Clavicle Fractures: Is Open Reduction and Internal Fixation the Right Option?

Peter L.C. Lapner, M.D., FRCSC
The Ottawa Hospital, University of Ottawa
Ottawa, ON

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.

 

Two trials have compared the outcome of plate fixation with non-operative outcome. In 2007, McKee et al.1 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 one 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 al.2 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 treatment 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 three weeks favoured internal fixation, functional scores were similar at six months and 12 months. In another study, Smekal et al.4 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 six months and two years after 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 1000 clavicle fractures, Robinson et al.5 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 al.6 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%.

Given the incidence of nonunion with non-operative treatment, it is logical to categorize the factors that increase this risk (Figure 1). Factors identified to increase the risk of nonunion are displacement5, segmental comminution,5 female gender,7 increased number of fragments,8 and advancing age.8 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.

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

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 of 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 al.10 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 al.11 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 three months; the sling group only wore a sling for one week; and the figure of 8 group was only splinted for three weeks.

In 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.

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.
 

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