Displaced mid shaft clavicular fractures ORIF or conservative?

DR.MOHAMMED RAEEZ PALAKKAL
MBBS DORTHO DNB(ORTHO)-JR

Fracture Clavivle middle third
IS IT STILL A GREY AREA IN
ORTHOPAEDICS?

rough
 Sx on coservative
 Conserative mx
 Pitfalls
 Surgery traditional indications
 Changing trends
 Literature review
 Literature proper
 Conclusions

General:
 A clavicular fracture accounts for 2.6%–5 % of
adult fractures
 Fractures in the middle-third (OTA 15-B) represent
69%–82% of all clavicular fractures.
 There is no consensus among orthopedic surgeons
regarding treatment for these fractures:
many support conservative treatment even for
displaced middle-third clavicular fractures, while
others choose operative treatment.

Treatment Options
 Nonoperative
 Sling
 Brace
 Surgical
 Plate Fixation
 Screw or Pin Fixation
 Ex Fix

Conservative:
Simple Sling vs. Figure-of-8
Bandage
 Prospective randomized trial of 61 patients
 Simple sling
 Less discomfort
 Functional and cosmetic results identical
 Alignment of healed fractures unchanged
from the initial displacement in both groups
Andersen et al., Acta Orthop Scand 58: 71-4, 1987.

Traditional teaching as indications
for surgery…
 the absolute indications for surgical treatment
include open fractures, fractures associated
with skin compromise and neurovascular
involement.

CHANGING TRENDS IN MANAGEMENT OF
ACUTE CLAVICULAR MIDSHAFT FRACTURES
 Traditionally been treated non-operatively,
even when substantially displaced
 Early reports suggested non-union was
extremely rare
4 (0.8%) out of 556 (3.7% with surgery)
 Rowe CR. An atlas of anatomy and treatment of midclavicular
fractures. CORR 1968
3 (0.1%) out of 2235 (4.6% with surgery)
Neer CS 2nd. Nonunion of the clavicle. JAMA
1960
most important causal factor for
nonunion of a midshaft clavicular
fracture is improper open surgery

Recent studies on non-operative mx
reports:
 Higher non-union rate (15%)
 Higher rate (32%) of unsatisfactory patient
outcome
 Hill et al. Closed treatment of middle-third clavicle
fractures gives poor results. JBJSB 1997
There is new evidence that the outcome of
non-operative management of displaced
middle-third clavicle fractures is not as
good as traditionally thought, with many
patients having significant functional
problems.

 Several recent studies reported
high union rates with surgical
intervention using a variety of internal
fixation devices
 Ali Khan MA, Lucas HK: Plating of fractures of the
middle third of the clavicle. Injury 1978
 Zenni EJ Jr, Krieg JK, Rosen MJ: Open reduction and
internal fixation of clavicular fractures. JBJSA 1981

MOST OF THE STUDIES
UNVEILS …
 THE LIMITATIONS OF CONSERVATIVE
MANAGEMRNT
AND
 THE ADVANTAGES OF FIXATION IN A
DISPLACED MID THIRD FRX CLAVICLE

Its been proven that
displaced midshaft clavicle fractures can
cause significant, persistent disability,
even if they heal uneventfully.

 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
• Prospective study 245 patients with 9-10 years follow-up
 Displacement without bony contact,
especially with comminuted transverse
fracture, and an elderly patients, strongly
predictive of long term sequelae and

 Robinson CM, Court-Brown CM, McQueen
MM, Wakefield AE:
Estimating the risk of nonunion
following non-operative treatment of
a clavicular fracture.
J Bone Joint Surg Am 2004
• Prospective review of 581 midshaft clavicular
fractures
• 4.5 % non-union rate
 Fracture displacement, fracture comminution,
female gender, advanced age significantly

Wick M, Müller EJ, Kollig E, Muhr G:
Midshaft fractures of the clavicle with a
shortening of more than 2 cm predispose
to nonunion.
Arch Orthop Trauma Surg 2001
• Retrospective analysis of 39 clavicle non-union /
delayed union
 Shortening of 2 cm in midshaft clavicular
fractures was associated with an
increased risk of pain, limitation of
motion, or nonunion

McKee MD et al:
Deficits following non-operative treatment
of displaced midshaft clavicular
fractures.
J Bone Joint Surg Am 2006
• Prospective study of 30 cases with displaced
midshaft clavicle #s (mean follow-up 55 months)
• assessed functional outcome and noted
significantly inferior scores for both the upper
extremity–specific (DASH) outcome scores and
the Constant scores compared with the general
population.
 fractures with >2 cm of shortening
tended to be associated with
decreased abduction strength and
greater patient dissatisfaction

Deficits following nonoperative treatment
of displaced midshaft clavicular fractures
 The strength of the injured shoulder was 81% for
maximum flexion, 75% for endurance of flexion,
82% for maximum abduction, 67% for endurance
of abduction, 81% for maximum external rotation,
82% for endurance of external rotation, 85% for
maximum internal rotation, and 78% for
endurance of internal rotation (p < 0.05 for all).
 The mean Constant score was 71
points, and the mean DASH score was
24.6 points, indicating substantial
residual disability.
McKee et al. J Bone Joint Surg Am 2006;88-A:35-40.

