Plate ®xation of fresh displaced midshaft clavicle fractures

Wun-Jer Shen M.D.*, Tsung-Jen Liu M.D., Young-Shung Shen M.D.

Po-Cheng Orthopaedic Institute, 100 Po-Ai 2nd Road, Kaohsiung, 813, Taiwan

Received 4 November 1998; received in revised form 5 March 1999; accepted 22 March 1999

Abstract

From 1992±1994, we operated on 251 fresh completely displaced mid-third clavicle fractures in adults; 232 were followed up.The fractures were plated with a Mizuho C-type plate or an AO/ASIF 3.5 mm reconstruction plate. Comminuted fragments

were reduced and wired (133 cases). There were 150 men and 82 women; the median age was 37.3 years (range 18±79). Themean follow-up was 4.4 years (range 3.0±5.9). The mean time to radiographic union was 10 weeks. Seven patients (3%)developed nonunion. Healing with angulation occurred in 14 patients. Deep infection developed in one patient, and super®cial

infection in four cases; 21 patients reported soreness with changes in the weather and activity; 28 patients had residual skinnumbness caudal to the incision. No patient had shoulder droop, and none had impairment of range of motion or shoulderstrength. None developed new or late neurovascular impairment; 171 patients eventually had the hardware removed at anaverage 401 days post operatively. Overall, 94% were satis®ed with the procedure. For completely displaced clavicle fractures in

adults, plating is a reliable procedure. # 1999 Published by Elsevier Science Ltd. All rights reserved.

1. Introduction

The incidence of nonunion of midclavicular fracturesis usually quoted as being from 0.1 to 0.8% [1,2], andthe mainstay of treatment has long been nonoperative.These data, however, are based on studies in whichclavicle fractures were not adequately classi®ed regard-ing patient age and fracture displacement. More recentdata, based on detailed classi®cation of fractures,suggest that the incidence of nonunion in displacedcomminuted midshaft clavicular fractures in adults isbetween 10 and 15% [3±5].

The literature favours rigid internal ®xation withplates for symptomatic midclavicular nonunion [6].However, the use of open reduction in the treatmentof fresh fractures is controversial, with wide geo-graphic and institutional variations in the choice oftreatment. More papers have been published on the

complications of clavicle fractures and the treatment ofnonunion than on the primary operative treatment.

Moderately displaced fractures of the mid-third ofthe clavicle can be treated nonoperatively with satisfac-tory results. However, it is our experience that theresults of nonoperative treatment for severely displacedfractures (Robinson types 2B and worse) in adults arepoor [5]. This was recently supported by Hill et al. [4]who found 8/52 (15%) of patients developed nonunionand 16/52 (31%) reported unsatisfactory results.

2. Materials and methods

For the past three decades, the standard treatmentfor displaced midclavicular fractures at our hospitalhas been operative. We found the Allman classi®cation[7] for midshaft fractures to be too simple, and havebeen using a classi®cation system that takes intoaccount displacement and comminution. Our system isvery similar to the one recently published by Robinson[5], so his classi®cation will be used in this article.

Injury, Int. J. Care Injured 30 (1999) 497±500

0020-1383/99/$ - see front matter # 1999 Published by Elsevier Science Ltd. All rights reserved.

PII: S0020-1383(99 )00140 -0

www.elsevier.com/locate/injury

* Corresponding author: Tel.: +886-7-347-9860; fax: +886-7-345-

2216.

E-mail address: w2212@ms14.hinet.net (W.J. Shen M.D.)

From 1992±1994 inclusive, a total of 862 patientswere seen with acute non-pathologic clavicle shaft frac-tures; 251 patients older than 18 years of age with afresh displaced or comminuted fracture of the shaft ofthe clavicle (Robinson types 2B, 2B1 and 2B2) wereoperated upon. Patients with multiple shoulder girdleinjuries were not included. The fracture was caused bymotorcycle accidents in 138 cases, other vehicle acci-dents in 57 cases, and falls in 41 cases. Sporting inju-ries and direct violence accounted for only 15 cases; 43patients had associated injuries. Six cases were type Iopen fractures; another 15 cases had marked skin tent-ing with abrasions or ecchymoses that threatened theskin integrity; 206 cases were operated upon within 3days of injury, the remainder within 2 weeks. The indi-cations for operation included displacement of thebone ends by more than 100% of the diameter of theclavicle or the presence of fracture comminution.

