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SICOT e-Newsletter

Issue No. 71 - December 2014

Scientific Debate

Treatment for displaced closed midshaft clavicle fracture

    
Non-operative treatment of closed midshaft clavicle fracture

Syah Bahari
KPJ Seremban Specialist Hospital, Seremban, Malaysia

Until recently, treatment for closed clavicle fracture had been a conservative approach by means of either immobilization in a broad arm sling or figure of eight sling. However, recent evidence suggests that open reduction and internal fixation has become the preferred treatment option.

Nordqvist et al [1] looked at 225 consecutive patients, of which 197 with fracture of the midshaft of clavicle which were all treated conservatively with a figure of
eight splint for 3 weeks. The remaining patients were allowed early range of motion as tolerated. They found that, after an average 17 years after injury, 185 patients were asymptomatic. The final clinical outcome of 39 patients was rated as fair and one patient was rated poor. The authors concluded that only a few patients with fracture of midshaft clavicle require operative treatment.

However, in order to compare the two treatment modalities, one needs to compare the main advantages and disadvantages of each treatment.

For conservative treatment of closed midshaft clavicle fracture, the main issue is the risk of non-union.

Studies by Neer [2] and Rowe [3] in the 1960s showed that the risk of non-union through non-operative treatment was 0.1% and 0.8% respectively. Thus, it was accepted that displaced midshaft clavicle fracture could be treated satisfactorily non-operatively until a more recent study suggested that the risk of non-union is much higher than previously reported [4]. However, the question is, what is the characteristic of the fracture that can predict the risk of non-union.

A study most often quoted by the proponent of operative treatment for displaced midshaft clavicle fracture is by the Canadian Orthopaedic Trauma Society [5]. The study showed that in a randomised control trial that the operative treatment for displaced closed midshaft clavicle fracture was superior to conservative treatment for fracture displacement or shortening more than 2cm. However, the most recent Cochrane Database review suggests that, although the evidence does favour surgical intervention, the available evidences are still limited and suggest the treatment option should be individualised [6].

Also, a recently published online survey on the treatment of closed midshaft clavicle fracture among Dutch trauma surgeons did not come to a definitive conclusion where conservative treatment was favoured for displaced fracture while operative treatment was for comminuted fracture [7].

The surgical treatment option is also not without its complications. A study by Leroux et al [8] showed that nearly every 1 in 4 patients treated with operative intervention had repeat surgeries ranging from implant removal, deep infection, non-union, pneumothoraces and malunion. The study also suggested surgeons experience matters, where less experienced surgeons are likely to encounter more complications.

Finally, there is cosmesis, a topic rarely discussed by us orthopaedic surgeons but that does matter to patients. This is a very subjective matter and what is accepted in terms of cosmesis is debatable. Also, other subjective outcomes such as numbness over the operative site, prominent implant and the need for surgical removal of implant are factors that need to be fully discussed with patients when offering them operative treatment options for closed midshaft fracture of the clavicle.

In the right patient, non-operative treatment will likely yield similar results to operative treatment without the risk associated with operative intervention.


References:
  1. Nordqvist A, Petersson CJ, Redlund-Johnell I. Mid-clavicle fractures in adults: End result study after conservative treatment. J Ortho Tr (1998) 8:572-576
  2. Neer CS. Nonunion of the clavicle. J Am Med Assoc (1960) 172:1006-11
  3. Rowe CR. An atlas of anatomy and treatment of midclavicular fractures. Clin Orthop Relat Res (1968) 58:29-42
  4. Hill JM, McGuire MH, Crosby LA. Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg Br. (1997) 79(4):537-9
  5. Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicle fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am (2007) 89:1-10
  6. Lenza M, Buchbinder R, Johnston RV et al. Surgical versus conservative interventions for treating fractures of the middle third of the clavicle. Cochrane Database Syst Rev (2013) 6:6:CD009363
  7. Stegeman SA, Fernandes NC, Krijnen P et al. Online radiographic survey of midshaft clavicular fractures: no consensus on treatment for displaced fractures. Acta Orthop Belg (2014) 80(2):161-5
  8. Leroux T, Wasserstein D, Henry P et al. Rate of and risk factors for reoperation after open reduction and internal fixation of midshaft clavicle fractures. J Bone Joint Surg Am (2014) 96(13):1119-25

Operative treatment of closed midshaft clavicle fracture

Mohd. Yazid Bajuri

UKM Medical Centre, Kuala Lumpur, Malaysia


The treatment paradigm for closed midshaft clavicle fracture has changed from conservative to operative intervention. The exponent for operative intervention is due to reduced incidence of non-union, malunion and better functional outcome.

From our own experience, we conducted a study on functional outcome of patients with closed midshaft clavicle fracture treatment by non-operative treatment [1]. From a series of 70 patients treated, we found that nearly half of the patients had impairment of shoulder function. We also concluded from that study, factors that predict poor outcome from non-operative treatment are fracture comminution, fracture displacement of more than 21mm and shortening of more than 15mm. Malunion and non-union of clavicle fracture were also correlating with poor functional outcome.

Our results were also similar to a study by Hill et al where they reported an increase in the incidence of non-union in displaced clavicle fractures which were correlating with reduced functional outcome [2].

A landmark study by the Canadian Orthopaedic Trauma Society [3] is a multicentre randomised controlled study between non-operative treatment compared to operative treatment for displaced closed midshaft clavicle fracture. This study showed a superior outcome of operative treatment to non-operative treatment in terms of time to radiographic union (16 weeks vs. 28 weeks) and significantly improved the functional outcome score (Constant and DASH) at all times during the period of the study. The main complication of the operative group was prominent implant, but arguably, with the advent of anatomical low profile locking plate, the need for implant removal can be avoided.

Similar outcomes were also reproduced by other randomised controlled studies comparing operative to non-operative treatment of displaced, closed midshaft clavicle fracture. Kulshretha et al [4] conducted a prospective cohort study of 73 patients. The non-operative group had 29% of non-union, 36% symptomatic malunion compared to no non-union and 4% symptomatic malunion respectively for the operative group. A more recent study is by Robinson et al [5]. They published a multicentre, randomised controlled trial of 200 patients where there was a significant reduction in the incidence of non-union in the operative group with a significantly better functional outcome score compared to the non-operative group.

However, there is still an indication for non-operative treatment of midshaft clavicle fracture. Midshaft clavicle fracture without significant comminution, shortening or displacement is not recommended for the operative treatment. Paediatric and low-demand patients are likely to do well with the non-operative treatment.


References:
  1. Bajuri MY, Maidin S, Rauf A et al. Functional outcomes of conservatively treated clavicle fractures. Clinic (Sao Paulo). (2011) 66(4):635-9
  2. Hill JM, McGuire MH, Crosby LA. Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg Br. (1997) 79(4):537-9
  3. Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicle fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am (2007) 89:1-10
  4. Kulshrestha V, Roy T, Audige L. Operative versus nonoperative management of displaced midshaft clavicle fractures. A prospective cohort study. J Orthop Trauma. (2011) 25(1):31-8
  5. Robinson CM, Goudie EB, Murray IR et al. Open reduction and plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures: a multicenter, randomized, controlled trial. J Bone Joint Surg Am (2013) 95(17):1576-84