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EVIDENCE-BASEDMEDICINE

Displaced, Comminuted Diaphyseal Clavicle Fracture

César J. Bravo, MD, Christopher A.Wright, BS-MSII

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HE PATIENT43-year-old man presents with an injury to his right

houlder that occurred while he was riding his mountainike. He was told in the emergency department that head fractured his collarbone and that surgeons hadtarted recommending surgical treatment for this injury.e is very active, wants the best possible shoulder

unction, and desires early return to his outdoor activi-ies. There is visible deformity, swelling, ecchymosis,nd tenderness of the clavicle and chest wall. Radio-raphs demonstrate a superiorly displaced middle thirdlavicle fracture with complete loss of apposition andpproximately 2.0 cm of axial shortening.

HE QUESTIONSs surgical or nonsurgical treatment a better option forhis patient? If surgery is elected, is there a preferredethod of fixation?

URRENT OPINIONhe traditional complacency regarding diaphyseal clav-

cle fractures has given way to the realization thatisplaced comminuted fractures are at risk for nonunionnd symptomatic malunion. Surgical treatment is nowonsidered for acute diaphyseal fractures of the clavicle,ut there is variation regarding indications and surgicalechniques.

HE EVIDENCEetrospective and prospective cohort studies, random-

zed prospective trials, and retrospective reviews havestablished that fracture displacement (specifically,omplete loss of apposition and greater than 2 cmhortening), comminution, and older age are associatedith nonunion and symptomatic malunion after nonsur-ical care of displaced diaphyseal clavicle fractures.1–5

From the Carilion Clinic, Roanoke, VA.

Received for publication October 15, 2009; accepted in revised form October 15, 2009.

No benefits in any form have been received or will be received related directly or indirectly to thesubject of this article.

Corresponding author: César J. Bravo, MD, Carilion Clinic, 3 Riverside Circle, Roanoke, VA 24016;e-mail: cbravo@carilion.com.

0363-5023/09/34A10-0021$36.00/0

udoi:10.1016/j.jhsa.2009.10.012

atient-based outcome measures have shown deficits inhoulder strength and endurance after displaced diaph-seal clavicular fractures. A meta-analysis of articlesddressing the treatment of displaced middle-third clav-cle fractures between 1975 and 2005 demonstrates5.1% nonunion rate for closed treatment, 2.2% withompression plating, and 2% with intramedullary fixa-ion.4

Among 581 diaphyseal fractures of the clavicleulled from a prospective trauma database, the overallrevalence of nonunion at 24 weeks was 4.5%.1 Theisk of nonunion was significantly increased by olderge, female gender, displacement of the fracture, andhe presence of comminution.

A prospective, multicenter study of displaced mid-le-third clavicle fractures randomized 132 patients toither nonsurgical treatment or plate and screw fixation.isabilities of the Arm, Shoulder, and Hand (DASH)

nd Constant Shoulder scores were notably superior inatients treated surgically.5 There were significantlyewer nonunions and malunions among the surgicallyreated patients (2 of 62 vs 7 of 49 nonunions, p � .042;nd 0 of 62 vs 9 of 49 malunions, p � .001). In theonsurgical subgroup, there was a direct relationshipetween greater displacement at the fracture site andower scores on the DASH questionnaire. The surgicalroup had a complication rate of 34% and a reoperationate of 18%; most reoperations were for implant re-oval.Another clinical trial compared treatment of a dis-

laced diaphyseal fracture of the clavicle with a simplehoulder sling and elastic stable intramedullary nailingithin 3 days after trauma in 30 patients each.6 Of 30atients treated nonsurgically, 3 had nonunion, com-ared with none of the surgically treated patients. Me-ial nail protrusion treated with a second surgery toemove the implant occurred in 7 patients in the surgicalroup. DASH scores were lower in the surgical grouphroughout the first 6 months and 2 years after trauma.

Number-needed-to-treat analysis revealed that surgi-al fixation of 9 fractures would be required to prevent

nonunion, and fixation of 3.3 fractures would beequired to prevent 1 symptomatic malunion or non-

nion.7

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Nowak et al. evaluated 245 patients aged 15 years orolder with fracture of the clavicle.8 Of the 208 patientsseen at the 9- to 10-year follow-up, 112 had recoveredcompletely, whereas 96 still had sequelae. Nonunionoccurred in 15 patients and was most strongly corre-lated with the absence of bony contact between fracturefragments. Comminuted fractures with an interveningtransversely oriented fragment demonstrated a signifi-cantly increased risk for remaining symptoms. Age wasalso correlated with symptoms, but gender was not.Fracture location and shortening were associated withaesthetic, but not functional, results. Pain during activ-ity, pain at rest, and cosmetic defects at 10-year fol-low-up were associated with fracture shortening.