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
• Retrospective review of 52 midshaft clavicular fractures
 final shortening ≥2 cm was
associated with an unsatisfactory
result but not with non-union

Ledger M, Leeks N, Ackland T, Wang A:
Short malunions of the clavicle: An anatomic and
functional study.
J Shoulder Elbow Surg 2005
• Evaluated the effects of clavicular malunion (15mm
shortening) in 10 subjects using CT with 3D recon,
shoulder score assessments and biomechanical testing
 Significant increase in upward angulation
of the SC joint and an increased scapular
version compared with the uninjured side
 Significantly weaker muscle strength than
that of the uninjured arm
 Significant poorer shoulder scores
outcome
 These studies indicate that although clavicular
deformities are complex and hard to assess,

 Moving on to the journal under study…

Yaron S. Brin MD, Ezequiel Palmanovich MD, Eran Dolev MD,
Meir Nyska MD and Benyamin J. Kish MD Department of
Orthopedic Surgery, Meir Medical Center, Kfar Saba, affiliated
with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv,
Israel
Displaced Mid-Shaft Clavicular
Fractures: Is Conservative
Treatment Still Preferred?

Objectives:
To assess the attitudes of orthopedic
surgeons regarding treatment of displaced
mid-shaft clavicular fractures

Traditionally..
 the absolute indications for surgical treatment
include open fractures, fractures associated
with skin compromise and neurovascular
involement.
 Conservative treatment for these fractures was
the common practice since older studies
claimed the non-union rate to be less than 1%
 A certain amount of deformity with return of
satisfactory function of the shoulder was
expe…….

Several recent studies reported
worse results with conservative
treatment:
 a non-union rate of 15–20%
 shoulder muscle strength loss of 18–33%
 poor early functioning of the injured
shoulder
 and as many as 42% of patients with
residual sequelae 6 months after injury

Since this injury occurs most often in young
active patients who want to avoid the above
complications, primary operative treatment
has become common.
Several fixation treatments are used, such as
 intramedullary nail
 plate and screws and
 a locking plate and screws
 Ex fix devices

Numerous randomized studies
comparing conservative to operative
treatment have been conducted
 Xu et al and McKee et al performed a meta-
analysis to determine the preferred treatment.
 They found a higher non-union rate and
symptomatic mal-union rate after conservative
treatment.

 It seems that the traditional guidelines for
operative treatment of the displaced mid-shaft
clavicular fracture are less strict than in the
past.
 Guidelines in many medical fields change with
time, and the emergence of new technologies
mandates expert opinion

In this paper we review the literature
and determine the current trends and
common practices for treating a
displaced mid-shaft clavicular fracture

METHODS
 We developed a multiple-choice questionnaire
on displaced mid-shaft clavicular fractures
 X-rays were included
 The questionnaires were distributed
to orthopedic surgeons during the 13 EFORT
meeting in Berlin, Germany in May 2012.

 Figure : X-ray of a 50
year old healthy
active patient
admitted to the
emergency room with
a closed injury.
Physical examination
revealed no
neurovascular injury
and no skin tenting

The first question
 The first question addressed the
preferred treatment option for a
displaced mid-shaft clavicular fracture
(OTA 15-B1) that was shown on an
X-ray
 Possible response was conservative
or operative

The second question
 The second question addressed the
preferred operative technique for
fixation of the illustrated fracture.
 The choices were
non-locking plate and screw,
a locking plate and screw, or
an intramedullary nail.

third question
 The third question related to the
experience of the surgeons with
operative treatment of displaced mid-
shaft clavicular fractures.
They were asked to report how many
displaced mid-shaft clavicular
fractures they had operated on the
year before.

Statistical analysis
 A univariate analysis was performed using the
chi-square test to detect significant differences
in choices among surgeons from different
subspecialties and with varying levels of
experience. Data were presented as numbers
and percentages. Differences between
selected subspecialties were compared using
the chi-square test.
 A P value of < 0.05 was considered statistically
significant.

Question 1
177 surgeons responded:
50.6% chose conservative treatment
49.4% recommended operative treatment.
Among the trauma specialists:
58% suggested operative treatment (P = 0.033).
Among shoulder specialists:
82% preferring operative treatment (P = 0.046).

Question 2
 177 surgeons responded: 37% chose a non-
locking plate, 49% chose a locking plate, and
14% chose an intramedullary nail.
 Orthopedic trauma specialists and shoulder
specialists answered this question with
approximately the same distribution.

Question 3
From the total population of surgeons who participated in the survey:
36% had not operated on clavicle fractures in the last year,
38% had operated on up to 5 cases, and
15% operated on 6–10 cases.
Only 11% had operated on more than 10
cases in the last year.
These included :
15% of the trauma specialists,
6.5% of the non-trauma or shoulder
specialists, and
20% of the shoulder specialists

Discussion:
Conservative vs. operative
treatmentMost mid-shaft clavicular fractures can be treated
conservatively.
These include:
- children and adolescents with a greater chance of
healing because of delayed closure of the medial
epiphysis
-simple or multi-fragmentary fractures with minimal
displacement,and
-patients with high risk for low compliance

During the 1960s, mid-clavicular
fractures were considered the domain
of non-operative treatment, based on
two studies conducted by :
Neer and Rowe
Regardless of fracture type and displacement,
complete recovery of shoulder function was
anticipated

Pitfalls of study
favouring conservative Rx..
There are several reasons for
discrepancies between those studies
and newer studies that support
operative over conservative
treatment.

One is the patients’ expectations of
treatment results. Osseous consolidation
and range of motion, which were the
main considerations for treatment
success in the past, are not the only
factors today.
Patient-based scoring systems
(Constant Score and DASH Score) also
consider factors such as
pain, cosmetic result and daily function.

Constant Shoulder Score
 Pain
 Activity level
 Arm positioning
 Strength of abduction in pounds
 ROM
 Foreward flexion
 Lateral elevation
 External rotation
 Internal rotation

Grading the Constant Shoulder Score
(Difference between normal and Abnormal
Side)
>30 Poor
21-30 Fair
11-20 Good
<11 Excellent

The Disabilities of the Arm,
Shoulder and Hand (DASH)
Score

Neer and Rowe
concluded in their well-known studies that
conservative treatment is good enough, since both
included in their series a large number of
adolescents.
The clavicle has a great potential for remodeling at
those ages due to late closure of its diaphysis.
Conservative treatment is sufficient for young
patients but should not be the treatment of choice
in older patients.

