Midshaft clavicle fractures: Current concepts.

Clavicle fractures are common fractures and the optimal treatment strategy remains debatable. The present paper reviews the available literature and current concepts in the management of displaced and/or shortened midshaft clavicle fractures.Operative treatment leads to improved short-term functional outcomes, increased patient satisfaction, an earlier return to sports and lower rates of non-union compared with conservative treatment. In terms of cost-effectiveness, operative treatment also seems to be advantageous.However, operative treatment is associated with an increased risk of complications and re-operations, while long-term shoulder functional outcomes are similar.The optimal treatment strategy should be one tailor-made to the patient and his/her specific needs and expectations by utilizing a shared decision-making model. Cite this article: EFORT Open Rev 2018;3:374-380. DOI: 10.1302/2058-5241.3.170033.

Introduction

Clavicle fractures are common fractures, comprising 5% to 10% of all fractures.[1] They occur due to falls on the lateral aspect of the shoulder, the outstretched hand or due to high-energy direct impact over the bone. The incidence of clavicle fractures has increased in recent years and the operative treatment of these fractures has increased disproportionately.[2,3] Clavicle fractures are most commonly classified according to the Allman classification and/or the Robinson classification. The location and type of fracture is important in the decision-making as it influences management strategies. This paper focuses on the most common clavicle fractures, which are those in the mid-diaphyseal third (Allman 1 and Robinson 2).[1,4-6] Described conservative treatment options for the clavicle fracture consist of pain reduction by temporary immobilization using a sling or collar and cuff in combination with analgesics and/or kinesio tape. Operative treatment comprises open reduction and internal fixation (ORIF) using plates and screws or intramedullary fixation (IMF), of which the titanium elastic nail (TEN) is the most commonly used and described option.[7-16] Classical operative treatment indications are open fractures, compromised skin, neurovascular complications or an additional fracture of the scapular neck (floating shoulder).[17,18] Others have described relative indications for operative management, which are displaced midshaft clavicle fractures, a shortening of ⩾ 2 cm, age, activity level and dominant side.[17,19]

Even though the ancient Egyptians reported on the fractured clavicle and numerous studies have been conducted to fill the gaps in evidence, there is still no consensus regarding the management of these fractures. In this article, both conservative and operative treatment and the current concepts will be discussed, based on the available evidence.

Physical examination and radiological assessment

During physical examination, a dropped shoulder on the affected side, swelling and haematoma at the middle third of the clavicle are usually observed. Often the fracture elements are palpable. Assessment of possible skin compromise and neurovascular status is important. In addition to the physical assessment, radiological assessment is part of the diagnostic work-up.

Operative treatment

Current radiographic indicators for surgery are displacement and shortening. Displacement is a reproducible measure,[20,21] but its implications for long-term results remain unclear. There is no clear cut-off point that discerns which patients will benefit from operative management. As for shortening, a decrease of > 10% in length is suggested to affect scapular kinematics in vivo.[22,23] It is reported that scapular upward rotation, posterior tilting and internal rotation increase.[22,24,25] A shortening of > 2 cm or > 10% is presumed to be an indicator for poorer outcomes and a possible increased risk of gleno-humeral arthritis in those treated conservatively.[19,26-34] Others report the that the amount of shortening is not influential in the long-term functional outcomes.[35-37] To the authors’ knowledge, there is no universal standardized method of measuring and imaging the fracture reliably and accurately, which could account for these discrepancies. The direction and magnification of the divergent radiographs, as well as the patient's position, affect the imaging and subsequent measurements.[38-40] A variety of imaging and measuring techniques are reported, ranging from a tape measure [31] to anteroposterior (AP) panoramic radiograph views,[19,29,35,37,41] tilted AP views (ranging from a 45° craniocaudal to 45° caudocranial views)[27,30,33,42,43] or CT scans.[36] Measuring shortening by comparing the fractured side with the contralateral non-fractured side seems less reliable than expected, since 30% of the population has a physiological asymmetry of ⩾ 6 mm.[44] Accurate and reproducible imaging and measurement methods should be developed if shortening is to be used as a radiographic indicator for surgery.

Non-operative treatment

Conservative treatment consists of pain reduction by temporary immobilization using a sling or collar and cuff with or without analgesics. Although there are no clinical trials on its efficacy as yet, kinesiotape is also used. The use of a figure-of-eight bandage is not advised. Research from the 1980s and a recent study from 2015 compared conservative treatment with a sling and figure-of-eight bandage.[45,46] They showed that both techniques have similar outcomes but that the patients in the latter group suffered more from pressure sores in the axillae. Range of motion exercises can be increased as tolerated to prevent adhesive capsulitis.

