional outcome and satisfaction among patients who were discharged without further review.

PATIENTS AND METHODS

A retrospective review was performed of patients who attended the ED with a clavicle fracture between October 2011 and September 2012. 138 patients were included. The number of patients who were discharged without a physical review was analysed. All radiographs were classified according to the Robinson classification. We recorded the number of undisplaced/minimally-displaced fractures that were discharged virtually. The number of patients with a displaced midshaft fracture who were seen at a specialist clinic was also recorded. A questionnaire was sent to all patients at one year post-injury to evaluate their outcome (QuickDASH and EQ-5D) and satisfaction with the new service.

RESULTS

62/138 (45%) were directly discharged from the VFC. The majority of virtual discharges occurred in the undisplaced fracture types (84% versus 13%, RR 6.4, 95% CI 3.5-11.5). 78% patients responded to the questionnaires. 91% of patients were satisfied with their recovery from the injury. 86.4% patients were satisfied with the information provided regarding their treatment. In the virtually discharged group the mean EQ-5D VAS was 78.1 (EQ5D range 0.06-1, SD 0.248). The mean Quick DASH score was 16.1(SD 25.2).

CONCLUSIONS

Virtual discharge of undisplaced clavicle fractures is appropriate and results in acceptable clinical outcomes and patient satisfaction. This redesigned process has significant benefits for patients as there were far fewer hospital visits by avoiding unnecessary appointments. The orthopaedic service also benefited by having more time available for the management of complex cases.

Clavicle fractures: epidemiology, classification and treatment of 2 422 fractures in the Swedish Fracture Register; an observational study

Background

Large multi-centre studies of clavicle fractures have so far been missing. The aim of this observational study was to describe the epidemiology, classification and treatment of clavicle fractures in the The Swedish Fracture Register (SFR) that collects national prospective data from large fracture populations.

Methods

Data were retrieved from the SFR on all clavicle fractures sustained by patients ≥ 15 years of age in 2013–2014 (n = 2 422) with regards to date of injury, cause of injury, fracture classification and treatment.

Results

Sixty-eight per cent of the clavicle fractures occurred in males. The largest subgroup was males aged 15–24 years, representing 21% of clavicle fractures. At the ages of 65 years and above, females sustained more clavicle fractures than males. Same-level falls and bicycle accidents were the most common injury mechanisms. Displaced midshaft fractures constituted 43% of all fractures and were the most frequently operated fractures. Seventeen per cent of the patients underwent operative treatment within 30 days of the injury, where plate fixation was the choice of treatment in 94% of fractures.

Conclusion

The largest patient group was young males. Displaced midshaft fractures were the most common type of clavicle fracture as well as the most frequently operated type of fracture.

Clavicle fractures

Management of clavicle fracture has progressed over the last decade, notably with wider use of surgery in midshaft fracture, and new techniques for lateral fracture. Midshaft clavicle fracture treatment needs to be personalized and adapted to the patient's activity level. Whichever the segment involved, treatment for non-displaced fracture is functional; elbow-to-body sling immobilization seems the best tolerated. Apart from regular surgical indications (shoulder impaction, floating shoulder, open fracture or fracture with neurovascular complications), surgery is recommended in case of bone shortening exceeding 1.5cm in young active patients. The technique needs to take account of clavicle anatomy: notably periosteal vascularization in midshaft fracture and acromioclavicular ligament integrity and location in case of lateral fracture. Plate osteosynthesis should take account of bone diameter and 3D curvature; intramedullary fixation should take account of intramedullary canal morphology. Although iatrogenic vascular complications are rare, vessel relations and variants need to be known, especially in the medial end of the clavicle and midshaft. Lateral segment fractures are a particular entity. Large-scale randomized studies are needed to assess indications and results for the various possible internal fixation techniques: isolated or associated to ligament reconstruction, rigid or flexible, and open or arthroscopic.

Comparative Results of External Fixation, Plating, or Nonoperative Management for Diaphyseal Clavicle Fractures

OBJECTIVE

The aim of this study was to compare the treatment outcomes of mid-diaphyseal clavicular fractures between an external fixator and more widely selected treatment options such as plate osteosynthesis or conservative methods.

MATERIALS AND METHODS

The medical records of 64 patients who were treated for mid-diaphyseal clavicular fracture in our clinic from 2009 to 2013 were reviewed. The inclusion criterion was mid-diaphyseal closed clavicular fractures with shortening of more than 2 cm. The Constant and DASH (disabilities of the arm, shoulder, and hand) scores at the final follow-up, initial displacement, nonunion, and complication rates were compared. Statistical differences between groups were assessed with the Kruskal-Wallis test, and pairwise comparison analysis was used to evaluate the differences within the groups.