Only in 1998 was a new classification described that
took into account the degree of displacement and
comminution.
With the newer classification, devised by Robinson
,a suitable treatment can be assigned according
to fracture type.

 Abstract
 Background: There is a growing trend to treat displaced midshaft clavicular fractures with primary open
reduction and plate fixation; whether such treatment results in improved patient outcomes is debatable. The aim
of this multicenter, single-blinded, randomized controlled trial was to compare union rates, functional outcomes,
and economic costs for displaced midshaft clavicular fractures that were treated with either primary open
reduction and plate fixation or nonoperative treatment.
 Methods: In a prospective, multicenter, stratified, randomized controlled trial, 200 patients between sixteen and
sixty years of age who had an acute displaced midshaft clavicular fracture were randomized to receive either
primary open reduction and plate fixation or nonoperative treatment. Functional assessment was conducted at six
weeks, three months, six months, and one year with use of the Disabilities of the Arm, Shoulder and Hand
(DASH) and Constant scores. Union was evaluated with use of three-dimensional computed tomography.
Complications were recorded, and an economic evaluation was performed.
 Results: The rate of nonunion was significantly reduced after open reduction and plate fixation (one nonunion) as
compared with nonoperative treatment (sixteen nonunions) (relative risk = 0.07; p = 0.007). Group allocation to
nonoperative treatment was independently predictive of the development of nonunion (p = 0.0001). Overall,
DASH and Constant scores were significantly better after open reduction and plate fixation than after
nonoperative treatment at the time of the one-year follow-up (DASH score, 3.4 versus 6.1 [p = 0.04]; Constant
score, 92.0 versus 87.8 [p = 0.01]). However, when patients with nonunion were excluded from analysis, there
were no significant differences in the Constant scores or DASH scores at any time point. Patients were less
dissatisfied with symptoms of shoulder droop, local bump at the fracture site, and shoulder asymmetry in the open
reduction and plate fixation group (p < 0.0001). The cost of treatment was significantly greater after open
reduction and plate fixation (p < 0.0001).
 Conclusions: Open reduction and plate fixation reduces the rate of nonunion after acute displaced midshaft
clavicular fracture compared with nonoperative treatment and is associated with better functional outcomes.
However, the improved outcomes appear to result from the prevention of nonunion by open reduction and plate
fixation. Open reduction and plate fixation is more expensive and is associated with implant-related complications
that are not seen in association with nonoperative treatment. The results of the present study do not support
routine primary open reduction and plate fixation for the treatment of displaced midshaft clavicular fractures.

Mal-union is one of the factors that cause
reduced shoulder function.
It was noted recently that displaced mid-shaft
clavicular fractures have a high rate of mal-
union, non-union, and sequelae.

Robinson noted four risk factors for the above
complications:
age, female gender, displacement of more than
one clavicular shaft width, and comminution
Displaced mid-shaft clavicular fractures might be
complicated with mal-union and non-union in
19-33% of cases.
When the fracture is comminuted, the rate of mal-
union and non-union increases to between 33%
and 47%

Several recent studies stressed the
importance of clavicular length restoration.
They showed that clavicular shortening of
more than 15 mm following healing caused a
higher incidence of pain.
33% of patients were dissatisfied after
treatment for displaced mid-shaft clavicular
fractures that resulted in shortening.
Strength reduction was also noted in shoulder
flexion, abduction and rotation.

Robinson reported a higher dissatisfaction rate in
patients treated conservatively for displaced mid-shaft
clavicular fractures .
These findings have led to the tendency to operate
even on adolescents when the fracture is completely
displaced or when the length of the clavicle cannot

Of the surgeons who took part in this
study, 49.4% felt that operative
treatment is the preferred option for
this injury.
Interestingly, among trauma specialists
and shoulder specialists (the surgeons
who treat these injuries most often),
the proportion of surgeons who prefer
operative treatment was much higher.

Conclusions
According to our survey results there is still no
consensus regarding conservative vs.
operative treatment for a displaced mid-shaft
clavicular fracture.
Orthopedic trauma specialists and shoulder
specialists have a greater propensity toward
operative treatment.
Most surgeons who operate on these fractures
prefer to use a locking plate as a fixation
system.

professor of orthopedic surgery at the
University of Minnesota, and director of
orthopedic research at Hennepin County
Medical Center
Dr. Schmidt presented
“Clavicle Fractures: Which Ones Really Should
Be Operated On?”
during the 2014 AAOS Annual Meeting in
New Orleans.
Andrew H. Schmidt, MD

 According to Dr. Schmidt, a 1997 study
was first to challenge the belief that all
clavicle fractures heal well with conservative
treatment.
 The authors evaluated 3-year outcomes of
52 displaced midshaft clavicle fractures
treated nonsurgically.
 “They found that 31 % of patients with
initial shortening of more than 2 cm
reported poor functional outcomes, and
15% of the fractures developed
nonunions,” he said.

 These findings were supported by a similar
study published in 2006 that documented the
functional deficits of 30 patients after
nonsurgical care of a displaced midshaft
clavicle fracture.
 At a minimum 12-month follow-up (mean = 55
months),
Constant and Disabilities of the Arm,
Shoulder and Hand (DASH) scores
indicated substantial residual disability.
“All shoulders had deficits in muscle strength,
compared to the noninjured shoulder,” Dr.
Schmidt said.

 Published in 2013, the study found that
99 percent of fractures in the surgical
group healed, compared to 74 percent in
the nonsurgical group, but that half of the
nonunions were asymptomatic.

