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Surgical versus Nonsurgical Management of Displaced Clavicle Fractures

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In this point-counterpoint article, Drs. Rouleau and Lapner discuss the benefits of surgical versus nonsurgical management of displaced fractures of the clavicle. This is quite an interesting debate, especially with the recent Level 1 evidence clearly favouring open reduction and internal fixation of clavicle fractures.

It would then appear that no controversies would remain, given the impression that nonsurgical management should be rarely considered for these injuries. However, both authors clearly demonstrate that there is still a need for patient selection because of the potential risks and complications associated with open reduction and internal fixation. Although the functional outcome of patients being treated operatively are excellent, the risk of surgery should always be weighed against the benefits which, in certain types of clavicle fractures, surgical management may not be warranted.

Viewpoint 1: Dominique Rouleau, Emilie Sandman

Clavicle Fracture - Plate Fixation for All

Clavicle fractures are recognized as being among the “best fractures” to have in the upper limb, since most heal well without complication. Over the last few decades, conservative treatment, or “careful” neglect, was the standard of care. Closed reduction was considered wishful thinking; thus fracture displacement was accepted.5

However, our comprehension of the management of clavicle fractures has evolved as a result of recent studies.

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Nowac et al conducted a prospective study of 208 cases of clavicle fractures and showed that 46% presented with a functional deficit at the 10-year follow-up.11 McKee et al also found a significant functional impairment when clavicle fractures were treated conservatively.9 Moreover, Kulshrestha et al reported 29% nonunion and 36% malunion following conservative treatment of displaced clavicle fractures at 18 months.6

In the face of these striking data, standard conservative treatment of clavicle fractures has been put in doubt. We must now ask: 1) Can we obtain better results with surgery? 2) Are the surgical risks worth it? Our answer is YES for a large percentage of patients.

Advantages of Surgery

Two Level 1 articles have illustrated the advantages of surgery over conservative treatment. The study done by the Canadian Orthopedic Trauma Society (COTS) demonstrated improved function, according to the Constant score and DASH score, at 1-year follow-up in the plate group when compared to the conservative treatment group for displaced middle third clavicle fractures.2 One third of the conservatively treated patients developed significant malunion (18%) or nonunion (15%).

Furthermore, a smaller randomized study of 60 patients by Mirzatolooei et al reported similar results in terms of improved outcome with surgery.10 Several other studies have also demonstrated better functional outcomes in the surgical group, when evaluating the differences between nailing and conservative treatment.7,14,15

Risks of Surgery

In the COTS study, 5% of the patients in the surgical group had wound healing problems and 8% required plate removal.2 The Mirzatolooei study obtained a similar 4% infection rate (1/26).10 The risk of nonunion following surgery was respectively 1/61 (2%) and 4% in both Level 1 studies.

Who to Fix

The following question must be asked: Who should we fix? The literature offers us guidelines in order to identify patients at risk of nonunion and lower functional outcome.1,5,11,13 These risk factors for poorer results with conservative treatment can be used to guide surgeon-patient discussions.

Factors Orienting Toward Fracture Fixation

  • Open fracture
  • Shortening > 1.5 cm
  • Skin tenting
  • Comminutive fracture
  • No bone contact between fragments
  • Older patients and women{^}13*
  • Higher-demand patients (manual workers or upper limb sports participants)

How to Fix?

When the decision is made to operate, how should we fix the clavicle?. Clinical studies comparing nail versus plate fixation have not shown any difference between the implants; however, the studies were either underpowered4 or using retrospective8 design. Nail migration and clavicle telescoping in cases of fracture comminution have been reported in the literature.14, 15 With complex fractures, biomechanical studies have demonstrated better results with plate fixation and locking.3,12

Conclusion

Plate fixation is recommended for displaced clavicle fractures in healthy adult patients in order to obtain improved functional outcomes and better patient satisfaction at mid-term follow-up, enhanced healing rates, as well as a better restoration of the anatomy. However, patients must be aware of the potential risks associated with surgery, such as infection (5%) and plate removal (8%).

