Comparison between conservative treatment and plate fixation for displaced middle third clavicle fracture: clinical outcomes and complications

Gian Mario Micheloni; Luigi Tarallo; Giuseppe Porcellini; Fabio Catani

doi:10.23750/abm.v90i12-S.8995

Comparison between conservative treatment and plate fixation for displaced middle third clavicle fracture: clinical outcomes and complications

Authors

Gian Mario Micheloni Department of Orthopedics and Traumatology, Ospedale civile San Bortolo, Vicenza
Luigi Tarallo Department of Orthopedics and Traumatology, Policlinico di Modena, UNIMORE
Giuseppe Porcellini Department of Orthopedics and Traumatology, Policlinico di Modena, UNIMORE
Fabio Catani Department of Orthopedics and Traumatology, Policlinico di Modena, UNIMORE

DOI: https://doi.org/10.23750/abm.v90i12-S.8995

Keywords:

clavicle fracture, plate fixation, figure of eight bandage, complication rate

Abstract

Background: Clavicle fractures are common injuries in adults, especially due to sport activities or road traffic accidents. Most lesions occur at the level of the middle-third presenting some degree of displacement often. Traditionally, non-surgical management was considered the first treatment option for the most clavicle fractures. Nowadays, various authors suggest early surgical fixation of displaced midshaft fractures. The aim of this study is to compare surgical versus non-surgical treatment and to evaluate the outcomes and the incidence of complications following to both treatment options. Matherial and methods: 87 patients with 2 displaced clavicle fractures fragments (AO 15.2A) were included in the retrospective study, evaluating the clinical and functional outcomes and the complication rate with a follow-up average of 48 months. Results: The risk of nonunion resulted lower in the surgically treated patients. The Constant Score after 1 year was slightly better after the plate fixation (94,36 vs 91,36), while the DASH score resulted better in the conservatively treated patients (3,86 vs 4,63). The delay or revision surgery rates were similar for both groups and most of the complications were associated with the conservative treatment. Conclusions: According to our results, the plate fixation does not lead to better clinical and functional outcomes, instead it reduces the risk of nonunion. We suggest to tailor the treatment patient-by-patient considering the functional demand, patient’s comorbidity and nonunion risk factor.

References

1) Moore TO. Internal pin fixation for fracture of the clavicle. Am Surg 1951;17(7):580–583.
2) Neer CS 2nd. Fractures of the distal third of the clavicle. Clin Orthop Relat Res 1968;58:43–50.
3) Nordqvist A, Petersson C. The incidence of fractures of the clavicle. Clin Orthop Relat Res 1994;300:127–132.
4) Postacchini F, Gumina S, De Santis P, Albo F. Epidemiology of clavicle fractures. J Shoulder Elbow Surg 2002;11(5):452–456
5) Stanley D, Trowbridge EA, Norris SH. The mechanism of clavicular fracture. A clinical and biomechanical analysis. J Bone Joint Surg Br 1988;70:461-4.
6) Khan LA, Bradnock TJ, Scott C, Robinson CM. Fractures of the clavicle. J Bone Joint Surg Am 2009;91:447-60.
7) Nowak J, Mallmin H, Larsson S. The aetiology and epidemiology of clavicular fractures. A prospective study during a two-year period in Uppsala, Sweden. Injury 2000;31:353-8.
8) Van der Meijden OA, Gaskill TR, Millett PJ, Treatment of clavicle fractures: current concepts review. J Shoulder Elbow Surg 2012;21,423-429.
9) Neer CS 2nd. Nonunion of the clavicle. J Am Med Assoc 1960;172:1006–1011.

10) Stanley D, Trowbridge EA, Norris SH. The mechanism of clavicular fracture. A clinical and biomechanical analysis. J Bone Joint Surg Br 1988;70(3):461–464.

11) Allman FL. Fractures and ligamentous injuries of the clavicle and its articulation. J Bone Joint Surg Am 1967;49(4):774–784.

12) Craig EV. Fractures of the clavicle. In: Rockwood CA, Green DP (eds) Fractures in adults, vol 1, 6th edn. Lippincott Williams & Wilkins, Philadelphia 2006; pp 1216–1217.

13) Robinson CM. Fractures of the clavicle in the adult. Epidemiology and classification. J Bone Joint Surg Br 1998;80(3):476–484.

14) Rowe CR. An atlas of anatomy and treatment of midclavicular fractures. Clin Orthop Relat Res 1968;58:29–42.

15) O’Neill BJ, Hirpara KM, O’Briain D, McGarr C, Kaar TK. Clavicle fractures: a comparison of five classification systems and their relationship to treatment outcomes International Orthopaedics (SICOT) 2011;35:909–914.

16) Hill JM, McGuire MH, Crosby LA. Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg Br 1997;79(4):537–539.

17) McKee MD, Pedersen EM, Jones C, Stephen DJ, Kreder HJ, Schemitsch EH, Wild LM, Potter J. Deficits following nonoperative treatment of displaced midshaft clavicular fractures. J Bone Joint Surg Am 2006;88(1):35–40.

18) Lenza M, Belloti JC, Gomes Dos Santos JB, Matsumoto MH, Faloppa F. Surgical interventions for treating acute fractures or non-union of the middle third of the clavicle. Cochrane Database Syst Rev 2009;(4):CD007428.