 Also in 2013, the Cochrane Collaboration
reviewed eight randomized trials involving
555 participants with middle third clavicle
fractures.
 Four studies compared plate fixation to
nonsurgical treatment;
 the other four studies compared
intramedullary nails to nonsurgical
treatment.

 The authors concluded, that evidence in favor
of surgical versus nonsurgical treatment for
these fractures was insufficient and that
treatment options must be chosen on an
individual patient basis, after careful
consideration of the relative benefits and
harms of each intervention and of patient
preferences

 He added that studies have shown that early
ORIF reduces the nonunion rate from 15% to 2
% or less and also
 reduces the symptomatic malunion rate from
20 % to 2 % or less.
 However, most patients whose fractures are
treated nonsurgically have acceptable functional
outcomes.
 “Nonetheless, evidence exists to support early
surgical intervention for select midshaft clavicle
fractures. ORIF speeds up healing in high-
demand patients and is a consideration in the
worker or athlete,” he said.

Still another…
“Nonoperative Treatment Compared
with Plate Fixation of Displaced
Midshaft Clavicular Fractures”
Sahal A. Altamimi, MD, FRCS(C); Michael
D. McKee, MD, FRCS(C)
J Bone Joint Surg Am, 2008 Mar; 90

 A high prevalence of symptomatic
malunion and nonunion after
nonoperative treatment of displaced
midshaft clavicular fractures.
 compared patient-oriented outcome and
complication rates following nonoperative
treatment and those after plate fixation of
displaced midshaft clavicular fractures.

METHODS:
 In a multicenter, prospective clinical trial, 132
patients with a displaced midshaft fracture of the
clavicle were randomized (by sealed envelope) to
either operative treatment with plate fixation (67 pts)
or nonoperative treatment with a sling (65 pts).
 Outcome analysis included standard clinical follow-up
and the Constant shoulder score, the Disabilities
of the Arm, Shoulder and Hand (DASH) score,
and plain radiographs.
 111 patients (62 managed operatively and 49
managed nonoperatively) completed one year of
follow-up.
 There were no differences between the two groups
with respect to patient demographics, mechanism of
injury, associated injuries, Injury Severity Score, or
fracture pattern.

RESULTS:
 Constant shoulder scores
and DASH scores
were significantly improved in
the operative fixation group at
all time-points (p = 0.001 and p
< 0.01, respectively).


 The mean time to radiographic union was 28.4
weeks in the nonoperative group compared
with
16.4 weeks in the operative group (p = 0.001).
 There were 2 nonunions in the operative group
compared with 7 in the nonoperative group (p =
0.042).
 Symptomatic malunion developed in 9 patients
in the nonoperative group and in none in the
operative group (p = 0.001).

CONSERVATIVE
GROUP
OPERATED
GROUP
MEAN TIME OF
RADIOGRAPHIC
UNION
28.4 WEEKS 16.4 WEEKS
NON-UNIONS 7 2
MALUNIONS 9 NONE

 At one year after the injury, the patients in the
operative group were more likely to be satisfied
with the appearance of the shoulder (p = 0.001)
and with the shoulder in general (p = 0.002)
than were those in the nonoperative group.

CONCLUSIONS:
 Operative fixation of a displaced fracture of the
clavicular shaft results in improved functional
outcome and a lower rate of malunion and
nonunion compared with nonoperative
treatment at one year of follow-up.
 Hardware removal remains the most common
reason for repeat intervention in the operative
group.
 This study supports primary plate
fixation of completely displaced
midshaft clavicular fractures in active
adult patients.

 CRITICAL CONCEPTS INDICATIONS: The majority of
clavicular fractures can be treated effectively with
nonoperative means. Operative fixation is indicated in
healthy, physically active individuals between the
ages of sixteen and sixty years with any of the
following: • A completely displaced midshaft fracture
with shortening of >2 cm • Superior displacement
with skin tenting and/or an impending open fracture •
An associated neurovascular injury • An open
clavicular fracture • A floating shoulder with a
completely displaced clavicular fracture • An obvious
clinical deformity with shoulder asymmetry (a
combination of shortening, rotation, and
displacement) • Multiple injuries with any of the
above indications

 CONTRAINDICATIONS: • Active infection
in the operative area • Prior soft-tissue
irradiation in the operative area • Burns
over the clavicular area • Debilitating
medical conditions • A high risk of poor
patient compliance, especially due to
substance abuse (drugs and/or alcohol) •
An elderly patient with a sedentary
lifestyle

POSTOPERATIVE CARE
 The arm is maintained in a sling on a full-time
basis for two weeks, after which use of the sling
is discontinued and active assisted range-of-
motion exercises of the shoulder in the scapular
plane are begun. Full active motion is initiated at
four weeks. When clinical and radiographic signs
of union are present, strengthening and resistive
exercises of the rotator cuff, deltoid, and
trapezius are begun, usually at six to eight
weeks. By three to four months, most patients
are allowed to participate in all sports activities.

 PITFALLS: • Preoperative planning and patient selection are crucial. Patients at
high risk for multiple falls, alcohol abuse, or noncompliance may have early
mechanical failure of the fixation and are not candidates for this procedure. •
Failure to carefully contour the plate to accommodate the s-shape of the
clavicle can lead to implant prominence and softtissue irritation at the ends of
the plate. The use of a precontoured anatomic plate helps to decrease soft-
tissue irritation. • A minimum of three 3.5-mm screws should be placed in
each of the proximal and distal fragments, and ideally the plate should be
applied in compression mode to reduce the risk of delayed union or nonunion.
• Cautious drilling, especially when sharp drills and taps are used, is of
paramount importance in this procedure. A blunt retractor placed under the
clavicle, which adds undesired soft-tissue dissection, can be used if necessary.
We have found that this step is not required as experience increases. • The
intervening fragments should not be stripped. They should be teased into
position, with preservation of soft-tissue attachments and ensuring that the
length and rotation of the clavicle are correct. • A postoperative chest
radiograph is required only in rare circumstances where a pleural injury is
suspected.