Reprinted with permission from the Fall 2011 issue of COA Bulletin

References

  1. Bravo C.J., Wright C.A. Displaced, comminuted diaphyseal clavicle fracture. J Hand Surg Am. 2009 Dec;34(10):1883-5. Review. PubMed PMID: 19969194.
  2. 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 Jan;89(1):1-10. PubMed PMID: 17200303.
  3. Celestre P., Roberston C., Mahar A., Oka R., Meunier M., Schwartz A. Biomechanical evaluation of clavicle fracture plating techniques: does a locking plate provide improved stability? J Orthop Trauma. 2008 Apr;22(4):241-7. PubMed PMID: 18404033.
  4. Ferran N.A., Hodgson P., Vannet N., Williams R., Evans R.O. Locked intramedullary fixation vs plating for displaced and shortened mid-shaft clavicle fractures: a randomized clinical trial. J Shoulder Elbow Surg. 2010 Sep;19(6):783-9. PubMed PMID: 20713274.
  5. Hillen R.J., Burger B.J., Pöll R.G., de Gast A., Robinson C.M. Malunion after midshaft clavicle fractures in adults. Acta Orthop. 2010 Jun;81(3):273-9. Review. PubMed PMID: 20367423; PubMed Central PMCID: PMC2876826.
  6. Kulshrestha V., Roy T., Audige L. Operative versus nonoperative management of displaced midshaft clavicle fractures: a prospective cohort study. J Orthop Trauma. 2011 Jan;25(1):31-8. PubMed PMID: 21164305.
  7. Lee Y.S., Lin C.C., Huang C.R., Chen C.N., Liao W.Y. Operative treatment of midclavicular fractures in 62 elderly patients: knowles pin versus plate. Orthopedics. 2007 Nov;30(11):959-64. PubMed PMID: 18019991.
  8. Liu H.H., Chang C.H., Chia W.T., Chen C.H., Tarng Y.W., Wong C.Y. Comparison of plates versus intramedullary nails for fixation of displaced midshaft clavicular fractures. J Trauma. 2010 Dec;69(6):E82-7. PubMed PMID: 20664374.
  9. McKee M.D., Pedersen E.M., Jones C., Stephen D.J., Kreder H.J., Schemitsch E.H., Wild L.M., Potter J. Deficits following nonoperative treatment of displaced midshaft clavicular fractures. J Bone Joint Surg Am. 2006 Jan;88(1):35-40. PubMed PMID:16391247.
  10. Mirzatolooei F. Comparison between operative and nonoperative treatment methods in the management of comminuted fractures of the clavicle. Acta Orthop Traumatol Turc. 2011;45(1):34-40. doi: 10.3944/AOTT.2011.2431. PubMed PMID: 21478660.
  11. 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 Sep-Oct;13(5):479-86. PubMed PMID: 15383801.
  12. Renfree T., Conrad B., Wright T. Biomechanical comparison of contemporary clavicle fixation devices. J Hand Surg Am. 2010 Apr;35(4):639-44. PubMed PMID: 20138445.
  13. Robinson C.M., Court-Brown C.M., McQueen M.M., Wakefield A.E. Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. J Bone Joint Surg Am. 2004 Jul;86-A(7):1359-65. PubMed PMID: 15252081.
  14. Smekal V., Irenberger A., Attal R.E., Oberladstaetter J., Krappinger D., Kralinger F. Elastic stable intramedullary nailing is best for mid-shaft clavicular fractures without comminution: results in 60 patients. Injury. 2011 Apr;42(4):324-9. Epub 2010 Apr 14. PubMed PMID: 20394920.
  15. Smekal V., Irenberger A., Struve P., Wambacher M., Krappinger D., Kralinger F.S. Elastic stable intramedullary nailing versus nonoperative treatment of displaced midshaft clavicular fractures-a randomized, controlled, clinical trial. J Orthop Trauma. 2009 Feb;23(2):106-12. PubMed PMID: 19169102.

