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Fig. 1 Postoperative anteroposterior radiograph of a clavicle fracture that was stabilized with a 3.5mm reconstruction plate.
Courtesy of Kaisa J. Virtanen, MD

AAOS Now

Published 4/1/2010
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Jennie McKee

Should surgery come before the sling?

Surgery may be better for displaced clavicle fractures

Clavicle fractures, common injuries in active adults, are conventionally treated with arm immobilization in a sling. But according to the results of a study presented by Kaisa J. Virtanen, MD, at the AAOS 2010 Annual Meeting, surgical treatment of clavicle fractures may have some advantages over conservative measures in patients with a high level of activity.

“Our data suggest that nonsurgical and surgical treatment of displaced midshaft clavicle fractures provide equal functional outcomes, as well as relief of pain at rest and activity at 1-year follow-up,” said Dr. Virtanen. “Nonsurgical treatment, however, had a relatively high risk of nonunion.”

She noted that although conservative treatment with sling immobilization should be considered first in most patients, the study’s results suggest that surgical treatment may be more effective for physically active adults due to the reduced risk of nonunion and an acceptable risk of complications.

Comparing surgical, nonsurgical measures
Between August 2004 and October 2007, 60 patients were enrolled in the prospective, randomized, controlled trial performed at Helsinki University Töölö Hospital in Finland. All patients were aged 18 to 70 years and had a completely displaced middle third clavicle fracture with no cortical contact between main fragments. Fractures were treated within 7 days after injury.

Potential study participants were identified and enrolled as they arrived in the emergency department. Patients were randomized to either the nonsurgical group (32 patients) or the surgical group (28 patients).

Patients in the nonsurgical group wore an arm sling for 3 weeks and were advised to perform the pendulum movement, in which the patient bends forward at the waist and lets the injured arm hang down toward the ground. The patient then makes small clockwise and counterclockwise circles, letting momentum move the hand.

Patients in the surgical group underwent surgical treatment with plate osteosynthesis within 7 days of the injury (Fig. 1). After surgery, the arm was immobilized in a sling for 3 weeks, and physical therapy using the pendulum movement was started on postoperative day one.

The following outcome measures were used:

  • Constant-Murley Shoulder Outcome Score (CSS)—pain, function, range of motion, and strength
  • Disability of the Arm, Shoulder and Hand (DASH)—physical function and symptoms
  • pain at rest and activity as measured by the visual analog score (VAS)
  • union rate
  • complications or adverse events

“Surprising” number of nonunions
At 1 year follow-up after injury, 26 patients remained in the surgical group and 25 patients in the nonsurgical group.

“We found no clinically significant difference in CSS or DASH scores, or in pain at rest or activity,” said Dr. Virtanen. “The differences in DASH scores and pain between the surgical and nonsurgical [groups] were statistically significant, but not clinically significant.”

The nonsurgical group had five nonunions, while the surgical group had none. Dr. Virtanen noted that no patients in the surgical group—and only 3 of 25 patients in the nonsurgical group—had symptoms above acceptable levels (VAS scores more than 24 at rest). In addition, mean DASH scores of both groups were below 10 points, indicating that most patients achieved tolerable pain relief and subjective function regardless of whether they received nonsurgical or surgical treatment.

Dr. Virtanen noted that the rate of complications and adverse events was acceptable. One patient in the nonsurgical group underwent surgery at 4 months because of plexus irritation. No patients had postoperative infections, while two complications occurred in the surgical group—a refracture after a new fall and a broken plate.

“Even though we expected more nonunions in the nonsurgical group than in the surgical group,” said Dr. Virtanen, “the high incidence of nonunion in the nonsurgical group surprised us. This could be explained by the relatively low number of patients in this study.

“Our data assert,” she concluded, “that equal functional outcomes can be obtained at 1-year follow-up with either nonsurgical or surgical treatment of displaced midshaft clavicle fractures. In physically active adults, surgical treatment may secure the union with acceptable risk of complications.”

Dr. Virtanen was the lead author of “Nonoperative Versus Operative Treatment of Midshaft Clavicle Fractures: A Randomized, Controlled Trial.” Her coauthors included Ville Remes, MD, PhD; Jarkko Pajarinen, MD, PhD; Vesa Savolainen, MD, PhD; Jan-Magnus Björkenheim, MD, PhD; and Mika Paavola, MD, PhD. Dr. Virtanen reports no conflicts.

Dr. Remes—Smith & Nephew; Stryker; Dr. Björkenheim—Acta Orthopaedica. Drs. Pajarinen, Savolainen, and Paavola—no conflicts.

Jennie McKee is a staff writer for AAOS Now. She can be reached at mckee@aaos.org

Bottom Line

  • Most patients with clavicle fractures should be considered for nonsurgical treatment (sling immobilization).
  • Younger, active adults with displaced clavicle fractures may do better with surgical treatment.
  • In this study, patients treated nonsurgically had a higher rate of nonunion; patients treated surgically had an acceptable rate of complications.