 ABSTRACT We evaluated 242 consecutive fractures of the clavicle in adults
which had been treated conservatively. Of these, 66 (27%) were originally in
the middle third of the clavicle and had been completely displaced. We
reviewed 52 of these patients at a mean of 38 months after injury. Eight of the
52 fractures (15%) had developed nonunion, and 16 patients (31%) reported
unsatisfactory results. Thirteen patients had mild to moderate residual pain
and 15 had some evidence of brachial plexus irritation. Of the 28 who had
cosmetic complaints, only 11 considered accepting corrective surgery. No
patient had significant impairment of range of movement or shoulder strength
as a result of the injury. We found that initial shortening at the fracture of > or
= 20 mm had a highly significant association with nonunion (p < 0.0001) and
the chance of an unsatisfactory result. Final shortening of 20 mm or more was
associated with an unsatisfactory result, but not with nonunion. No other
patient variable, treatment factor, or fracture characteristic had a significant
effect on outcome. We now recommend open reduction and internal fixation of
severely displaced fractures of the middle third of the clavicle in adult patients.

 St. Charles Hospital, Port Jefferson, New York, United States
 Journal of Shoulder and Elbow Surgery (Impact Factor: 2.37). 03/2006;
15(2):191-4. DOI: 10.1016/j.jse.2005.08.007
 Source: PubMed
 ABSTRACT Fractures of the clavicle are common and most often occur in the
middle third. The clavicle has several important functions, each of which may
be affected after fracture and malunion. In this retrospective study, we
reviewed 132 patients with united fractures of the middle third of the clavicle
after conservative management. Residual symptoms and overall patient
satisfaction after treatment were assessed through a questionnaire. Clavicular
shortening after union was calculated on a standardized anteroposterior chest
radiograph. Intraobserver variability and interobserver variability of
measurements by use of this method are insignificant. The mean follow-up was
30 months (range, 12-43 months). The mean modified Constant score was 84
(range, 62-100). Of the patients, 34 (25.8%) were dissatisfied with the result
of their management. Final clavicular shortening of more than 18 mm in male
patients and of more than 14 mm in female patients was significantly
associated with an unsatisfactory result.

 Displaced Fractures of the Clavicle: Who
Should Be Fixed?
 Commentary on an article by C.M. Robinson,
FRCSEd(Tr&Orth) et al.: “Open Reduction and
Plate Fixation Versus Nonoperative Treatment
for Displaced Midshaft Clavicular Fractures. A
Multicenter, Randomized, Controlled Trial”
 Michael D. McKee, MD, FRCS(C)
 J Bone Joint Surg Am, 2013 Sep
04; 95 (17): e129 .
http://dx.doi.org/10.2106/JBJS.M.00527

 Commentary
 This study is yet another high-quality, well-
designed, and robust (N = 200) randomized
clinical trial from a group of investigators who
are well recognized for their contributions to
evidence-based medicine in the field of
orthopaedics. There has been increasing
interest in the primary fixation of displaced
midshaft fractures of the clavicle since the
landmark article by Hill et al., published in
1997, describing a high rate of dissatisfaction
following the nonoperative

 treatment of these injuries1. In the current study, Robinson
et al. randomized such individuals to primary plate fixation
or a collar and cuff for three weeks. The study design and
the inclusion/exclusion criteria (with the study group
comprising active healthy patients sixteen to sixty years of
age with completely displaced fractures) are nearly
identical to those in a number of other recent randomized
clinical trials, most of which concluded that primary
operative fixation was beneficial for patients2-5. The reader
may be justifiably confused by Robinson and colleagues’
conclusion that their results do not support primary plate
fixation for these injuries. However, in my opinion, the
results of these studies are very similar and
complementary, not contradictory, and some clear facts
emerge

 First, the rate of delayed and nonunion is
high after the nonoperative treatment of
displaced midshaft clavicular fractures.
Robinson reported that twenty-four (26%) of
ninety-two patients in the nonoperative
treatment group were not healed at six
months and that seventeen (18%) eventually
underwent reconstructive surgery (thirteen
for the treatment of nonunion and four for
the treatment of malunion). This finding is
consistent with those in the other randomized
trials on this topic

 Second, primary fixation with a plate is a safe, reproducible
operative technique, within the technical grasp of most
orthopaedic surgeons, that dramatically lowers the
nonunion rate compared with nonoperative care. In the
study by Robinson et al., there was only one nonunion after
eighty-six operative procedures, for a rate of 1%,
representing a relative risk reduction for nonunion of 93%
compared with the nonoperative treatment group (p =
0.007). This finding is nearly identical to those of the other
published trials2-4.
 Third, the major complication rate following plate fixation is
low, and the most common reason for reoperation is
hardware removal. Ten patients in the current series had
plate removal because of local irritation, which again was
consistent with the findings of other studies.