The operation was performed under general anesthe-sia or interscalene block, with the patient in a supineposition, by experienced attending surgeons. A longi-tudinal incision parallel to the long axis of the clavicleand centred above the fracture was made along the su-perior border of the bone. The fracture was platedwith a Mizuho C type plate (Mizuho Medical, Tokyo,Japan) in 205 cases, and a 3.5 mm AO/ASIF recon-struction plate (Synthes, Bochum, Switzerland) in 46cases. Comminuted fragments were reduced and heldwith cerclage wire. Interfragmentary screws were usedas needed. The length of the plate was determined bythe degree of comminution, and the aim was to restoreclavicular length and to obtain purchase of at least sixcortices on each side of the fracture. Thin plates, suchas the one-third tubular plate, were never used. Wehave not found it necessary to bone graft primarily.Postoperatively, the limb was maintained in a sling for2±3 weeks for patient comfort. No other support wasused. Motorcycle riding was not allowed for onemonth. The patients were seen at regular intervalsuntil the ®nal result of treatment was clear. Plates wereremoved if desired by the patient, no sooner than 12months after the procedure.

The outcome review was performed by a surgeonnot involved in the care of the patients. Case noteswere reviewed. Patients were contacted by telephoneand questioned about pain, di�culty in lifting, painwith shoulder straps, pain on sleeping on a�ected side,local tenderness/numbness on palpation, impairedrange of movement, impaired strength, signs of nervecompression, cosmetic abnormality, return to work,and overall patient satisfaction. All contacted patientswere asked to come to clinic for evaluation, withemphasis placed on patients with inadequate radio-graphs and those who reported any untoward results;117 patients were seen at clinic, including 38 of the 42patients who had problems.

3. Results

Su�cient data were available for follow-up in 232patients. There were 150 men and 82 women, the aver-age age being 37.3 years (range 18±79). The mean fol-low-up was 4.4 years (range 3.0±5.9). The right claviclewas fractured in 122 cases and the left in 110 cases.Cerclage wires were used in 133 cases.

No patient had neurovascular impairment or pul-monary injury attributable to the procedure. Pain sub-sided rapidly, becoming a `soreness' about 1 week afteroperation compared with about 4 weeks for non-oper-ative treatment [2,8]. Deep infection withStaphylococcus aureus occurred in one patient with aclosed fracture, this was associated with loosening ofthe plate and skin ulceration. The infection was mana-ged by removal of the plate and debridement. Thefracture subsequently developed into an establishednonunion, but the patient refused further treatment.Super®cial infection developed in four patients (one inan open fracture); all were successfully treated withlocal debridement and antibiotics, followed by healingof the fracture. No case of osteomyelitis was observedin these four cases.

The mean time to radiographic union was 10 weeks.No plate fractured. Bending or loosening of the plate(by screw pull-out) and healing with obvious angula-tion occurred in 14 patients (6.0%). Nonunion devel-oped in seven patients (3.0%), including the previouslydescribed infection case. All of the other 6 nonunionsoccurred in Robinson type 2B2 fractures. In ®ve ofthese cases, technical errors were identi®ed, includingscrews or wires having been placed in the fracture line(three cases), and insu�cient purchase on the lateralside of the clavicle (two cases).

Clinically, 21 patients (9%) reported occasional painwith changes in the weather and activity. Twenty-eightpatients (12%) complained of residual skin numbnesscaudal to the incision, more on the lateral side thanmedially. No patient seen had an obvious clavicularlump or shoulder droop, and with the exception of thepatients who developed nonunion, none reportedimpairment of range of movement or shoulder strengthas a result of the injury. None developed late neuro-vascular compromise or complained of hand numb-ness. There was no di�culty with shoulder straps orwith lying on the a�ected side. Cosmetically, none ofthe men and eight of the women brought up the sub-ject of the scar. But when speci®cally asked, 11 (7.3%)men and 17 (21%) of the women wished there were noscar. However, none had further operation for cos-metic reasons.

The total time o� work varied from 1 week to over6 months, depending on the type of job, availablity ofunemployment bene®ts, and litigation.

In total, 171 patients eventually had the hardware

W.-J. Shen et al. / Injury, Int. J. Care Injured 30 (1999) 497±500498

removed an average of 401 days (range 350 days to 3.1years) postoperatively, mostly out of cultural habitand due to hardware prominence. Two patients sus-tained a fracture of the same clavicle after plateremoval: one when she fell while getting o� a bus, theother when he slid into base playing baseball. Overall,218 (94%) stated they were satis®ed with the oper-ation.

4. Discussion

In this retrospective assessment we present the out-come and complications of plating of fresh displacedmid-third clavicle fractures at our institution.