Viewpoint 2: Peter L.C. Lapner

Clavicle Fracture - Is Open Reduction and Internal Fixation the Right Option

The question of open reduction and internal fixation (ORIF) of clavicle fractures remains controversial. For the purpose of defining the question, discussion will be limited to closed, mid-shaft clavicle fractures. Although no surgeon would ever advocate closed treatment of all clavicle fractures, it appears that the metaphorical pendulum has swung in the direction of ORIF for many clavicle fractures that previously would have been treated by conservative means. In this age of escalating health care costs, it is imperative to be selective in offering operative treatment.

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Evidence for Surgical Intervention?

Two trials have compared the outcome of plate fixation with non-operative outcome. In 2007, McKee et al1 compared ORIF to treatment with a sling in a prospective, randomized controlled trial (PRCT). Patients in the operative arm had higher functional scores, and lower rates of nonunion and malunion compared with non-operative treatment at 1 year. A positive correlation was identified in the non-operative group between the degree of displacement and functional outcome. Nonunion occurred in 2/62 (3.2%) in the operative group, and 7 of 49 (14.2%) in the non-operative group. Malunion requiring further treatment did not occur in the operative group, but occurred in 9/49 (18%) in the non-operative group. Overall the complication rate was higher in the non-operative group (63% vs. 37%, p=0.008).

In a recent study, Mirzatolooei et al2 reported the outcomes of a PRCT in which operative fixation with a 3.5 mm reconstruction plate was compared with sling/swathe treatment in communited fractures of the clavicle. Operatively treated patients had higher Constant scores (89.8 vs 78.8, p<0.001) and higher levels of satisfaction.

Hagie pin fixation was compared with closed treatment by Judd et al.3 A high complication rate related to pin prominence in the posterior shoulder was reported. Although results at 3 weeks favoured internal fixation, functional scores were similar at 6 months and 12 months.

In another study, Smekal et al4 compared operative treatment with elastic stable intramedullary nailing to non-operative treatment for midshaft clavicular fractures. Fracture union occurred in all patients in the operative group, but nonunion occurred in 3/30 patients in the non-operative group. Medial nail protrusion occurred in seven cases in the operative group, and implant failure with revision surgery was necessary in two patients after additional trauma. Constant scores were significantly higher after 6 months and 2 years following IM stabilization. The incidence of shortening was lower in the operative group.

Although the evidence presented in these trials seems compelling, review of the epidemiology is helpful to inform the decision to treat non-operatively. In a report of 1,000 clavicle fractures, Robinson et al5 observed that closed treatment of undisplaced or angulated fractures with cortical contact yielded a good prognosis with few complications. Displaced diaphyseal fractures healed in most cases, but 5.8% had delayed union beyond 12 weeks, and 3.2% had nonunion at 24 weeks. In a meta-analysis of clavicle fracture studies, Zlowodski et al6 reported a nonunion rate of 5.9% for non-operative treatment. In the same study, non-operative treatment of 159 displaced fractures resulted in a nonunion rate of 15.1%.

To Treat or Not to Treat

Given the incidence of nonunion with non-operative treatment, it is logical to categorize the factors that increase this risk (Figure 1).


Figure 1. Factors associated with increased nonunion risk and loss of function: displacement, comminution, and shortening

Factors identified to increase the risk of nonunion are:

  • Displacement5
  • Segmental comminution5
  • Female gender7
  • Increased number of fragments8
  • Advancing age8

Is it possible however that some of these factors may be reflective of more complex or higher-energy fractures that might also show higher risk of nonunion with operative treatment.

It is not clear what degree of shortening may compromise quality of life or function. The correlation between shortening and functional outcomes was studied by De Giorgi et al.9 Among satisfied patients, mean clavicle shortening was 10 mm (6.5%), compared with 15.2 mm (9.7%) in the dissatisfied group. The authors concluded that marked shortening was correlated with failure of conservative treatment; they suggested that shortening of greater than 9.7% be used as an indication for ORIF.