An important complication of conservative treatment is the development of a non-union, which occurs in 15% to 17% of conservatively treated patients.[47-49] It appears that this risk is highest in patients with clavicular fractures displaced more than a shaft width or a shortening of > 2 cm.[17,19] Approximately two-thirds of patients with a non-union undergo operative management because of persistent complaints.[49]

Other risks of conservative management include mal-union and (temporary) neurological issues.[19,30,50-52] Scapulo-thoracic kinematics in patients with shortened clavicles differ significantly from those in uninjured shoulders in the resting position and in movement.[22,23] These changes do not seem to lead to decreased functional outcomes after four months,[43] but can be associated with an increased risk of gleno-humeral arthritis.[34] Several papers demonstrate that corrective surgery for mal-union is challenging but will lead to good results.[26,51] Late reconstruction of mal-union results in restoration of objectively assessed muscle strength similar to those receiving immediate fixation; however, there are subtle decreases in endurance.[53] The aforementioned arguments may lean towards a predominantly conservative management and operative management only being indicated for symptomatic mal- and non-unions.

ORIF using plates and screws

ORIF using plates and screws is considered the current gold standard for the operative management of displaced and/or shortened midshaft clavicular fractures (Fig. 1a). The advantage of operative intervention is the restoration and preservation of the natural anatomy and length of the fractured clavicle. There are uniform reports of lower non-union rates of approximately 2%.[49,54,55] An improved patient satisfaction and earlier return to work compared with conservative treatment is also reported.[47,48,52]

Fig. 1

a) Example of plate fixation of a clavicle fracture (patient treated in OLVG Amsterdam); b) example of intramedullary fixation of a clavicle fracture (patient treated in OLVG Amsterdam).

As for all operative interventions, the risk of complications should not be ignored. Risks associated with operative management of the fractured clavicle include neuropathy of the supraclavicular nerve, infection, pneumothorax, implant failure and the need for hardware removal due to hardware-related complaints.[30] Nineteen per cent of patients have persistent loss of sensation around the scar and the anterior aspect of the chest wall due to neuropathy of the supraclavicular nerve.[54] A recent randomized clinical trial (RCT) of 160 patients reported 10.7% of patients undergoing a re-intervention because of complications from ORIF within one year.[54] The most common reason for this was early implant failure, followed by deep infection, late implant failure and non-union. A database study involving 1350 patients found that one in four patients underwent re-operation (24.6%) within two years.[56] Primary implant removal was most common (77%); median time to implant removal was 12 months. A re-operation secondary to non-union, deep infection and mal-union occurred in 2.6%, 2.6% and 1.1% of the patients after a median of six, five and 14 months, respectively.

Concerning the type of incision, patients are reported to be cosmetically more satisfied when a necklace incision is used compared with a longitudinal incision.[57]

Whether an operation leads to better shoulder function is debatable.[47,48,54] Short-term data show that ORIF using plates and screws results in a more rapid return to normal function compared with conservative treatment.[47,48] Shoulder function after six weeks may therefore play a role in choosing operative management.[55] Long-term results show no significant difference in functional outcomes according to a recent meta-analysis of 614 patients.[49]

The type of plate can affect plate-related complications. A reconstruction plate is easily contoured to the morphology of the clavicle, but biomechanical studies show that it is a weaker construct than other plates such as the Low Contact Dynamic Compression Plate (LC-DCP) or an anatomically pre-contoured plate.[58,59] A retrospective review of 111 patients reported that the use of reconstruction plates leads to 5% hardware failure.[60] Comparing the LC-DCP plate with the reconstruction plate, more plate-related complications are found in the latter, 1% versus 9%.[61] Lower patient satisfaction and high rates of plate prominence have led to the use of lower profile and smaller plates. The position of the plate remains controversial. Superior plating is the most commonly used technique, but anterior-inferior plating, anterior plating or double plating with mini-fragment plates are described as well.[62-64] A biomechanical study comparing anterior and superior plate placement showed that, for all fracture patterns, more construct stiffness was achieved in axial compression and with a superior plate, whereas more construct stiffness was achieved in cantilever bending with an anterior plate.[65] Antero-inferior plating of midshaft clavicle fractures results in lower hardware removal due to plate prominence.[62,66] It was found that anterior-inferior plating reduces the time to union, but the location of the plate does not seem to influence functional outcomes or infection rates.[63]

Dual mini fragment plating was investigated in a small retrospective study (17 patients).[64] Neither of these patients required a second operation to remove at least one of the plates within one year. No non-union was reported and functional outcomes were similar to other studies.[52] Compared with single plating, dual plating is biomechanically equivalent in axial loading and torsion.[64]