Nordqvist and coworkers reviewed 225 diaphysealfractures of the clavicle retrospectively. A total of 197of these fractures were treated with a figure-of-8 ban-dage for an average of 3 weeks.9 The authors found that71 fractures were nondisplaced, 69 were displaced withoutcomminution, and 85 were displaced and comminuted. Atotal of 125 fractures healed, 53 healed with malunion, and7 did not unite. Forty patients had moderate shoulder painand were rated as fair (39) or poor (1).

Treatment of established nonunions and malunionsresulted in DASH and Constant scores comparable tosurgical treatment of an acute clavicle fracture in astudy of 15 patients receiving each treatment. However,there was decreased shoulder flexion muscle endurancean average of 63 months after surgery.10 This study andthat of Rosenberg et al. documented diminished func-tion compared with the uninjured shoulder.11

Specific surgical techniques

Plate fixation versus intramedullary nailing: Biomechanical ev-idence suggests that plate fixation provides a strongerconstruct than intramedullary fixation.12

Bostman et al. noted a 23% complication rate with platefixation, but most complications were seen in patients whoare usually considered high-risk individuals (heavy alcoholuse or noncompliance with the postoperative protocol).13

In the high-demand athlete, plate and screw fixationhas been shown to provide 90% radiographic union at 3months.14 Complications included refracture (5%), un-specified transient neurologic complications (7%), andnonunion (5%).

Lee et al. examined 62 patients older than 50 years ofage with middle-third fractures repaired using eitherKnowles pins or a plate and screws.15,16 An average of30 months after surgery, the mean Constant Shoulderscore was 85 in patients treated with Knowles pinningand 84 in patients treated with a plate and screws.

Complication rates were higher in the plating group.

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Specific plate type or position: In a nonrandomized study of64 elderly patients with middle-third clavicle fractures,29 were repaired with locking compression plates and35 received nonlocking compression plates. The lock-ing compression plate group had lower complicationrates and higher rates of return to work and exercise.17

In the locking compression plate group, only 1 compli-cation was a nonunion that was treated nonsurgically.The shoulder score was 84 points. In the nonlockingplate group, 6 complications were related to plate loos-ening (n � 4), wound infection (n � 1), and nonunion(n � 1). The loosening plates and screws were attrib-uted to noncompliance with postoperative orders andpoor bone quality.

The potential advantages of anterior-inferior platinginclude diminished implant prominence and the abilityto place longer screws in the coronal plane.18 On theother hand, superior plate application of a limited-con-tact dynamic compression plate has been shown to havebiomechanical advantages over an anterior plate, espe-cially in the presence of inferior cortical commin-ution.19

Complications of surgical treatment

Complications related to use of plate fixation are infec-tion, plate failure, hypertrophic or dysesthetic scars,implant loosening, nonunion, refracture after plate re-moval, and rare intraoperative vascular injury.7 Re-ported shortcomings of intramedullary fixation includehigh rates of implant breakage, temporary brachialplexus palsy, poor rotational control of the fracture inthe presence of comminution, and skin breakdown overthe entry portals.20

SHORTCOMINGS OF THE EVIDENCEMost data regarding clavicle fractures are derived fromuncontrolled series and incomplete cohorts that may bebiased toward inclusion of symptomatic patients. The 2published prospective, randomized trials appropriatelyreport results according to treatment assignment, but itwould also be interesting to compare the results ofhealed fractures treated surgically and nonsurgically.Studies of patients with malunion and nonunion arerestricted to symptomatic patients who present for treat-ment, whereas we know that there is an uncertain—butpresumably large—percentage of patients with mal-union and nonunion who do not present to the doctorwith problems or present with problems insufficient towarrant consideration of surgery.

THE FUTUREFuture therapeutic research should compare surgical

and nonsurgical treatment to confirm that the risks of

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surgery are outweighed by the benefits. Trials should bedesigned to determine the results of a treatment schemeor protocol rather than just 1 single treatment interven-tion. Large, long-term, prospective cohort studies ofpatients treated nonsurgically would establish the ratesand risks for nonunion, malunion, and the grounds for apatient to have sufficient symptoms to seek medicalattention.

Studies comparing different fixation techniques in aprospective randomized manner based on an adequatesample size to allow meaningful interpretation of theresults are scarce. The advantages and disadvantages ofvarious implants merit further study. Risks of infracla-vicular paresthesias, painful supraclavicular neuroma,brachial plexus palsy, wound problems, infections, anddifficult-to-salvage nonunions with devitalized boneneed to be better defined. A 15% risk of nonunionwould be acceptable to some patients if they had betterinformation about the results of malunion in general aswell as the results of salvage surgery.