Perhaps the most compelling argument not to treat all fractures with the potential for nonunion or malunion with ORIF is that there is little evidence that delayed treatment yields significantly inferior results. Potter et al10 compared early (0.6 month) vs. late (63 months) ORIF following completely displaced fractures of the mid-clavicle. Constant score results favoured acute treatment (acute, 95; delayed, 89; p=0.02). The superior functional results with early fixation in this study were subtle, however, and it is debatable whether this statistically significant result in Constant score superiority is in fact clinically relevant. Strength testing did not reveal a significant difference in shoulder flexion; however, shoulder flexion muscle endurance was decreased significantly in the delayed group (acute 109%, delayed 80%; p=0.05).

No clear guidelines exist regarding the optimal protocol for non-operative treatment. Only one study attempted to answer this question; Andersen et al11 compared sling vs. figure of 8 splinting in a prospective, randomized trial. The authors reported less discomfort and fewer complications in the sling group compared with the figure of 8 group. However, the study had several weaknesses including a short duration of follow-up at 3 months; the sling group only wore a sling for 1 week; and the figure of 8 group was only splinted for 3 weeks.

Summary

Non-operative treatment can yield a high union rate and patient satisfaction in simple (non-multifragmentary) fractures in which cortical contact exists, in younger patients, and in fractures with little displacement overall. The risk of nonunion and poor functional outcome increases in older patients; in multifragmentary or displaced fractures; in fractures with shortening greater than 9.7%; and with female gender. It is important to discuss the option of non-operative treatment even with these patients however, as delayed operative treatment, when necessary, can still yield excellent results in this subset of patients.

Reprinted with permission from the Fall 2011 issue of COA Bulletin

References

  1. Canadian Orthopedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am. 2007 Jan;89(1):1-10.
  2. Mirzatolooei F. Comparison between operative and nonoperative treatment methods in the management of comminuted fractures of the clavicle. Acta Orthop Traumatol Turc. 2011;45(1):34-40.
  3. Judd D.B., Pallis M.P., Smith E., Bottoni C.R. Acute operative stabilization versus nonoperative management of clavicle fractures. Am J Orthop (Belle Mead NJ). 2009 Jul;38(7):341-5.
  4. Smekal V., Irenberger A., Struve P., Wambacher M., Krappinger D., Kralinger F.S. Elastic stable intramedullary nailing versus nonoperative treatment of displaced midshaft clavicular fractures-a randomized, controlled, clinical trial. J Orthop Trauma. 2009 Feb;23(2):106-12.
  5. Robinson C.M. Fractures of the clavicle in the adult. Epidemiology and classification. J Bone Joint Surg Br. 1998 May;80(3):476-84.
  6. Zlowodzki M., Zelle B.A., Cole P.A., Jeray K., McKee M.D. 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 Aug;19(7):504-7.
  7. Robinson C.M., Court-Brown C.M., McQueen M.M., Wakefield A.E. Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. J Bone Joint Surg Am. 2004 Jul;86-A(7):1359-65.
  8. 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 Sep-Oct;13(5):479-86.
  9. De Giorgi S., Notarnicola A., Tafuri S., Solarino G., Moretti L., Moretti B. Conservative treatment of fractures of the clavicle. BMC Res Notes. 2011;4:333.
  10. Potter J.M., Jones C., Wild L.M., Schemitsch E.H., McKee M.D. Does delay matter? The restoration of objectively measured shoulder strength and patient-oriented outcome after immediate fixation versus delayed reconstruction of displaced midshaft fractures of the clavicle. J Shoulder Elbow Surg. 2007 Sep-Oct;16(5):514-8.
  11. Andersen K., Jensen P.O., Lauritzen J. Treatment of clavicular fractures. Figure-of-eight bandage versus a simple sling. Acta Orthop Scand. 1987 Feb;58(1):71-4.

Reprinted with permission from the Fall 2011 issue of COA Bulletin

 

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