 Fourth, in general, there are modest improvements in functional outcome (5 to
10 points on a 100-point scale such as the Constant shoulder score) following
operative fixation that are especially evident in the early postinjury period. The
magnitude and time course of this improvement do vary between studies
(roughly a 5-point improvement in Constant scores in the operative treatment
group at one year in the study by Robinson et al. compared with 11 points in
another similar study2). Other studies have demonstrated earlier return to
work and sports following operative repair; however, this was not evident in
the report by Robinson et al.
 Fifth, many, if not most, patients with a displaced midshaft fracture of the
clavicle will respond relatively well to nonoperative care, and the “number
needed to treat” (NNT) to avoid a specific negative outcome such as nonunion
is high. For example, Robinson et al. calculated that it would be necessary to
treat 6.2 fractures with primary plate fixation in order to prevent one
nonunion. A recent meta-analysis demonstrated a slightly lower NNT of 4.6 for
both

 nonunion and symptomatic malunion4. It is clear that refined prognostic
criteria that allow the surgeon to recognize patients who are at high risk for
nonunion or symptomatic malunion would result in a focusing of surgical
resources on such individuals, decreasing unnecessary procedures and
lowering the NNT substantially. Practically speaking, it can be argued that
increasing degrees of fracture displacement or shoulder deformity, with
increasing functional demands, warrant a more aggressive approach to primary
fixation. Robinson et al. point out that, in their series, it was typically the
sixteen to thirty-year-old active male who most often opted for surgery when
the risks and benefits were explained.
 Sixth, in a similar vein, there are as yet undetermined factors affecting
outcome following these injuries, including cultural responses to pain and
disability, that may explain differences in results. For example, in the Finnish
study by Virtanen et al., the nonunion rate following nonoperative treatment
was 24%, yet few of those patients sought surgical reconstruction3. The North
American literature suggests that surgical repair of the nonunion would be
sought by most such individuals.

 In summary, the information from this important
study can be added to the growing library of
evidence-based data that the practicing
orthopaedic surgeon can use in the day-to-day
treatment of displaced midshaft fractures of the
clavicle. In contrast to the rudimentary
responses of the past, we now have extensive
knowledge with which to answer our patients’
questions and concerns. It is important that we
use this information in a clear, nonbiased fashion
to assist our patients in making the appropriate
therapeutic choice for their displaced midshaft
clavicular fracture.

 Open Reduction and Plate Fixation Versus Nonoperative
Treatment for Displaced Midshaft Clavicular Fractures
 A Multicenter, Randomized, Controlled Trial
 C.M. Robinson, FRCSEd(Tr&Orth); E.B. Goudie, BMedSci(Ho
ns), MRCSEd; I.R. Murray, BMedSci(Hons), MRCSEd, Dip
SEM; P.J. Jenkins, FRCSEd(Tr&Orth); M.A. Ahktar, MRCSEd;
E.O. Read, BMedSci(Hons);C.J. Foster, MBChB; K. Clark, B
Sc; A.J. Brooksbank, FRCS(Tr&Orth); A. Arthur, FRCS(Tr&O
rth); M.A.Crowther, FRCS(Tr&Orth); I. Packham, BMBS,
BMedSci, FRCS(Tr&Orth); T.J. Chesser, FRCS(Tr&Orth)
 J Bone Joint Surg Am, 2013 Sep 04; 95 (17): 1576 -1584 .
http://dx.doi.org/10.2106/JBJS.L.00307

 Abstract
 Background: There is a growing trend to treat
displaced midshaft clavicular fractures with
primary open reduction and plate fixation;
whether such treatment results in improved
patient outcomes is debatable. The aim of this
multicenter, single-blinded, randomized
controlled trial was to compare union rates,
functional outcomes, and economic costs for
displaced midshaft clavicular fractures that were
treated with either primary open reduction and
plate fixation or nonoperative treatment.

 Methods: In a prospective, multicenter, stratified,
randomized controlled trial, 200 patients between
sixteen and sixty years of age who had an acute
displaced midshaft clavicular fracture were
randomized to receive either primary open reduction
and plate fixation or nonoperative treatment.
Functional assessment was conducted at six weeks,
three months, six months, and one year with use of
the Disabilities of the Arm, Shoulder and Hand
(DASH) and Constant scores. Union was evaluated
with use of three-dimensional computed tomography.
Complications were recorded, and an economic
evaluation was performed.

 Results: The rate of nonunion was significantly reduced after
open reduction and plate fixation (one nonunion) as compared
with nonoperative treatment (sixteen nonunions) (relative risk =
0.07; p = 0.007). Group allocation to nonoperative treatment was
independently predictive of the development of nonunion (p =
0.0001). Overall, DASH and Constant scores were significantly
better after open reduction and plate fixation than after
nonoperative treatment at the time of the one-year follow-up
(DASH score, 3.4 versus 6.1 [p = 0.04]; Constant score, 92.0
versus 87.8 [p = 0.01]). However, when patients with nonunion
were excluded from analysis, there were no significant differences
in the Constant scores or DASH scores at any time point. Patients
were less dissatisfied with symptoms of shoulder droop, local
bump at the fracture site, and shoulder asymmetry in the open
reduction and plate fixation group (p < 0.0001). The cost of
treatment was significantly greater after open reduction and plate
fixation (p < 0.0001).

 Conclusions: Open reduction and plate fixation
reduces the rate of nonunion after acute displaced
midshaft clavicular fracture compared with
nonoperative treatment and is associated with better
functional outcomes. However, the improved
outcomes appear to result from the prevention of
nonunion by open reduction and plate fixation. Open
reduction and plate fixation is more expensive and is
associated with implant-related complications that are
not seen in association with nonoperative treatment.
The results of the present study do not support
routine primary open reduction and plate fixation for
the treatment of displaced midshaft clavicular
fractures.