RESULTS

Of the 64 patients, 24 (37.5%) were treated with plate osteosynthesis (group 1), 11 (17.2%) with an external fixator (group 2), and 29 (45.3%) conservatively with a figure-of-eight bandage (group 3). The mean follow-up periods were as follows: group 1: 37 ± 10.4 months, group 2: 33 ± 7 months, and group 3: 35 ± 9.4 months. The initial amount of displacement and DASH score were: group 1: 89.1 ± 7.8, group 2: 89.1 ± 7.8, and group 3: 6.1 ± 6.6) (p = 0.079). The Constant score of group 2 (93 ± 6.1) was significantly higher than that of group 3 (85 ± 8.4) (p = 0.013). No statistical difference was found in the distribution of nonunions (p = 0.387). However, in group 3, the number of malunions (11/29, 37.9%) was significantly higher compared to the other 2 groups (group 1: 1/24, 4.2%; group 2: 2/11, 18.2%) (p = 0.006).

CONCLUSIONS

This study revealed that the treatment of acute clavicular fractures with an external fixator was a good alternative to plate osteosynthesis or conservative treatment.

Conservative interventions for treating middle third clavicle fractures in adolescents and adults

BACKGROUND

Clavicle (collarbone) fractures account for around 4% of all fractures. Most (76%) clavicle fractures involve the middle-third section of the clavicle. Treatment of these fractures is usually non-surgical (conservative). Commonly used treatments are arm slings, strapping and figure-of-eight bandages.This is an update of a Cochrane review first published in 2009 and updated in 2014.

OBJECTIVES

To evaluate the effects (benefits and harms) of different methods for conservative (non-operative) treatment for acute (treated soon after injury) middle third clavicle fractures in adolescents and adults.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE (from 1966), Embase (from 1980), LILACS (from 1982), trial registers, orthopaedic proceedings and reference lists of articles. We applied no language or publication restrictions. The date of the last search was 5 January 2016.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials testing conservative interventions for treating adolescents and adults with acute middle third clavicle fractures. The primary outcomes were shoulder function or disability, pain and treatment failure.

DATA COLLECTION AND ANALYSIS

For this update, two review authors selected eligible trials, independently assessed risk of bias and cross-checked data extraction. We calculated risk ratios and 95% confidence intervals for dichotomous variables, and mean differences and 95% confidence intervals for continuous variables. There was very limited pooling of data.

MAIN RESULTS

We included four trials in this review with 416 participants, who were aged 14 years or above. One new trial was included in this update.Very low quality evidence was available from three trials (296 participants) that compared the figure-of-eight bandage with an arm sling for treating acute middle third clavicle fractures. The three trials were underpowered and compromised by poor methodology. Shoulder function was assessed in different ways in the three trials (data for 51, 61 and 152 participants); each trial provided very low quality evidence of similar shoulder function in the two groups. Pooled data from two trials (203 participants) showed no clinical difference between groups after two weeks in pain (visual analogue scale: 0 (no pain) to 10 (worst pain); mean difference (MD) 0.43, 95% confidence interval (CI) -0.35 to 1.21; I² = 74%; very low quality evidence). A third trial (61 participants) provided very low quality evidence based on a non-validated scoring system of more pain and discomfort during the course of treatment in the figure-of-eight group. Treatment failure, measured in terms of subsequent surgery, was not reported in two trials; the third trial (152 participants) reported one participant in the arm sling group had surgery for secondary plexus nerve palsy. There was very low quality evidence from one trial (148 participants) of little difference in time to clinical fracture healing (MD 0.2 weeks, 95% CI -0.11 to 0.51); data from four non-symptomatic non-unions in the figure-of-eight group were not included. The very low evidence quality data for individual adverse outcomes (poor cosmetic appearance; change in allocated treatment due to pain and discomfort, worsened fracture position on healing; shortening > 15 mm; non-symptomatic non-union and permanent pain) did not confirm a difference between the two groups. There was no clear between group difference in the time to return to school or work activities (MD -0.12 weeks, 95% CI -0.69 to 0.45; 176 participants; very low quality evidence).Moderate quality evidence was available from one trial (120 participants; reporting data for 101 participants), which evaluated therapeutic ultrasound. This trial was at low risk of bias but was underpowered and did not report on shoulder function or quality of life. The trial found no evidence of a difference between low-intensity pulsed ultrasound and placebo in pain, treatment failure (subsequent surgery: 6/52 versus 5/49; RR 1.13, 95% CI 0.37 to 3.47), the time to clinical fracture healing (MD -0.32 days, 95% CI -5.85 to 5.21), adverse events (one case of skin irritation was reported in each group) or time to resume previous activities.

