Orthopedics

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Midshaft Clavicle Fractures: Are Surgical Indications Changing?

Jonathan T. Bravman, MD; Armando F. Vidal, MD

Abstract

Clavicle fractures are common injuries, comprising approximately 40% of fractures about the shoulder and between 5% to 12% of all fractures overall. With a reported incidence of 20 to 50 per 100,000 patients per year, an estimated >100,000 of these injuries occur annually in the United states alone.1,2 Despite centuries of documented clinical experience with the treatment of these injuries, controversy exists about their optimal management. Historically, these fractures have been treated conservatively, and the culture of orthopedic surgery training has fostered a “benign neglect” approach to their management despite a paucity of validated, patient-oriented outcomes to support this position. In fact, to orthopedic surgeons, the phrase “clavicle fracture” often invokes images of simple injuries, simple treatments, and favorable outcomes.1 However, the application of evidence-based techniques and validated patient-oriented outcome measures is challenging our classical perception of these injuries.

The Ancient Egyptians were the first to report on the management of these injuries. Reports of the nonoperative treatment of clavicle fractures dates back to the Edwin Smith Papyrus, written in the 17th century BC.3 Here it is recorded that the patient with a clavicle fracture should be placed “prostrate on his back with something folded between his shoulder blades . . . with his two shoulders to stretch apart his collar bone until the break falls in its place. Place two splints of linen, one on the inside and the other on the underside of his arm. Thou shouldst bind it with yarn, (and) treat it afterward with honey every day, until he recovers.” With the exception of treating these fractures with “honey” this description of a “figure-of-eight” brace (Figure 1) has not evolved much in almost four millennia despite advancements in surgical and medical management of other maladies.

Classically, surgical indications for primary internal fixation of clavicle fractures have been limited to open fractures, impending open fractures, associated neurovascular injury, floating shoulder, and fractures in the multiply injured patient.4,5 The goal of this article is to challenge this long held bias and present the current evidence regarding patient outcomes and the role of primary surgical management for these injuries.

Charles Neer6 and Carter Rowe7 ushered in the modern era in the management of these injuries. The long-held views of favorable results of nonoperative clavicle fracture treatment are based principally on their reports from the 1960s. These classic series were the first to document, on a large scale, the widely held belief that clavicle fractures have a favorable prognosis and predictable healing. They demonstrated clavicle nonunion to occur very infrequently with a prevalence of <1% in series of 566 patients and 2235 patients respectively.6,7 At the time, clavicle malunion was felt to have no clinical relevance and was of radiographic interest only. Patient-oriented outcome measures had not yet been developed. Thus, the determination of “outcome” was based solely on the status of fracture union.

In the ensuing 30 years, with a combined experience of >3000 reported patients with clavicle fractures, the published literature demonstrated an overall nonunion rate of only 0.4%.6-11 These data suggested that these injuries could be regarded as benign and that bony union can be achieved in all but the rarest of cases. However, these studies were often not stratified by age, fracture location, or severity and often included pediatric clavicle fractures that have a much greater potential for healing and remodeling. Despite the shortcomings of these reports, the opinion that these fractures could almost universally be treated nonoperatively dominated the clinical realm for several decades. It wasn’t until more recent evidence began to select out subsets of patients with less favorable results that these long held…

Clavicle fractures are common injuries, comprising approximately 40% of fractures about the shoulder and between 5% to 12% of all fractures overall. With a reported incidence of 20 to 50 per 100,000 patients per year, an estimated >100,000 of these injuries occur annually in the United states alone.1,2 Despite centuries of documented clinical experience with the treatment of these injuries, controversy exists about their optimal management. Historically, these fractures have been treated conservatively, and the culture of orthopedic surgery training has fostered a “benign neglect” approach to their management despite a paucity of validated, patient-oriented outcomes to support this position. In fact, to orthopedic surgeons, the phrase “clavicle fracture” often invokes images of simple injuries, simple treatments, and favorable outcomes.1 However, the application of evidence-based techniques and validated patient-oriented outcome measures is challenging our classical perception of these injuries.