OUR CURRENT CONCEPTS FOR THIS PATIENTGiven the rates of nonunion and malunion of displaced,comminuted diaphyseal fractures of the clavicle, wewould offer this patient surgery, carefully counselinghim about the risks and the alternatives. Our preferenceis superior plate application and screw fixation, espe-cially in the presence of inferior cortical comminution.If the patient declined surgery, he would be counseledregarding risks and outcomes of nonsurgical treatmentand the likely outcome of nonsurgical treatment as wellas the potential for salvage surgery.21,22

REFERENCES1. Robinson CM, Court-Brown CM, McQueen MM, Wakefield AE.

Estimating the risk of nonunion following nonoperative treatment ofa clavicular fracture. J Bone Joint Surg 2004;86A:1359–1365.

2. Hill JM, McGuire MH, Crosby LA. Closed treatment of displacedmiddle-third fractures of the clavicle gives poor results. J Bone JointSurg 1997;79B:537–539.

3. McKee MD, Wild LM, Schemitsch EH. Midshaft malunions of theclavicle. J Bone Joint Surg 2003;85A:790–797.

4. Zlowodzki M, et al. Treatment of acute midshaft clavicle fractures:systematic review of 2144 fractures. On behalf of the Evidence-Based Orthopaedic Trauma Working Group. J Orthop Trauma 2005;19:504–507.

5. Society COT. Nonoperative treatment compared with plate fixation

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of displaced midshaft clavicular fractures: a multicenter, randomizedclinical trial. J Bone Joint Surg 2007;89A:1–10.

6. Smekal V, Irenberger A, Struve P, Wambacher M, Krappinger D,Kralinger FS. Elastic stable intramedullary nailing versus nonopera-tive treatment of displaced midshaft clavicular fractures: a random-ized, controlled, clinical trial. J Orthop Trauma 2009;23:106–112.

7. Khan LA, Bradnock TJ, Scott C, Robinson CM. Fractures of theclavicle. J Bone Joint Surg 2009;91A:447–460.

8. Nowak J, Holgersson M, Larsson S. Can we predict long-termsequelae after fractures of the clavicle based on initial findings? Aprospective study with nine to ten years of follow-up. J ShoulderElbow Surg 2004;13:479–486.

9. Nordqvist A, Petersson CJ, Redlund-Johnell I. Mid-clavicle fracturesin adults: end result study after conservative treatment. J OrthopTrauma 1998;12:572–576.

10. Potter JM, Jones C, Wild LM, Schemitsch EH, McKee MD. Doesdelay matter? The restoration of objectively measured shoulderstrength and patient-oriented outcome after immediate fixation ver-sus delayed reconstruction of displaced midshaft fractures of theclavicle. J Shoulder Elbow Surg 2007;16:514–518.

11. Rosenberg N, Neumann L, Wallace AW. Functional outcome ofsurgical treatment of symptomatic nonunion and malunion of mid-shaft clavicle fractures. J Shoulder Elbow Surg 2007;16:510–513.

12. Golish SR, et al. A biomechanical study of plate versus intramed-ullary devices for midshaft clavicle fixation. J Orthop Surg 2008;3:28.

13. Bostman O, Manninen M, Pihlajamaki H. Complications of platefixation in fresh displaced midclavicular fractures. J Trauma 1997;43:778–783.

14. Verborgt O, Pittoors K, Van Glabbeek F, Declercq G, Nuyts R,Somville J. Plate fixation of middle-third fractures of the clavicle inthe semi-professional athlete. Acta Orthop Belg 2005;71:17–21.

15. Lee YS, Lin CC, Huang CR, Chen CN, Liao WY. Operative treat-ment of midclavicular fractures in 62 elderly patients: Knowles pinversus plate. Orthopedics 2007;30:959–964.

16. Lee YS, Huang HL, Lo TY, Hsieh YF, Huang CR. Surgical treat-ment of midclavicular fractures: a prospective comparison ofKnowles pinning and plate fixation. Int Orthop 2008;32:541–545.

17. Pai HT, Lee YS, Cheng CY. Surgical treatment of midclavicularfractures in the elderly: a comparison of locking and nonlockingplates. Orthopedics 2009;32:257.

18. Collinge C, Devinney S, Herscovici D, DiPasquale T, Sanders R.Anterior-inferior plate fixation of middle-third fractures and non-unions of the clavicle. J Orthop Trauma 2006;20:680–686.

19. Iannotti MR, Crosby LA, Stafford P, Grayson G, Goulet R. Effectsof plate location and selection on the stability of midshaft clavicleosteotomies: a biomechanical study. J Shoulder Elbow Surg 2002;11:457–462.

20. Ring D, Holovacs T. Brachial plexus palsy after intramedullaryfixation of a clavicular fracture: a report of three cases. J Bone JointSurg 2005;87A:1834–1837.

21. Jupiter JB, Leffert RD. Non-union of the clavicle: associated com-plications and surgical management. J Bone Joint Surg 1987;69A:753–760.

22. Manske DJ, Szabo RM. The operative treatment of mid-shaft cla-

vicular non-unions. J Bone Joint Surg 1985;67A:1367–1371.

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