AUTHORS' CONCLUSIONS

The current evidence available from randomised controlled trials is insufficient to determine which methods of conservative treatment are the most appropriate for acute middle third clavicle fractures in adolescents and adults. Further research is warranted.

Overtreatment of displaced midshaft clavicle fractures

Background and purpose - The best treatment for displaced clavicle fractures has been debated for decades. Operative treatment has become more common. However, several randomized trials comparing non-operative and operative treatment have not shown any compelling evidence in favor of surgery. We identified the preferred treatment of displaced midshaft clavicle fractures at public hospitals in 3 countries in Scandinavia. Patients and methods - A purpose-made multiple-choice questionnaire in English was sent to all public hospitals in Denmark, Sweden, and Finland. This was addressed to the orthopedic surgeon responsible for treatment of clavicle fractures, and completed questionnaires were obtained from 85 of 118 hospitals. Results - In the 3 countries, 69 of the 85 hospitals that responded would treat displaced clavicle fractures operatively. Clear criteria for treatment allocation were used at 58 of the hospitals, with the remaining 27 using individual assessment in collaboration with the patient. Precontoured locking plates were mostly used, placed either superiorly (64/85) or anteriorly (10/85). Interpretation - Displaced midshaft clavicle fractures are mainly treated operatively in Sweden, Denmark, and Finland. This treatment is not supported by compelling evidence.

Short-term Results of Robinson Type 2B2 Clavicular Fractures Treated Conservatively or Surgically

The most frequently treated injuries, representing approximately 82% of all clavicular fractures, involve the midshaft clavicle. Historically, most acute displaced midshaft clavicular fractures were treated nonsurgically. However, the outcomes of nonsurgical treatment have recently been thought to be not as good as expected in the past, and the trend is to treat these fractures surgically. The goal of this study was to evaluate the short-term clinical outcomes of Robinson type 2B2 clavicular fractures treated conservatively vs with locked plate fixation. Among 59 patients included in the study, 30 patients (mean age, 45±13.7 years; range, 30-62 years) treated conservatively were designated as group A, and 29 patients (mean age, 38.8±11.1 years; range, 20-60 years) treated with locked plate fixation were designated as group B. All patients were evaluated using Oxford and Constant scoring systems at final follow-up. Mean follow-up was 18 months (range, 12-24 months). In group A, mean Constant score was 70.5±15.1 (range, 98-43) and mean Oxford score was 46.6±1.3 (range, 49-44) at final follow-up. In group B, mean Constant score was 89.2±8 (range, 100-77) and mean Oxford score was 46.5±1.2 (range, 48-44) at final follow-up. Callus was detected radiographically in both groups at 6-week follow-up. Patients in groups A and B started active range-of-motion exercises at weeks 6 and 3 after treatment, respectively. Locked plate fixation of Robinson type 2B2 clavicular fractures can be the first treatment option because of good clinical results, low complication rates, and good cosmesis.

Figure-of-eight bandage versus arm sling for treating middle-third clavicle fractures in adults: study protocol for a randomised controlled trial

BACKGROUND

Fracture of the clavicle is common, accounting for 2.6 to 4.0 % of all fractures, with an overall incidence of 36.5 to 64 per 100,000 per year. Around 80 % of clavicle fractures occur in the middle third of the clavicle. Randomised controlled trials comparing treatment interventions have failed to indicate the best therapeutic practices for these fractures. The objective of this study is to evaluate the effects (benefits and harms) of two commonly-used conservative interventions: the figure-of-eight bandage versus the arm sling as treatments of middle-third clavicle fractures.

METHODS/DESIGN

This project has been designed as a single-centre, two-arm randomised controlled trial that will compare two interventions: figure-of-eight bandage versus the arm sling. We propose to recruit 110 adults, aged 18 years or older, with an acute (less than 10 days since injury) middle-third clavicle fracture. The primary outcomes to be evaluated will be function and/or disability measured by the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire. In order to assess the secondary outcomes, the Modified University of California at Los Angeles (modified - UCLA) Shoulder Rating Scale will be used. The occurrence of pain (Visual Analogue Scale for pain (VAS)), treatment failure, adverse events and the ability to return to previous activities will also be recorded and evaluated as secondary outcomes.