The Ancient Egyptians were the first to report on the management of these injuries. Reports of the nonoperative treatment of clavicle fractures dates back to the Edwin Smith Papyrus, written in the 17th century BC.3 Here it is recorded that the patient with a clavicle fracture should be placed “prostrate on his back with something folded between his shoulder blades . . . with his two shoulders to stretch apart his collar bone until the break falls in its place. Place two splints of linen, one on the inside and the other on the underside of his arm. Thou shouldst bind it with yarn, (and) treat it afterward with honey every day, until he recovers.” With the exception of treating these fractures with “honey” this description of a “figure-of-eight” brace (Figure 1) has not evolved much in almost four millennia despite advancements in surgical and medical management of other maladies.

Figure 1A: Figure-of-eight brace Figure 1B: Figure-of-eight brace
Figure 1: "Figure-of-eight" brace.

Classically, surgical indications for primary internal fixation of clavicle fractures have been limited to open fractures, impending open fractures, associated neurovascular injury, floating shoulder, and fractures in the multiply injured patient.4,5 The goal of this article is to challenge this long held bias and present the current evidence regarding patient outcomes and the role of primary surgical management for these injuries.

Achievement of Fracture Union

Charles Neer6 and Carter Rowe7 ushered in the modern era in the management of these injuries. The long-held views of favorable results of nonoperative clavicle fracture treatment are based principally on their reports from the 1960s. These classic series were the first to document, on a large scale, the widely held belief that clavicle fractures have a favorable prognosis and predictable healing. They demonstrated clavicle nonunion to occur very infrequently with a prevalence of <1% in series of 566 patients and 2235 patients respectively.6,7 At the time, clavicle malunion was felt to have no clinical relevance and was of radiographic interest only. Patient-oriented outcome measures had not yet been developed. Thus, the determination of “outcome” was based solely on the status of fracture union.

In the ensuing 30 years, with a combined experience of >3000 reported patients with clavicle fractures, the published literature demonstrated an overall nonunion rate of only 0.4%.6-11 These data suggested that these injuries could be regarded as benign and that bony union can be achieved in all but the rarest of cases. However, these studies were often not stratified by age, fracture location, or severity and often included pediatric clavicle fractures that have a much greater potential for healing and remodeling. Despite the shortcomings of these reports, the opinion that these fractures could almost universally be treated nonoperatively dominated the clinical realm for several decades. It wasn’t until more recent evidence began to select out subsets of patients with less favorable results that these long held beliefs were questioned.

Hill et al12 published one of the first studies that began to reshape long-held ideas regarding the treatment of clavicle fractures in 1997. They found that adult patients with completely displaced middle third clavicle fractures treated nonoperatively had a nonunion rate of 15.3%, considerably higher than previously reported. This study elucidated that nonunion was significantly associated with initial fracture shortening of >2 cm (Figure 2).12 In a subsequent prospective cohort study, Robinson et al13 demonstrated a 4.5% nonunion rate in a series of 868 patients treated nonoperatively. However, although their overall nonunion rate supported historical data, on further analysis, a nonunion rate of 21% was found in the subgroup with displaced, comminuted midshaft fractures.14

Figure 2: Bilateral clavicles

Figure 2: Fifteen degree cephalad tilted radiographic view of bilateral clavicles. Direct measurement can be made to reliably determine fracture shortening. It is essential to ensure imaging without rotational artifact to determine length accurately.

Advancing age and female gender were significantly associated with increased nonunion rates (P<.05). Importantly, these higher nonunion rates have been further supported in both a recent meta-analysis as well as a multicenter randomized controlled trial comparing plate fixation to nonoperative care in the subset of displaced midshaft injuries.15,16 These studies demonstrated a nonunion rate of 15% and 14.3% respectively in their nonoperatively treated groups.

Thus, while it has become clear that many clavicle fractures go on to bony union when treated nonoperatively, an at-risk patient population exists with displaced, comminuted midshaft clavicle fractures that have a higher rate of nonunion compared to historical figures.

Functional Outcomes

Although union rates following these injuries are one critical piece of the puzzle, patient outcomes are ultimately the true test of the superiority of one technique over another. Patient-oriented outcome measures were largely missing from earlier reports on the outcomes of these injuries. It is clear that not all clavicle fractures have the same prognosis in regards to healing rates, but when they heal, do all clavicle fractures do well? Persistent symptoms and dissatisfaction as a result of pain, weakness, neurologic symptoms, and displeasing cosmesis have begun to be recognized and reported as contributing to poor outcomes in a significant number of these patients despite successful union.