 Fractures of the Clavicle
 L.A. Kashif Khan, BSc(Hons),
MRCSEd; Timothy
J. Bradnock, BSc(Hons),
MRCSEd; Caroline Scott,MBChB; C.
Michael Robinson, BMedSci, FRCSEd(Orth)
 J Bone Joint Surg Am, 2009 Feb
01; 91 (2): 447 -460 .
http://dx.doi.org/10.2106/JBJS.H.00034

 Nonoperative Treatment
 Many conservative treatment methods have been described32, but
the simple sling and the so-called figure-of-eight bandage have
been used most widely. A comparative study demonstrated better
patient satisfaction with the simple sling, and the functional and
cosmetic results of the two treatment methods were identical24.
Neither technique reduces a displaced fracture24, but the risk of
axillary pressure sores, compression of the neurovascular bundle,
and nonunion are higher in patients treated with the figure-of-
eight bandage13,20,24,27,33-35. For this reason, the simple sling is
most commonly used. Use of the sling can normally be
discontinued once the acute pain has subsided, and patients are
encouraged to undertake normal activities as pain allows.
Recovery of the range of motion and function of the shoulder is
usually swift if the fracture unites, and supervised physiotherapy
is only rarely required. Most patients respond well to a simple
self-administered program of range-of-motion and muscle-
strengthening exercises.

 A recent multicenter trial comparing nonoperative treatment with primary plate
fixation for displaced fractures in 138 patients demonstrated better functional
outcomes, lower rates of malunion and nonunion, and a shorter time to union
in the latter group29. However, the operative group had a complication rate of
34% and a reoperation rate of 18%, although most reoperations were for
hardware removal. The two validated functional scores that were reported
showed a small but significant benefit from plate fixation (p = 0.001 for the
Constant score46 and p < 0.01 for the Disabilities of the Arm, Shoulder and
Hand [DASH] score47). However, the poorer overall scores in the nonoperative
group may have been due to a minority of outlying patients with poor scores
due to nonunion. It was unclear whether any distinct functional benefit was
gained from the operative treatment in the patients with a healed fracture as
compared with the outcome in those in whom the fracture healed after
nonoperative treatment. The authors stated that their results supported the
use of primary plate fixation of displaced fractures in active adults. However,
this interpretation may lead to overtreatment, as a number-needed-to-treat
analysis revealed that operative fixation of nine fractures would be required to
prevent one nonunion, and fixation of 3.3 fractures would be required to
prevent one symptomatic malunion or nonunion48

 A recent study49 comparing acute operative treatment of midshaft
fractures with delayed treatment of established nonunions and
malunions showed no significant difference in the DASH score and
a significant difference (p = 0.05) in only one of six strength and
endurance variables that were tested. There was a significant
difference (p = 0.02) of 6 points in the Constant score, but all
patients reported a high level of satisfaction.
 As yet, there is no firm consensus regarding which displaced
fractures should be treated operatively. Many younger patients
now seek operative treatment in the hope of obtaining a better
functional outcome and an earlier return to contact sports. It is
our opinion that these patients should be offered the option of
operative treatment, after they have been adequately counseled
regarding the risks involved and the likely outcome of that
treatment.

Operative Techniques
 A wide variety of methods have been described for operative
fixation of shaft fractures (seeAppendix)21,29,36,38,50-67.
 Plate Fixation
 This technique provides immediate rigid stabilization and pain
relief and facilitates early mobilization7,39,42,44,45,68. Most
commonly, the plate is implanted on the superior aspect of the
clavicle, and biomechanical studies have shown this to be
advantageous, especially in the presence of inferior cortical
comminution69. However, the approach is associated with a
greater risk of injury to the underlying neurovascular structures
during fracture manipulation and drilling, and subsequent
prominence of the plate may necessitate its removal. In an
attempt to address these problems, an anterior-inferior approach
to allow inferior implantation of the plate was developed. This
technique was associated with a low complication rate in a series
of fifty-eight patients65, although biomechanical testing has
suggested that a superior position of the plate provides more
secure fixation6

 Currently, the implants most commonly used are either dynamic
compression or locking plates. Reconstruction plates have fallen
into disfavor, since they are susceptible to deformation at the
fracture site, leading to malunion. Site-specific precontoured
locking plates have recently been introduced, and they may be
less prominent after healing, leading to lower rates of hardware
removal after union29,71. There is now also the option of locking
screws into these plates, to improve the fixation of fractures that
extend into the lateral end of the clavicle and of those in elderly
patients with osteoporotic bone. The efficacy of these implants
has not yet been fully tested in comparative clinical studies. The
complications related to the use of plate fixation are infection36,
plate failure36, hypertrophic or dysesthetic scars72, implant
loosening36,73, nonunion63, refracture after plate removal36,63,73,
and very rarely intraoperative vascular injury74.

 Intramedullary Fixation
 The sigmoid shape of the clavicle poses specific problems in the
design and insertion of intramedullary devices, and static locking
is not possible with the implants that are currently available. The
nail must be narrow and flexible enough to pass through the
narrow medullary canal and sigmoid curvature of the clavicle, yet
strong enough to withstand the forces acting on the fracture until
it unites21,75,76. There is biomechanical evidence to suggest that
plate fixation provides a stronger construct than intramedullary
fixation77. A variety of devices, including Knowles pins38,57, Hagie
pins, Rockwood pins, and minimally invasive titanium nails, have
been used54. Two methods of implant insertion have been
described: antegrade, through an anteromedial entry point in the
medial fragment, and retrograde, through a posterolateral entry
portal in the lateral fragment. As a result of the narrow medullary
canal, the fracture site must usually be opened through a
separate incision to expose the proximal and distal parts of the
canal for implant insertion.

 The reported results have been more mixed than
those after plate fixation38,53,57, and the inability to
statically lock these implants may lead to shortening,
especially if there is comminution. High rates of
implant breakage, temporary brachial plexus palsy,
and skin breakdown over the entry portal have also
been reported with the use of these techniques78,79.
Intramedullary fixation is therefore used less widely
than plate fixation, although proponents of the
technique suggest that the more minimally invasive
approach offers advantages for patients with multiple
injuries or other shoulder girdle injuries54.