DATA ANALYSIS

the primary outcome DASH score and the secondary outcomes - modified UCLA and VAS scores - will be analysed graphically. We will apply generalised mixed models with the intervention groups (two levels), and time-point assessments (seven levels) as fixed effects and patients as a random effect.

DISCUSSION

According to the current literature there is very limited evidence from two small trials regarding the effectiveness of different methods of conservative interventions for treating clavicle fractures. This is the first randomised controlled trial comparing the figure-of-eight bandage versus the arm sling for treating clavicle fractures that follows the CONSORT Statement guidelines.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02398006 .

Comparison of simple arm sling and figure of eight clavicular bandage for midshaft clavicular fractures: a randomised controlled study

Only a few randomised, controlled studies have compared different non-operative methods of treatment of mid-shaft fractures of the clavicle. In this prospective, randomised controlled study of 60 participants (mean age 31.6 years; 15 to 75) we compared the broad arm sling with the figure of eight bandage for the treatment of mid-shaft clavicle fractures. Our outcome measures were pain, Constant and American Shoulder and Elbow Surgeons scores and radiological union. The mean visual analogue scale (VAS) pain score on the first day after treatment was significantly higher (VAS 1 6.8; 4 to 9) in the figure of eight bandage group than the broad arm sling group (VAS 1 5.6; 3 to 8, p = 0.034). A mean shortening of 9 mm (3 to 17) was measured in the figure of eight bandage group, versus 7.5 mm (0 to 24) in the broad arm sling group (p = 0.30). The application of the figure of eight bandage is more difficult than of the broad arm sling, and patients experience more pain during the first day when treated with this option. We suggest the broad arm sling is preferable because of the reduction of early pain and ease of application.

Plate fixation versus conservative treatment of displaced midshaft clavicle fractures: Functional outcome and patients' satisfaction during a mean follow-up of 5 years

INTRODUCTION

The aim of the present prospective clinical trial was to compare patient-oriented and surgeon-based outcomes after non-operative care with operative treatment of displaced midshaft clavicle fractures.

PATIENTS/METHODS

Between January 2009 and July 2011, 97 consecutive patients presenting with a midshaft clavicle fracture were prospectively recorded and included in this study. The patients were placed in either of the treatment groups on their own preference. They were then seen in outpatient clinic at two, six and 24 weeks were all endpoints were investigated and motivation of choice of treatment was noted. Study follow-up was continued until Augustus 2014, being the time point that long-term functional outcome was measured through a DASH score by letter.

RESULTS

97 patients were included in the functional outcome analysis. The mean DASH and Constant scores were significant better in the operative (90.9±14.2 and 15.7±17.2) than in the conservative treatment group at six weeks (78.7±17.0 and 24.8±16.7). There was a significant improvement in the Constant (95.9±10.5 versus 94.5±5.9) and DASH scores (8.8±12.0 versus 7.1±10.7) for both groups at 24 weeks but there was no significant difference in functional scores between the groups. Four patients developed a non-union, one patient in the operative and three patients in the conservative group. Overall complications were significantly higher in the operative group (31%) compared to the conservative group (9%) (p<0.001). There was no significant difference in long-term functional outcome between the two treatment groups (5.2±9.8 versus 2.5±4.9 p=0.12). Patient's satisfaction was higher in the operative than in the conservative group (p<0.04).

CONCLUSION

Significant superior outcome scores were seen at six weeks for the operative group. However, at 24 weeks and 5-year follow-up no difference was seen in functional outcome scores for both treatment groups. Therefore, the challenge for the future is to better identify the subgroup of patients who might benefit from primary surgical intervention.

Clinical comparison of two different plating methods in minimally invasive plate osteosynthesis for clavicular midshaft fractures: A randomized controlled trial

AIM

The aim of this study was to compare the clinical and radiographic outcomes between two different plating methods (superior vs. anteroinferior) in minimally invasive plate osteosynthesis (MIPO) for acute displaced clavicular shaft fractures.

MATERIALS AND METHODS

A prospective, randomized controlled trial was performed in a single centre. Nineteen patients were treated with superior plating and 18 with anteroinferior plating using the MIPO technique. A 3.5-mm locking reconstruction plate was bent preoperatively and applied to either the anteroinferior or superior aspect of the clavicle through two separate incisions. The operating time, time to union, the proportional length difference, complications, and functional outcome of the shoulder joint were evaluated using the Constant score and the University of California Los Angeles (UCLA) score.