Hill et al,12 in addition to recognizing a higher risk of nonunion in displaced fractures, also challenged the notion that all united clavicle fractures do well. They reported on 66 consecutive, displaced midshaft clavicle fractures with an average of 11.4 mm of shortening treated conservatively.12 Although no standardized scoring system was used in evaluation of these patients, 31% remained dissatisfied with their final result while 25% had persistent pain, 29% parasthesias, and 54% reported a cosmetically displeasing result. They demonstrated that final fracture shortening of >2 cm was associated with a poor functional result in their cohort.

Nowak et al17 published a similar prospective report in 2004. They set out to determine the predictors of functional outcomes in nonoperatively treated clavicle fractures in 208 patients after a 9- to 10-year interval.17 They demonstrated that 46% of patients reported having “sequelae” of their clavicle fracture, indicating that they were “not fully recovered from their clavicle injury.” Additional outcome measures showed that 9% had pain at rest, 29% had pain with activity, and 27% felt they had a persistent cosmetic defect. Using logistic regression models, they found that predictors of poor functional outcome were lack of bony contact at the fracture site, comminuted fractures with transverse fragments, and increasing age.

Two reports published in 2006 went on to further objectify functional impairment after midshaft clavicle malunion using standardized, validated measures of shoulder function.18,19 Lazarides et al18 demonstrated in their retrospective review of 132 patients evaluated 30 months post-injury that 25.8% of patients were dissatisfied with their clinical outcome, with 30.3% experiencing continued pain, and 13.6% experience significant motion loss. Shortening of 18 mm in males and 14 mm in females correlated with poor functional outcomes as well as lower Constant scores.

McKee et al19 performed a similar retrospective review, incorporating both strength measurements and validated outcome scores into their analysis. They studied 30 patients with displaced nonoperatively treated clavicle fractures that went on to successful union. Seven were “partially satisfied” with their outcome, while 8 were frankly “dissatisfied.” Average DASH scores were 24.6 (normal =10.1) and Constant scores 71 (normal = 92) demonstrating significant residual disability in this cohort. Strength and endurance were decreased to between 67% and 85% compared to the uninjured limb, and while fracture shortening was correlated with this decrease in endurance and decrease in the objective scores, shortening >2 cm was associated with greater patient dissatisfaction.

The cause of persistent shoulder dysfunction following malunited clavicle fractures remains unclear. Likely, a “tethering” effect of the scapula occurs when the clavicle heals in a shortened position, resulting in positional and version changes in the scapula as described by Ledger et al.20 Using a computed tomography model, they demonstrated a 10.7° increase in sternoclavicular joint angulation and a 6.1° increase in scapular version in patients with >15 mm of clavicular shortening. In addition, all patients reported either pain or limited function and had objective weakness of shoulder extension, adduction and internal rotation with decreased peak shoulder abduction velocity.

The Role for Surgical Intervention

Defining the risks of fracture nonunion and symptomatic malunion with specific fracture types and in specific patient populations is useful to the physician treating these injuries. A better understanding of the natural history of displaced, midshaft clavicle fractures allows one to better analyze interventions and the possible role of surgery in the acute setting. However, this data alone does not justify sweeping application of surgical intervention to all displaced clavicle fractures. It introduces the key question: Does acute surgical intervention result in better patient outcomes and lower or comparable complication rates as does nonoperative management? Until recently, there was no answer to this question.

In 2005, Zlowodzki et al15 presented a systematic review encompassing 2144 fractures of which 97% were midshaft injuries. Their analysis of displaced midshaft fractures demonstrated a nonunion rate of 15.1% using nonoperative treatment, compared to 2.2% and 2% for plate fixation and intramedullary fixation respectively. This demonstrated a relative risk reduction of 86% to 87% for surgical intervention regarding development of nonunion. They found increasing age, fracture displacement, female gender and fracture comminution to be associated with development of nonunion and long-term sequelae after nonoperative treatment (Figure 3). Most recently, the Canadian Orthopaedic Trauma Society presented a multi-center prospective randomized controlled trial comparing initial operative plate fixation to nonoperative treatment of displaced midshaft clavicle fractures in 132 patients.16 Constant and DASH scores were significantly improved in the operatively treated group at all time points (P=.001, P<.01 respectively). There were 2 nonunions in the operative group compared to 7 in the nonoperative group (P=.042), as well as 9 symptomatic malunions in the nonoperative group compared to none in the operative group. Time to radiographic union was decreased significantly from 28.4 to 16.4 weeks in the operative group (P=.001). The authors thus recommended operative treatment of these fractures to improve all of the above mentioned outcome measures at 1-year follow-up.

