What Is the Optimal Treatment of Displaced Midshaft Clavicle Fractures?

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Chapter 18 What Is the Optimal Treatment of Displaced Midshaft Clavicle Fractures?

Clavicle fractures most commonly occur in young active individuals as a result of a direct blow to the shoulder that produces axial compression of the bone. They account for approximately 2.6% of all fractures and are seen in most fracture clinics in large numbers. The most common type of injury is a fracture that occurs in the middle third (or midshaft) of the clavicle; this accounts for approximately 80% of all clavicle fractures and is the focus of this chapter. Proximal and distal third fractures are distinctly different entities with widely disparate mechanisms of injury, treatment methods, and prognoses; they are not discussed in this chapter. Even when significantly displaced, midshaft clavicle fractures traditionally have been treated without surgery. This treatment strategy was based on early reports suggesting that clavicular nonunion was extremely rare after nonoperative treatment, with an incidence rate of 0.1% to 1.0%.¹^–³ Similarly, clavicular malunion was described as being of radiographic interest only with no clinical significance.¹^–³

However, recent studies that are restricted to completely displaced midshaft fractures in adults (the focus of this chapter), that use patient-oriented outcome measures, and that have improved follow-up dispute this generally accepted orthopedic dogma.⁴^–⁸ Nonunion rates between 11% and 21% have been reported, which are exponentially greater than described previously. Also, a significant proportion of patients with healed fractures but ongoing symptomatology have been described: It would appear that clavicular malunion is a distinct clinical entity with characteristic clinical and radiographic features.^9,¹⁰ A variety of potential explanations has been proposed to explain this change, including survival of critically injured trauma patients with more severe fracture patterns, increased patient expectations, more complete follow-up (including patient-oriented outcome measures), and eliminating children (with their inherently good prognosis) from studies.⁴^–¹¹

Sufficient evidence now exists to conclude that the results of closed treatment are much inferior to what has been reported previously. Because there are numerous recent studies that support the safety and efficacy of primary operative fixation for completely displaced midshaft clavicle fractures,¹²^–¹⁴ a discussion of the advantages and disadvantages of operative versus nonoperative treatment is warranted to augment what heretofore would have been a short chapter.

OPTIONS

Nonoperative Treatment

For centuries, attempts have been made to obtain and maintain “closed reduction” of displaced clavicular fractures, and literally hundreds of casts, splints, slings, and wraps have been described. Unfortunately, currently, no convincing evidence exists that any significant improvement can be made to the original position of the fracture. The “figure-of-eight” bandage has been popular in North America for many years, but no convincing clinical evidence is available that a closed reduction of a displaced clavicle fracture can be maintained by this device. The other popular nonoperative method is simple sling immobilization, followed by early motion. Andersen and colleagues ¹⁵ performed a randomized, clinical trial comparing a sling versus a figure-of-eight bandage for displaced clavicular shaft fractures. The study revealed no functional or radiographic difference between the two groups at final follow-up, and in general, patients favored the sling. Because no significant difference exists between the two groups, both forms of nonoperative treatment are amalgamated as “nonoperative treatment” for the purposes of this chapter.

Operative Treatment

Currently, two basic operative techniques exist for the fixation of displaced midshaft fractures of the clavicle. Arguably, the most popular method is open reduction and plate fixation. This technique has been well described, has a proven track record, and with modern implants, surgical techniques, and soft-tissue handling, has a high success rate and low complication rate.¹²^–¹⁴ For example, Smith and colleagues¹⁶ report union in 30 of 30 cases treated in this manner in a prospective trial. The disadvantages of this technique include the prominence of the plate and potential wound complications from the soft-tissue dissection required. However, with newly available precontoured plates (as opposed to the straight plates used previously), this has become less of a problem. Some authors recommend the use of anterior-inferior placement of the plate as a means of decreasing local irritation (as well as avoiding neurovascular structures while drilling).¹⁷ For the purposes of this chapter, open reduction and plating are considered as a single group (whether superior or anterior-inferior).

The second method that is discussed is intramedullary pinning of the clavicle. Although it is intrinsically difficult to perform intramedullary fixation of a curved bone with a straight intramedullary device, it is possible. The advantages of this technique include minimal soft-tissue dissection at the fracture site, less soft-tissue prominence of the hardware, and in some applications of this technique, the ability to remove the hardware relatively early through a small incision.¹⁸^–²³ Chuang and coauthors²³ report success in 30 of 31 midshaft clavicle fractures treated with closed reduction and an intramedullary screw technique. Disadvantages of this technique, common to any unlocked intramedullary device, include difficulty in controlling shortening and rotation, especially in comminuted fractures. This led to a high rate of loss of reduction in one prospective, randomized study.²²

EVIDENCE

Nonoperative Treatment

Whereas prior reports had described generally favorable results after nonoperative care of displaced midshaft fractures of the clavicle, Hill, McGuire, and Crosby’s ⁷ landmark study published in 1997 reported a high degree of residual patient dissatisfaction. For the first time in this setting, they used a patient-based outcome tool and found that 31% of patients were dissatisfied with their outcomes, and noted a nonunion rate of 15%. Conversely, Nordqvist and coworkers⁸ describe good results after long-term follow-up of 225 clavicle fractures, with 185 good, 39 fair, and only 1 poor result. However, in the subcategory of displaced, comminuted fractures (the topic of the article), 27% of patients rated their shoulder as “fair,” which in the rating scale used, roughly corresponds to the dissatisfied group (31%) in Hill’s study. Another Scandinavian study by Nowak and investigators⁶ (the 2002 Neer Award article) found that 46% of 208 patients treated without surgery still had shoulder sequelae at 9- to 10-year follow-up. They found that comminution and displacement correlated with poor outcome. These and other nonoperative studies were summarized in a recent meta-analysis (see Comparative Studies section later in this chapter).

Operative Treatment

Initial reports regarding operative fixation of displaced clavicular fractures were plagued by selection bias (only the worst, comminuted, open fractures received surgery), poor soft-tissue handling, lack of antibiotic coverage (with correspondingly high infection rates), and especially inadequate or suboptimal fixation methods (i.e., cerclage wires or short, weak plates).¹^–³ Thus, not surprisingly, operative failure rates were high and fixation was avoided. More recent articles with improved techniques have conclusively proved that properly performed, primary operative repair of displaced midshaft clavicle fractures is a safe, reliable technique with a low complication rate. Collinge and coworkers¹⁷ report union in 39 of 42 cases treated with anterior/inferior plating, whereas Poigenfurst and coauthors¹² report similarly favorable results in 122 consecutive cases treated with superior plating. A summary of the results of operative fixation is given in the following section.