19) McKee RC, Whelan DB, Schemitsch EH, McKee MD. Operative versus nonoperative care of displaced midshaft clavicular fractures: a meta-analysis of randomized clinical trials. J Bone Joint Surg Am 2012;94:675-84.

20) Robinson CM, Goudie EB, Murray IR, Jenkins PJ, Ahktar MA, Foster CJ, et al. Open reduction and plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures: a multicentre, randomized, controlled trial. J Bone Joint Surg Am 2013;95:1576-84.

21) Andermahr J, Jubel A, Elsner A, Prokop A, Tsikaras P, Jupiter J, et al. Malunion of the clavicle causes significant glenoid malposition: a quantitative anatomic investigation. Surg Radiol Anat 2006;28:447-56.

22) Lazarides S, Zafiropoulos G. Conservative treatment of fractures at the middle third of the clavicle: the relevance of shortening and clinical outcome. J Shoulder Elbow Surg 2006;15:191-4.

23) Ledger M, Leeks N, Ackland T, Wang A. Short malunions of the clavicle: an anatomic and functional study. J Shoulder Elbow Surg 2005;14:349-54.

24) Matsumura N, Ikegami H, Nakamichi N, Nakamura T, Nagura T, Imanishi N, et al. Effect of shortening deformity of the clavicle on scapular kinematics: a cadaveric study. Am J Sports Med 2010;38: 1000-6.

25) Matsumura N, Nakamichi N, Ikegami H, Nagura T, Imanishi N, Aiso S, et al. The function of the clavicle on scapular motion: a cadaveric study. J Shoulder Elbow Surg 2013;22:333-9.

26) Nowak J, Holgersson M, Larsson S. Can we predict long-term sequelae after fractures of the clavicle based on initial findings? A prospective study with nine to ten years of follow-up. J Shoulder Elbow Surg 2004;13:479-86.

27) Postacchini R, Gumina S, Farsetti P, Postacchini F. Long-term results of conservative management of midshaft clavicle fracture. Int Orthop 2010;34:731-6.

28) Wick M, Muller EJ, Kollig E, Muhr G. Midshaft fractures of the clavicle with a shortening of more than 2 cm predispose to nonunion. Arch Orthop Trauma Surg 2001;121:207-11.

29) George DM, McKay BP, Jaarsma RL. The long-term outcome of displaced mid-third clavicle fractures on scapular and shoulder function: variations between immediate surgery, delayed surgery, and nonsurgical management J Shoulder Elbow Surg (2014), 1-8.

30) Hillen RJ, Burger BJ, Poll RG, van Dijk CN, Veeger DH. The effect of experimental shortening of the clavicle on shoulder kinematics. Clin Biomech (Bristol, Avon) 2012;27:777-81.

31) Huang TL, Lin FH, Hsu HC. Surgical treatment for non-union of the mid-shaft clavicle using a reconstruction plate: scapular malposition is related to poor results. Injury 2009;40:231-5.

32) Krishnan KG, Mucha D, Gupta R, Schackert G. Brachial plexus compression caused by recurrent clavicular nonunion and spaceoccupying pseudoarthrosis: definitive reconstruction using free vascularized bone flapa series of eight cases. Neurosurgery 2008; 62(Suppl 2):461-70.

33) Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder, and hand). Am J Ind Med 1996;29:602-8.

34) Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res. 1987 Jan;(214):160-4.

35) Woltz S et al, Plate Fixation Versus Nonoperative Treatment for Displaced Midshaft Clavicular Fractures A Meta-Analysis of Randomized Controlled Trials, The Journal of Bone and Joint surgery, 2017.

36) Robinson CM, Goudie EB, Murray IR, Jenkins PJ, Ahktar MA, Read EO et al. Open reduction and plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures: a multicenter, randomized, controlled trial. J Bone Joint Surg Am. 2013;95(17):1576-84.

37) Schemitsch LA, Schemitsch EH, Veillette C, Zdero R, McKee MD. Function plateaus by one year in patients with surgically treated displaced midshaft clavicle fractures. Clin Orthop Relat Res. 2011;469(12):3351-5.

38) Melean PA, Zuniga A, Marsalli M, Fritis NA, Cook ER, Zilleruelo M et al. Surgical treatment of displaced middle-third clavicular fractures: a prospective, randomized trial in a working compensation population. J Shoulder Elbow Surg. 2015;24(4):587-92.

39) Woltz S, Stegeman SA, Krijnen P, van Dijkman BA, van Thiel TP, Schep NW, et al. Plate fixation compared with nonoperative treatment for displaced midshaft clavicular fractures: a multicenter randomized controlled trial. J Bone Joint Surg Am. 2017;99(2):106-12.

40) van Kampen DA, Willems WJ, van Beers LW, Castelein, RM; Scholtes, VA, Terwee, CB. Determination and comparison of the smallest detectable change (SDC) and the minimal important change (MIC) of four-shoulder patient-reported outcome measures (PROMs). J Orthop Surg Res. 2013;8:40.

41) Figueiredo GS, Jun M, Tamaoki S, Dragone B, Utino AY, Netto NA, et al. Correlation of the degree of clavicle shortening after non-surgical treatment of midshaft fractures with upper limb function. BMC Musculoskeletal Disorders 2015;16:151.

42) Canadian Orthopaedic Trauma Society. Nonoperative Treatment Compared with Plate Fixation of Displaced Midshaft Clavicular Fractures A Multicenter, Randomized Clinical Trial. J Bone Joint Surg Am 2007;89(1):1-10.