Intramedullary fixation

Another option in the operative management of the displaced and/or shortened midshaft clavicle fracture is using an intramedullary device. Classically these comprise Rockwood Pins and Hagie Pins, but the current most used and described implant is the TEN (Fig. 1b).[7-16] The use of TEN leads to equivalent results as the ORIF in terms of function and union rates.[16] The advantage of this method is that the incision is smaller, causing less tissue damage and superior cosmetic results.[67] Besides these clinical outcomes, it has been reported in a finite element study that intramedullary treatment of the midshaft clavicle fracture with a TEN could be preferable to ORIF because it shows a stress distribution similar to the intact clavicle.[68]

The disadvantages of the TEN are hardware migration, secondary shortening, telescoping and the need for routine removal.[9,13,15,16,67,69,70] Most of these complications are attributed to the fact that the TEN aligns but does not fix itself in the fracture elements. The re-intervention ratio related to implant failures is reported to be in the range of 0% to 36%.[7,10,71] In cases where the TEN is removed, this can be done under local anaesthesia, but is more commonly done under general anaesthesia. In general, up to 100% of TENs are removed.[9,13,15,16,67,69,70]

A more recent development for intramedullary fixation is the Sonoma CRx. Although the body of evidence concerning this type of implant is small, it seems to lead to similar functional outcomes and reduced rates of implant removal. However, all papers report hardware failure of up to 5.7%.[72-76]

Cost-effectiveness

In a society in which health costs continue to increase, it is imperative to avoid unnecessary costs. Few data are available on the cost-effectiveness of operative management of the displaced and/or shortened midshaft clavicle fracture. A study published in 2010 reported that cost-effectiveness is not only defined by the actual cost of treatment but was also highly dependent on the duration and magnitude of functional benefit after operative management and the disability and increased time to union associated with non-operative treatment.[77] When functional benefits persisted for > 9 years, operative management using ORIF had a favourable value outcome. Another study with a follow-up of 2.5 years concluded that operatively managed patients cost more during their hospital stay but missed fewer days of work (8.4 days versus 35.2 days), required less assistance for care at home (3 days versus 7 days) and incurred lower costs for physical therapy ($971.76 versus $1820).[78] An overall cost reduction of $5091.33 in favour of the operatively managed patient was found.

Return to sport

For athletes and the active population, return rates and time to return to sport can be important factors in deciding the treatment modality. In case of non- or minimally displaced midshaft clavicle fractures, the return rate to sports was equal between the conservatively and operatively managed patients.[79] Time for return to sport was significantly longer in the conservatively managed patient when comparing the two treatment options for displaced midshaft clavicle fractures; 21.5 weeks (12 to 78) versus 10.6 weeks (10 to 13).[79]

In this review, operative management using intramedullary fixation was included.[79] No statistically significant differences were identified between ORIF and IMF groups concerning return rates (98% versus 99%). In those treated with ORIF, mean return time was 9.4 weeks (2 to 24); in the IMF group, return time was 9.9 weeks (2 to 14). It was concluded that operative management of displaced midshaft fractures offers improved rates and times to return to sport compared with non-operative management.

Shared decision-making

Defining the most suitable treatment for patients with midshaft clavicle fractures is challenging. A frequently used model is shared decision-making (SDM). It is widely used in treatment strategies for diabetes mellitus, cardiovascular disease and cancer. SDM is on the more patient-centred side of the spectrum, between paternalistic decision-making and informed decision-making.

Joint decision-making is subject to several conditions:

both the patient and the physician are involved in the decision-making;

both the patient and the physician exchange information;

both the patient and the physician indicate their preferences regarding diagnostic methods and treatments;

both the patient and the physician agree with the final decision.[80]

During a study in the Netherlands, the current daily practice of shared decisional behaviour in clavicle fracture treatment was evaluated.[81] After the decision-making moment a questionnaire was filled in. The mean score for perceived degree of SDM was 74 out of 100. In 68% of patients, the preferred role matched the actual role in making the decision. Thirty-two per cent of patients would have preferred either a less or a more active role. As a health provider it is meaningful to be aware of these nuances.

Conclusions

Operative treatment with either ORIF or IMF leads to improved short-term functional outcomes, increased patient satisfaction, an earlier return to sports and lower rates of non-union compared with conservative treatment. In terms of cost-effectiveness, operative treatment seems to be advantageous. However, operative treatment is associated with an increased risk of complications and re-operations, while long-term shoulder functional outcomes are similar.

Functional outcomes and union rates are similar between ORIF and IMF. Both ORIF and IMF are subject to implant-specific complications and should be evaluated with the patient before opting for operative management. The optimal treatment strategy should be one tailor-made to the patient and his/her specific needs and expectations by utilizing a shared decision-making model.

Further research on better discerning those who will benefit most from operative management remains necessary. A uniform method of imaging, measuring and reporting radiological parameters as possible indicators for operative management is a consideration for future studies.