evidence based management of mid-shaft clavicle … of mid-shaft clavicle fractures kenneth g. swan,...
TRANSCRIPT
Evidence Based Management of
Mid-shaft Clavicle Fractures
KennethG.Swan,Jr.,MDAssistantClinicalProfessor
RutgersMedicalSchool
DISCLOSURES
• None
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Clavicle Fractures
• TheClavicle– “…arelaCvelyagreeableandcooperaCvebone....requiringliHlemorethansymptomaCctreatment[whenfractured]…”
• DavidRing,JesseJupiter,~2002
• “Ifyouwanttogetintotrouble,thenfixaclaviclefracture….”– JC,ProfessorofOrthopaedicSurgery,NJMS,~2004
• “PrimaryoperaCveintervenConismeddlesomeandonlymakesthingsworse….”– SkeletalTrauma,3rdEd,2003
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Mid-shaft Clavicle Fractures
• TradiConalManagement– Simplesling– Figure-of-8strap– ReducConmaneuversnothelpfulornecessary– PaCentstypicallyself-regulatetheiracCvityunClhealinghasprogressed
• 3-4weeksinchildren,6-8weeksinadults
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Midshaft Clavicle Fracture
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Clavicle Fracture
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Clavicle Fractures: Non-operative Treatment
“…..theyalldofine!"
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Clavicle Fractures: Non-operative Treatment
“…..theyalldofine!“
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Clavicle Fractures: Non-operative Treatment
• McKee,JBoneJointSurg,2006• “Deficitsfollowingnon-operaCvetreatmentofdisplacedmid-sha_claviclefractures”
– 30paCentswithdisplacedfractures– 4.5yearclinicalf/u– Results:
• Residualdeficitsinstrengthandendurancepersistwithnon-opera5vetreatment
• Fractureshortening>2cmmaybepredic5veofworseoutcome
– LevelIIIstudy
• Shouldwebefixingmoreofthese?
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Management of Mid-shaft Clavicle Fractures: What’s the Evidence?
ClinicalQuesCons:• Whataretheoutcomeswithnon-operaCvevsoperaCvetreatment?
• Whatarethenon-unionrates?• Doesmalunioneffectoutcome?• ComplicaConrateoftreatmentopCons?
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Displaced Mid-shaft Clavicle Fractures: The Evidence
• CanadianOrthopaedicSociety,2007• MulCcenter,prospecCve,randomizedtrial• ORIFvsNon-Optreatment• LevelI• 111paCentswith1yearf/u• Results:
– ConstantandDASHscoressignificantlyimprovedinORIFgroup
– Fasterunion(16weeksvs28weeks)– Lowernon-unioninORIFgroup,fewsymptoma5cmalunions
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Canadian Orthopaedic Society
• Non-unionrate– NonOp:14%,Op:1.6%
• Malunionrate*– NonOp:18%,Op:0%
• ComplicaCons– InfecCon/Wound--Op:3/62,Non-op0/62– Hardwareremoval—Op:5/62– CRPS--Non-op:1pt
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The Evidence
• Kulshrestha,JOT,2011– ProspecCvecohortstudy,ORIFvsNon-Op– LevelIIstudy;excellentf/u(100%at6mos,90%at18mos)
– 73pts;6,12,18mosf/u– Results:
• Non-union:Op0%,Non-Op29%• Malunion:Op4%,Non-Op36%• ConstantscoressignificantlybeHerinORIFgroupatallCmepoints
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The Evidence
• Robinson,JBJS,2013• ORIFvsNon-opTxofdisplacedmidsha_claviclefxs
• MulC-centerRCT,LevelI• 200pts,1yearclinicalandCTf/u• DASHandConstantScores…..
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The Evidence • Robinson,JBJS,2013• Results:
– ORIFstaCsCcallysignificantlybeHerthannon-optx,bothclinicallyandradiographically
– DASHandConstantscoressignificantlybeHerinORIFgroup– Non-union:Non-op26%(14%requiringORIF);Op1.2%– Non-Opgroupmuchmore“dissasCsfied”– Non-OpgroupthathealedtheirfracturesdidaswellasORIFgroup– Needforsecondaryprocedures
• ORIFgroup18.6%• NonOpgroup18.5%
• Conclusions:– ORIFdecreasesrateofnon-union,givingbeHerresults
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The Evidence
• Virtanen,JBJS,2012– RCT,levelI,ORIFvsNon-Op
• 1yrf/u,DASH,Constantscores,xrays• Results:
– NODIFFERENCEINDASHORCONSTANTSCORESAT3MOSAND1YEAR!
