Clavicle Fractures- What is the evidence?
AOSSM Annual Meeting, Chicago, IL 2013
Nikhil N Verma, MD
Associate Professor
Rush University Medical Center
Josh Harris, MD
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Embryology
o Intramembranous ossification
o First bone to ossify in-utero
o Last physis (medial/proximal) to fuse in adulthood (22-25 years of age)
o Most longitudinal growth (80%) is from medial physis
Anatomy
o Only horizontal long bone in body
o Links axial and appendicular skeleton
o Flat and wide lateral 1/3; Tubular middle 1/3; Triangular medial 1/3
 Junction of lateral/middle 1/3's: no musculotendinous or ligamentous attachments
 Thinnest, weakest area of bone: prone to fracture
o Deforming muscle forces
 Medially:
 Clavicular head pectoralis major - fracture shortening
 Clavicular head SCM - "elevates/suspends " medial fracture fragment
 Laterally:
 Deltoid (and CC ligaments)- weight of upper extremity depresses lateral fracture
fragment
 Trapezius - fracture shortening
Fracture classification (Allman)
o Group I (middle 1/3): 80%
o Group II (distal 1/3): 15%
 Sub-classified (Neer) - relative to CC ligaments
 I: lateral to CC ligaments (stabilize proximal fragment), not into AC joint
 II: CC ligaments no longer attached to proximal fragment, allowing displacement
 III: into AC joint
o Group III (medial 1/3): 5%
Evaluation:
o History of trauma
o Physical exam: Evaluate for skin compromise, NV exam
o Imaging:
 "Clavicle" and shoulder views
 Clavicle views limited - not orthogonal - difficult to assess anterior-posterior
displacement and fracture comminution/butterfly fragments
 Recommend pre-, intra-, and post-op orthogonal views (Harris JD and Latshaw JC,
Int J Shoulder Surg 2012).
 Chest radiograph (symmetry, shortening measurement)
Management:
o Non-operative
 Simple sling
 Figure-of-eight brace
 Early studies (Neer CS; J Am Med Assoc. 1960; Rowe CR; Clin Orthop Rel Res. 1968) reported
low nonunion rates and high satisfaction rates with non-operative treatment
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Simple sling caused less discomfort and fewer complications than figure-of-8, with no
difference in functional and cosmetic outcomes or fracture healing rate (Andersen K et al,
Acta Orthop Scand 1987)
 Plocher EK, et al, J Trauma. 2011. 15/56 (27%) pts with midshaft clavicle fx initially shortened
< 2cm and treated nonop eventually underwent surgery d/t progressive deformity.
 10/15 (67%) progressive horizontal shortening 1.4 cm (0.6-2.9) at 14.8 days post-inj
 13/15 (87%) progressive vertical displacement
 8/15 (53%) both horizontal and vertical progressive displacement
 Thus, recommend serial weekly radiographs, even in minimally- or non-displaced
fractures for first 3 wks post-injury.
Operative - Mid-shaft fractures
 Open reduction and internal fixation (ORIF)
 Wijdicks FJ, et al. Arch Orthop Trauma Surg. 2012. Complications after plate ORIF
systematic review. Less than 10% rate of nonunion and malunion. Rate of plate
irritation 9-64%.
 Elastic stable intramedullary nailing (ESIN)
 Wijdicks FJ, et al. Can J Surg 2013. Complications after IMN clavicle systematic
review. Less than 7% rate of major complications (deep infxn, nonunion); Less than
31% rate of minor complications (minor irritation, superficial infxn)
 Plate vs ESIN:
 Houwert RM, et al. Int Orthop. Systematic review. No difference in functional
outcome or complication rate for displaced mid 1/3 shaft fractures.
Non-operative vs plate ORIF - mid-shaft fractures
 Canadian Orthopaedic Trauma Society; J Bone Joint Surg, Am. 2007. Multicenter RCT - 132
pts. 1 year follow-up. Displaced midshaft clavicle fracture. Sling vs plate ORIF.
 Better Constant (p=.001) and DASH (p<.01) scores in operative group at all time
points
 Mean union time: 28.4 wks (sling) vs 16.4 wks (ORIF) (p=.001)
 2 nonunions (ORIF) vs 7 nonunions (sling) (p=.042);
 0 (ORIF) vs 9 (sling) symptomatic malunions (p=.001)
 ORIF: 5 prominent hardware, 3 wound infxn, 1 mechanical failure
 Greater (p=.001) satisfaction in ORIF group vs sling.