 Other Techniques
 External fixators have been used to treat
clavicular fractures, although this technique is
most commonly recommended only for open
fractures or septic nonunions80. Kirschner wires
have been advocated to maintain reduction, but
numerous reports have described complications
arising as a result of wire breakage and
migration to a variety of anatomic locations, with
potentially catastrophic consequences42,81. The
use of these implants in the management of
clavicular fractures is therefore strongly
discouraged.

 Complications of Operative Treatment
 The main potential intraoperative
complication is injury to the subclavian artery
or vein at the time of fracture mobilization or
from drill penetration. The risk of this
complication should be very low, but it may
necessitate vascular or cardiothoracic surgical
intervention. Postoperative wound
complications, scar dysesthesia, infection,
fixation failure, and nonunion are relatively
common and may require revision surgery,
as does any other failed osteosynthesis.

 Overview and Recommendations
 There is a general consensus that undisplaced clavicular fractures are best
treated nonoperatively. The paucity of Level-I and II evidence makes it difficult
to produce concrete guidelines for the treatment of displaced clavicular
fractures (Table III). Operative reconstructions of diaphyseal nonunions have
good outcomes, and the large number of case series documenting consistently
satisfactory outcomes after plate fixation lends support to the use of this
technique as the treatment of choice (Grade-B recommendation). Although
good outcomes have been reported after operative treatment of acute
diaphyseal and lateral-end fractures, it is difficult to predict which patients
should be offered primary operative reconstruction and which technique should
be used (Grade-C recommendation). Although the results of a recent
multicenter study lend support to the use of primary operative intervention for
diaphyseal fractures29, the magnitude of the treatment effect may be
insufficient to justify offering surgery to all patients with this injury.
Independent validation from other multicenter studies is required before the
widespread use of this technique can be recommended (Grade-C
recommendation).

Researchs
Stanley and Norris reviewed a consecutive
series of 140 patients with fractures of the
clavicle. All had been treated with either a figure-
of-eight bandage or a sling. There was no
difference in either the rate or speed of recovery
between the groups.
Stanley D, Norris SH. Recovery following fractures of the clavicle treated
conservatively. Injury 1988;19:162-164

Researchs
 Hill et al:
 Evaluated 242 adult clavicle fractures treated closed
 66 (27%) completely displaced middle third
 Nonunion 8/52=15%. Unsatisfactory result 16/52=31%
 Mild-moderate pain 13/52=25%. Brachial plexus irritation 15/52=29%
 Cosmetic complaints 28/52 with 11/52 considered corrective surgery
 Initial shortening at fracture of > 2cm had a significant association
with nonunion and chance of unsatisfactory result
 Recommended ORIF of severely displaced fractures of the middle
third of the clavicle in adult patients
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;79:537â€“539.

Researchs
 Wick et al: clavicle fractures with greater than 20 mm of
shortening were highly predisposed to develop a
nonunion. Of middle third clavicle nonunions in their
series, 91% (30/33) were shortened by at least 2 cm.
Wick M, Muller EJ, Kollig E, et al. Midshaft fractures of the clavicle with a shortening of
more than 2 cm predispose to nonunion. Arch Orthop Trauma Surg 2001;121(4):207-
211

Researchs
Thompson reviewed more than 100 middle-third
clavicular nonunions reported in the literature and found
that 90% of the original fractures had displacement
greater than 100%, overriding more than 1 cm, or had
severe comminution .
Thompson JS. Operative Treatment of Certain Clavicle Fractures. An Orthopaedic
Controversy. Orthop Trans 1988;12:141

 Operative Treatment
 Indications of operative treatment
 Absolute
 Unstable Group II fxs (Type IIA, Type IIB, Type V).
 Open fxs.
 Widely displaced >= 2 cm: increased risk for nonunion.
 Displaced fx with skin tenting, hypertrophic callus.
 Subclavian artery or vein injury.
 Floating shoulder (clavicle and scapula neck fx).
 Symptomatic nonunion.
 Posteriorly displaced Group III fxs.
 Displaced Group I (middle third).
 Thoracic outlet.

Indications of operative treatment (con.)
 Fracture that threaten the overlying skin
 Bilateral clavicle fxs.
 With multiple ipsilateral rib fractures

Relative and controversial indications
- Brachial plexus injury.
- Closed head injury.
- Seizure disorder.
- Polytrauma patient.
- Contraindications of operative treatment
 Non-displaced fractures (no comminution , <3mm
displacement)
 Infection
 Elderly, low-demand, high surgical risk patients

 Stabilization techniques include
 Plate fixation
 Intramedullary fixation
 External fixation
 Coracoclavicular ligament repair or reconstruction in
Group II
 Postoperative rehabilitation
 Sling for 7-10 days followed by active motion
 Strengthening at ~ 6 weeks when pain free motion and
radiographic evidence of union
 Full activity including sports at ~ 3 months


Int J Shoulder Surg. 2009 Apr-Jun; 3(2): 23–27.

doi: 10.4103/0973-6042.57895

PMCID: PMC2904537
 Treatment of mid-shaft clavicle fractures: A comparative study
 David S. Thyagarajan, Marion Day, Colin Dent, Rhys Williams, and Richard Evans
 Author information ► Copyright and License information ►
 This article has been cited by other articles in PMC.
 Go to:
 Abstract
 We retrospectively evaluated 51 patients (17 in each of three groups) with mid shaft
clavicle fractures. Group 1 underwent intramedullary stabilization using clavicle pins.
Group 2 underwent open reduction and internal fixation using plates and group 3
underwent non operative treatment with a sling. Group1 patients progressed to union
within 8 to 12 weeks. In Group 2, six patients had scar related pain and two had
prominent metal work and discomfort and in group 3, three patients developed non
union and one had symptomatic malunion. Our results suggest that the displaced
and shortened midshaft clavicle fractures require operative fixation and the
techniques of clavicle pinning resulted in less complications, short hospital stay and
good functional outcome.

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