RESULTS

There was no statistically significant difference in the Constant score and UCLA score. The mean time to union was 16.8 weeks for superior plating and 17.1 weeks for anteroinferior plating (p=0.866). The average operation time was 77.2min in superior plating and 79.4min in anteroinferior plating (p=0.491). One patient in the superior plating group showed plate failure. Despite no significant difference, one patient had nonunion in the superior plating group (p>0.999).

CONCLUSIONS

From a clinical perspective, although MIPO with anteroinferior plating provides better outcomes especially in complications without statistically significant difference, both plating methods provided satisfactory clinical and radiographic outcomes.

LEVEL OF EVIDENCE

Level I, a single-centre, prospective, randomized controlled trial.

[Thrombosis of the subclavian vein after conservative treatment of a clavicular fracture: A rare complication]

We report the case of a 16-year-old male patient who presented with a clavicular fracture that was conservatively treated with a redressment bandage. After a few days the patient developed deep vein thrombosis of the subclavian, axillary and brachial veins, which was successfully treated with nadroparin. Conservative treatment of clavicular fractures is a common procedure in modern traumatology. Continuous, close monitoring and knowledge of rare but severe complications are necessary to avoid further complications.

Measurement of clavicular length and shortening after a midshaft clavicular fracture: Spatial digitization versus planar roentgen photogrammetry

PURPOSE

Clavicular shortening after fracture is deemed prognostic for clinical outcome and is therefore generally assessed on radiographs. It is used for clinical decision making regarding operative or non-operative treatment in the first 2weeks after trauma, although the reliability and accuracy of the measurements are unclear. This study aimed to assess the reliability of roentgen photogrammetry (2D) of clavicular length and shortening, and to compare these with 3D-spatial digitization measurements, obtained with an electromagnetic recording system (Flock of Birds).

PATIENTS AND METHODS

Thirty-two participants with a consolidated non-operatively treated two or multi-fragmented dislocated midshaft clavicular fracture were analysed. Two observers measured clavicular lengths and absolute and proportional clavicular shortening on radiographs taken before and after fracture consolidation. The clavicular lengths were also measured with spatial digitization. Inter-observer agreement on the radiographic measurements was assessed using the Intraclass Correlation Coefficient (ICC). Agreement between the radiographic and spatial digitization measurements was assessed using a Bland-Altman plot.

RESULTS

The inter-observer agreement on clavicular length, and absolute and proportional shortening on trauma radiographs was almost perfect (ICC>0.90), but moderate for absolute shortening after consolidation (ICC=0.45). The Bland-Altman plot compared measurements of length on AP panorama radiographs with spatial digitization and showed that planar roentgen photogrammetry resulted in up to 37mm longer and 34mm shorter measurements than spatial digitization.

CONCLUSION

Measurements of clavicular length on radiographs are highly reliable between observers, but may not reflect the actual length and shortening of the clavicle when compared to length measurements with spatial digitization. We recommend to use proportional shortening when measuring clavicular length or shortening on radiographs for clinical decision making.

Operative versus nonoperative treatment for displaced midshaft clavicle fractures: a meta-analysis based on current evidence

Literature searches of the Cochrane Library, PubMed, EMBASE, Web of Science, LILACS, China National Knowledge Infrastructure, and Wanfang Data databases were performed from 1966 to September 2014. Only randomized and quasi-randomized controlled clinical trials comparing operative and nonoperative treatments for displaced midshaft clavicle fractures were included. Data collection and extraction, quality assessment, and data analyses were performed according to the Cochrane standards. Thirteen studies were considered in the meta-analysis. Constant scores and the Disabilities of the Arm, Shoulder and Hand scores were improved in the operative fixation group at a follow up of one year or more. The nonunion and symptomatic malunion rates were significantly lower in the operative group. Additionally, the nonoperative group had a higher likelihood of neurological symptoms compared with the operative group. A significantly higher risk of complications was found in patients treated conservatively than in those who underwent operative fixation. However, when patients with nonunion and symptomatic malunion were excluded from the analysis, no significant differences in the complication rate were found. We concluded that based on the current clinical reports, operative treatment is superior to nonoperative treatment in the management of displaced midshaft clavicle fractures. However, we do not support the routine use of primary operative fixation for all displaced midshaft clavicle fractures in adults.