 Virtanen KJ, et al. J Bone Joint Surg, Am. 2012. RCT sling vs recon plate ORIF 60 pts 1y f/u
 No difference in Constant (p=.75), DASH (p=.89), pain (.98)
 6 nonunions (19%) in nonop vs 0 nonunions (0%) in plate ORIF group
 McKee RC, et al, J Bone Joint Surg, Am 2012. Meta-analysis of 6 studies, 412 pts.
 Higher nonunion (p=.001) in nonop (15%) vs ORIF (1.4%) group
 Higher symptomatic malunion (p<.001) in nonop (9%) vs ORIF (0%) group
 Zlowodzki M, et al, J Orthop Trauma. 2005. Systematic review of 2,144 pts nonop vs surgery
 15% rate of nonunion in nonoperative treatment.
 Fracture displacement (RR 2.3), comminution (RR 1.4), and female gender (RR 1.4)
associated with increased risk of nonunion in non-operative treatment
 Smekal V, et al. J Orthop Trauma. 2009. ESIN vs sling RCT in 60 pts with 2 year follow-up.
 Higher nonunion in sling (10%) vs ESIN (0%) group
 Higher symptomatic malunion in sling (7%) vs ESIN (0%) group
 Higher (p<.05) Constant score in ESIN group at 6 months and 2 years, while higher
(p<.05) DASH score in sling group at 6 months and 2 years
 ESIN group significantly more satisfied with overall outcome vs sling group
 Vander Have KL, et al. J Pediatr Orthop. 2010. Nonop vs ORIF plate in 42 adolescents (mean
age 15 years) at 1 year follow-up.
 Mean union time: 7.5 (ORIF) vs 9.9 (nonop) wks (p=.02)
o No nonunions in either group
 Mean time to return to activities: 12 (ORIF) vs 16 (nonop) wks.
Stegeman SA, et al. BMC Musculoskelet Disord 2011. Sleutel TRIAL design- multicenter RCT 21 hospitals. 350 pts. 2 years follow-up. Primary outcome: nonunion incidence. Secondary
outcome: Constant, DASH, SF-36, MicroFET-2 strength.
o Non-operative vs operative - Distal clavicle fracture
 Oh JH, et al. Arch Orthop Trauma Surg. 2011. Systematic review of 21 studies, 425 pts.
 Nonunion rate 33% (nonop) vs 1.6% (operative) (p<.001)
 Significantly (p=.002) higher complication rate with operative treatment
o Highest complication rate with hook plate (41%) and K-wire tension band
(20%) vs CC stabilization (5%), IMN (2%).
 Despite high nonunion rate, functional outcome was acceptable and satisfactory
even in cases of nonunion.
 Robinson CM, et al. J Bone Joint Surg, Am. 2004.
 Predictors of nonunion: complete displacement without cortical contact, older age
 Rokito AS, et al. Bull Hosp Jt Dis. 2002.
 No difference in outcomes in operative vs non-operative treated pts, despite 44%
rate of nonunion in nonoperative group.
 Robinson and Cairns. J Bone Joint Surg, Am. 2004.
 No difference in outcome between 3 groups: nonop, nonop w nonunion, nonop
nonunion eventually undergoing ORIF
Evidence summary:
o Middle 1/3 fracture:
 Non-operative treatment associated with higher nonunion and symptomatic malunion rates
 Operative treatment associated with higher complication rates
 Clinical outcomes after operative treatment associated with higher scores than nonoperative, including strength, endurance, return to work/sport
o Distal 1/3 fracture:
 Despite high non-union rates, patient satisfaction and clinical outcome scores are high
o Proximal 1/3 fracture:
 Rare, almost always do well with non-operative treatment, unless airway, nerve, vessel
compromise
Recommendations:
o Middle 1/3 fracture:
 Non-operative; unless >100% displaced, shortened > 2cm, comminuted, then ORIF
o Distal 1/3 fracture:
 Type I non- or minimally-displaced: Sling
 Type III: sling, unless significantly displaced, then consider excision vs fixation
 Type II: non- or minimally-displaced: sling. Completely displaced: surgery.
o Proximal/medial 1/3 fracture:
 Non-operative; unless tracheoesophageal / neurovascular compromise, then emergent ORIF
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