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The Evidence
• Virtanen,JBJS,2012– RCT,levelI,ORIFvsNon-Op
• 1yrf/u,DASH,Constantscores,xrays• Results:
– NODIFFERENCEINDASHORCONSTANTSCORESAT3MOS.AND1YEAR!
– NONUNIONRATEFORNON-OP,24%• ThesepaCentshadworseDASHscoresat1year,butConstantscoressimilartoOpgroup
• Displacementof>150%associatedwithnon-union;shorteningnotassociatedwithnon-union
• NosignificantcomplicaConsinOperaCvegroup• NoneofthepaCentswithnon-unionoptedforORIFlater!!?
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The Evidence
• Xu,JSES,2014• Meta-analysisofRCTs
– OpvsNon-Optx• 471pts,8studies• Results:
– OperaCvetxleadstofewernon-unionsandfewersymptomaCcmalunions
– OperaCvetxleadtobeHerDASH,Constantscores– OpertaCvetxleadstobeHerperceivedcosmesis– ComplicaConshigherinNon-Opgroup
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Risk Factors for Non-Union
• Murray,JBJS,2013– RiskFactorsforNon-uniona_erNon-operaCveTreatmentofDisplacedMid-
sha_FracturesoftheClavicle– LevelIIPrognosCcStudy– 941paCentstreatednon-operaCvely,minimum6mosf/u
• Results:– 125/941ptsnon-union13.3%– RiskFactorsforNon-union:Smoking(33%),Comminu5on,Displacement(>2cm??)
• NNT(NumberNeededtoTreat)– 7.5ORIFtoprevent1Non-Union;however,1.7ORIFifI.D.thoseathighestrisk
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Anteroposterior radiograph illustrating the methods for determining overlap, translation, and overall displacement.
I.R. Murray et al. J Bone Joint Surg Am 2013;95:1153-1158
©2013 by The Journal of Bone and Joint Surgery, Inc.
Clavicle Fixation: Plate vs Nail
• Andrade-Silva,JBJS,2015• ProspecCveRCT• 6monthDASH,Constant,Radiographicf/u• Results:
– ReconplatesandelasCcnailshadequivalentresultsinfuncCon,Cmetounion,paCentsaCsfacCon
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Complications ??
• “Ifyouwanttogetintotrouble,thenfixaclaviclefracture….”– JC,ProfessorofOrthopaedicSurgery,NJMS,~2004
• “PrimaryoperaCveintervenConismeddlesomeandonlymakesthingsworse….”– SkeletalTrauma,3rdEd,2003
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Complications • CanadianOrthopaedicTraumaSociety,JBJS,2007
• Op:37%– Woundinfec5on4.8%– Removalofhardware8%– NeuriCs13%– Non-union1.6%
• Non-Op:63%– Non-union14%– Malunion18%– CRPS2%– NeuriCs14%
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Clinical Case
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44 year old, right hand dominant, orthopaedic surgeon, injured playing in charity Thanksgiving flag
football tournament
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44M ORS, flag football injury
• RTWPOD#3,nosling• ReturntoORPOD#10• 3mosPO,fullfuncCon,nosignificantpain
• HardwarenoCceable
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The Evidence: Return to Function
• Smekal,JOT,2009– IMNailvsNon-Op(sling)
• RCTlevelI,60pts,2yrf/u,weeklyDASHscores• Results:
– Opera5vegroup:lowerrateofnon-unionanddelayedunion,faster5metounion,fasterreturntofunc5on,andabe`erfunc5onaloutcome
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Early Return of Function Post-Op Smekel, JOT, 2009
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Displaced Mid-shaft Clavicle Fractures: Summary
• Mostdisplacedmid-shaaclaviclefracturescanbesuccessfullytreatednon-opera5vely
• Non-unionratefornon-opera5vetreatmentis~15%,– Op:~1%
• RiskFactorsfornon-unionincludesmoking,comminu5onandamountofdisplacement(specific#notyetdefined;?20mm)
• Completelydisplacedmid-shaaclaviclefracturestreatedwithORIFhavealowernon-unionandmalunionrate,andbe`erfunc5onaloutcomesthannon-optreatment
• Complica5onswithORIF:needforhardwareremoval,woundinfx(rare)• Complica5onswithnon-op:needforORIFnon-union/malunion• Platevsnail,todatenodifference
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