Figure 3A: A shortened, displaced midshaft clavicle fracture Figure 3B: Six-month postoperative radiograph

Figure 3: AP radiograph of a 30-year-old woman demonstrating a shortened, displaced midshaft clavicle fracture with the typical "Z" type fracture pattern (A). Six-month postoperative radiograph demonstrating bony healing with restoration of anatomic rotation and length (B).

Several authors have demonstrated that although correcting symptomatic clavicular malunions is technically challenging, it can result in predictably favorable results.21-23 This has prompted many to recommend a “wait and see” approach and reserve surgical stabilization for symptomatic malunions. However, it remains unclear if delayed surgical repair of a malunion is equivalent to primary fixation for these at-risk fractures.

Potter et al24 compared 15 patients treated with acute (0.6 months to fixation) plate fixation versus 15 patients who underwent delayed fixation at an average 63 months for symptomatic malunion or nonunion of a displaced midshaft clavicle fracture. The acutely fixed group displayed superior outcomes in terms of Constant scores, although showed no difference with regard to DASH score. Strength measures did not differ significantly between groups, however the acute group demonstrated an approximate 30% greater endurance of shoulder flexion compared to the delayed group, while both groups rated their satisfaction with the procedure as “excellent.”

This data has begun to synthesize the concepts presented throughout this discussion in the clinical setting; culminating in the conclusion that given the appropriate injury characteristics, surgical indications may be changing regarding fixation of the displaced midshaft clavicle fracture.

Complications of Operative Fixation

Although it is becoming clear that successful anatomic union of a displaced clavicle fracture generally results in better outcomes than malunited or nonunited injuries, this must be weighed against the risk of serious complication with surgical intervention. Regarding plate fixation, the most frequently observed complications include infection and hardware-related problems. Infection has been reported at rates of 0% to 18% while painful, symptomatic hardware requiring removal has been reported as high as 50% to 100% in certain series.25-29

Following plate removal, refracture rates range from 0% to 8%25,26 and adhesive capsulitis has been reported in up to 7% of cases following operative fixation.30 Although considerably less frequent, potentially more serious complications include subclavian vessel injury directly at the time of surgery, neurogenic or arterial thoracic outlet syndrome, as well as subclavian artery pseudoaneurysm related to screw-tip penetration with bicortical fixation.31-33

Summary

The long held belief that clavicle fractures have a benign course and a predictably favorable outcome can be challenged. Despite centuries of experience with this injury, it is only recently that the sophisticated application of evidence-based techniques has called into question classic teaching. A closer examination of patients presenting with displaced midshaft clavicle fractures has demonstrated higher nonunion rates than expected and worse outcomes in patients with malunited fractures than previously reported. Factors associated with poor functional outcome as well as nonunion in these injuries include fracture displacement, fracture comminution, female gender, and advancing age.

Acute surgical treatment of these injuries has additionally been shown to be safe and effective in terms of achieving low nonunion rates and complication as well as being beneficial in terms of patient-centered functional outcome measures. Recent data presented has laid the groundwork for expanding surgical indications in these previously under-appreciated injuries. Additional high-level studies with intention-to-treat analysis are necessary to better define the clinical characteristics that predict unfavorable outcomes and to determine if a “wait-and-see” approach results in similar clinical outcomes to primary, acute surgical intervention.

References

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Authors

Drs Bravman and Vidal are from the Department of Orthopedics, University of Colorado Denver, Colorado.

The material presented in any Vindico Medical Education continuing education activity does not necessarily reflect the views and opinions of Orthopedics or Vindico Medical Education. Neither Orthopedics nor Vindico Medical Education nor the authors endorse or recommend any techniques, commercial products, or manufacturers. The authors may discuss the use of materials and/or products that have not yet been approved by the US Food and Drug Administration. All readers and continuing education participants should verify all information before treating patients or using any product.

Correspondence should be addressed to: Jonathan T. Bravman, MD, Department of Orthopedics, University of Colorado Denver, 12631 E 17th Ave, Academic Office 1, Room 4501, Mail Stop B-202, Aurora, Colorado 80045 (jonathan.bravman@ucdenver.edu).

doi: 10.3928/01477447-20091020-18

10.3928/01477447-20091020-18

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