Midshaft clavicle fractures get short shrift in medicaltexts. Craig, in classifying clavicle fractures, subdividedboth medial and distal third clavicle fractures into ®vesubtypes, but did not ®nd it necessary to sub-classifymid-third clavicle fractures [9]Ðthis despite the factthat midshaft fractures occur much more often thanmedial and distal fractures combined. We have foundit useful to separate out the displaced and comminutedfractures when deciding management, and for yearshave been using a classi®cation system very similar tothat recently published by Robinson [5]. In this system,type 2B indicates a displaced midclavicular fracture,type 2B1 indicates wedge comminution, and type 2B2indicates isolated or comminuted segmental fractures.

The mechanism of injury noted in our series di�ersdramatically from that in other series. In our patientcatchment area, motorcycles and scooters are a verycommon form of transportation, and road tra�c acci-dents account for 195/251 (78%) of the clavicle frac-tures. In Nordqvist and Petersson's series of 2035clavicular fractures, tra�c related causes accounted for20±26% [10]. Robinson, studying 1000 adults, found27% due to road tra�c accidents [5]. The relativelyhigh energy impact of motorcycle accidents probablyaccounts for the high percentage of open and commin-uted fractures in this series.

Neer found that only 3 out of 2235 (0.1%) cases ofclavicle fractures treated nonoperatively failed to heal,and this ®gure has been widely quoted [1].Unfortunately, it is misleading in that the patientpopulation was mixed with regard to age, clavicularfracture site, and severity and nature of the fracture.The many articles on the treatment of clavicular non-union and malunion found on computerized literaturesearches, and referenced by Simpson and Jupiter [6],suggest that the true incidence of nonunion is muchhigher.

In Robinson's series [5], the delayed union rate was2.1% and the nonunion rate was 4.6% for type 2B1fractures. For type 2B2, the delayed union rate was6.3% and the nonunion rate was 9.4%. In Hill's

series of displaced mid-third clavicle fractures [4], 8/52 (15%) developed nonunion. White and Ansonanalyzed 112 adult clavicle shaft fractures retrospec-tively, and found 18 delayed unions and 9 nonunions[3]. When further subclassi®ed, the nonunion rate was13% in the high energy group. The marked di�erencein nonunion rates from the above series comparedwith the Neer series highlights the importance of sub-classifying clavicle fractures when deciding treatment.We agree with Robinson that the initial morphologyof the fracture provides the best indication of the riskof delayed or nonunion, irrespective of the mechan-ism of injury.

Plate ®xation of fresh midclavicular fractures hasbeen practiced for decades, yet very few clinical serieshave been published on the subject in the English lit-erature [11]. To our knowledge, the largest is the seriesof 122 patients by PoigenfuÈ rst et al. [12], 102 of whichwere midclavicular fractures. They found nine cases(7.3%) of super®cial disturbances of wound healing,but no case of osteomyelitis or infected pseudarthrosis.Eleven fractures (9%) healed in angulation, and ®venonunions occurred (4%). Four patients had re-frac-tures after removal of the plate. It was stated thatmost of the unfavourable results could have beenavoided as they could be explained by technical failure.Recommendations included avoiding devitalization offragments, using an implant of adequate size andthickness, leaving the plates in place for at least sixmonths, and not forcibly removing interfragmentaryscrews.

In a study looking at closed treatment of displacedmid-third fractures of the clavicle, Hill et al. [4]reviewed 52 out of 66 patients 38 months afterinjury, and found that 13 patients had pain requiringthe use of medication, 20 patients had pain withshoulder straps, 23 patients had pain sleeping on thea�ected side, 20 patients had local tenderness on pal-pation, and 13 had notable cosmetic abnormality.Only 36 patients (69%) were satis®ed with the result.Nonunion developed in eight fractures (15%). Theyrecommended open reduction and internal ®xation ofseverely displaced fractures of the middle third of theclavicle in adult patients. Stanley and Norris, whilecomparing the e�cacy of ®gure-of-eight bandagesversus a broad arm sling, stated that 33% of thoseover the age of 20 still had symptoms 3 monthsafter fracture [8]. Sankarankutty and Turner [13]reported 15% of patients had noteworthy deformityat the fracture site in 100 cases treated nonopera-tively.

Retrospectively, BoÈ stman et al. [11] studied 103patients treated by open reduction and internal ®x-ation using plates. The postoperative course wasuneventful in 79 patients (77%). Five patients had adeep infection and three patients had a super®cial

W.-J. Shen et al. / Injury, Int. J. Care Injured 30 (1999) 497±500 499

infection. The infection rate was 7.8%. Two patients,treated with one-third tubular plates, su�ered platebreakage. Another four patients had plate loosening orangulation severe enough to require further treatment.There were three nonunions, three delayed unions, and12 malunions. Severely comminuted fractures and alco-hol intoxication on admission increased the risk of fail-ure. The authors speculated that the quick pain reliefa�orded by plate ®xation may have resulted in non-chalant premature use of the arm.

Even though early plate ®xation may never becomethe treatment of choice for clavicular fractures, aknowledge of its outcome and complications is necess-ary to determine its relative merits. The authors agreethat clavicular fractures which are not severely dis-placed can be managed non-operatively. However, dis-placed clavicle fractures belonging to Robinson type2B, 2B1, and 2B2, or American Trauma Associationfracture classi®cation types 06-B and 06-C [14], behavedi�erently from and should not be treated the sameway as undisplaced or minimally displaced fractures.Closed reduction is rarely successful for displaced orcomminuted clavicle fractures. The deforming pull ofthe sternocleidomastoid muscle is too great and the de-formity recurs very shortly despite the use of supportssuch as the ®gure-of-eight bandage.

At the authors' hospital, acute plating of displacedclavicle fractures has been standard procedure for thepast three decades. Compared with non-operativetreatment the non-union rate is lower (3±5% vs 10±15%), pain relief is quicker [15], and even when malu-nion occurs, it is much less severe. Clinically, there isless problem with shoulder straps. The infection rate ison a par with most clean operative procedures.

Wire ®xation is used at some centres [16], butwe have had better results with plate ®xation.Reconstruction plates can be contoured best to thecomplex three-dimensional anatomy of the clavicle.As with any tubular bone fracture, ®xation of six ormore cortices on each side is desirable. The plate

should not be removed for at least one year, to avoidrefracture.

References

[1] Neer CS. Nonunion of the clavicle. JAMA 1960;172:1006±11.

[2] Rowe CR. An atlas of anatomy and treatment of mid-clavicular

fractures. Clin Orthop 1968;58:29±42.

[3] White RR, Anson PS. Adult clavicle fractures: relationship

between mechanism of injury and healing. Orthop Trans

1989;13:514±5.

[4] Hill JM, McGuire MH, Crosby LA. Closed treatment of dis-

placed middle-third fractures of the clavicle gives poor results. J

Bone Joint Surg [Br] 1997;79-B:537±9.

[5] Robinson CM. Fractures of the clavicle in the adult.

Epidemiology and classi®cation. J Bone Joint Surg [Br] 1998;80-

B:476±84.

[6] Simpson NS, Jupiter JB. Clavicular nonunion and malunion:

evaluation and surgical management. J Am Acad Orthop Surg

1996;4:1±8.

[7] Allman Jr FL. Fractures and ligamentous injuries of the clavicle

and its articulation. J Bone Joint Surg [Am] 1967;49-A:774±84.

[8] Stanley D, Norris SH. Recovery following fractures of the clavi-

cle treated conservatively. Injury 1988;19:162±4.

[9] Craig EV. Fractures of the clavicle. In: Rockwood Jr CA,

Green DP, editors. Rockwood and Green's fractures in adults,

5th ed. Philadelphia: Lippincott±Raven Publishers, 1996. p.

1109±61.

[10] Nordqvist A, Petersson C. The incidence of fractures of the cla-

vicle. Clin Orthop 1994;300:127±32.

[11] BoÈ stman O, Manninen M, PihlajamaÈ ki H. Complications of

plate ®xation in fresh displaced midclavicular fractures. J

Trauma 1997;43:778±83.

[12] PoigenfuÈ rst J, Rappold G, Fischer W. Plating of fresh clavicular

fractures: results of 122 operations. Injury 1992;23(4):237±41.

[13] Sankarankutty M, Turner BW. Fractures of the clavicle. Injury

1975;7:101±6.

[14] Committee for Coding, Classi®cation. Orthopaedic trauma as-

sociation fracture and dislocation compendium. J Orthop

Trauma 1996;10S:78.

[15] Ali Kahn MA, Lucas HK. Plating of fractures of the middle

third of the clavicle. Injury 1978;9:263±7.

[16] Ngarmukos C, Parkpian V, Patradul A. Fixation of fractures of

the midshaft of the clavicle with Kirschner wires. J Bone Joint

Surg [Br] 1998;80-B:106±8.

W.-J. Shen et al. / Injury, Int. J. Care Injured 30 (1999) 497±500500