Historically, most clavicle fractures have been treated conservatively with a sling. Traditional indications for surgical fixation are open fractures, fractures that tent the skin, brachial plexus injuries, and the floating shoulder, according to Andrew H. Schmidt, MD, professor of orthopaedic surgery at the University of Minnesota, and director of orthopaedic research at Hennepin County Medical Center.

However, the growing trend to treat displaced clavicle fractures with open reduction and internal fixation (ORIF) may indicate that traditional conservative management no longer meets the expectations of today’s patients.

Dr. Schmidt presented “Clavicle Fractures: Which Ones Really Should Be Operated On?” during the 2014 AAOS Annual Meeting in New Orleans.

Surgery or sling?
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 percent of patients with initial shortening of more than 2 cm reported poor functional outcomes, and 15 percent 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, according to the study authors. “All shoulders had deficits in muscle strength, compared to the noninjured shoulder,” Dr. Schmidt said.

One year later, the Canadian Orthopaedic Trauma Society published the results of a multicenter trial in which 132 patients with displaced midshaft clavicle fractures were randomized to nonsurgical treatment or plate fixation. At 1-year follow-up, Constant and DASH scores were better in the surgical group. In addition, mean time to radiographic union was 16.4 weeks in the surgical group, compared to 28.4 weeks in the nonsurgical group. Higher patient satisfaction and fewer complications were also reported in the surgical group.

“The authors concluded that early surgical repair of completely displaced midshaft clavicle fractures results in improved patient-oriented outcomes, improved surgeon-oriented outcomes, earlier return to function, and decreased nonunion rate,” Dr. Schmidt said.

But other published reports are not as definitive. Results from a multicenter randomized trial conducted in Scotland that compared nonsurgical and surgical treatment for displaced midshaft clavicle fractures did not support routine primary ORIF. 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. “Overall, the researchers reported better function in the surgical group, but when nonunions were excluded, function was similar between the two groups,” he said.

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 review revealed that surgical treatment of acute middle third clavicle fractures may not result in a significant improvement in upper arm function at 1-year or more follow-up. The authors concluded, therefore, 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.

Surgical indications
Several studies have attempted to predict risk factors for poor outcomes to help define surgical indications. Dr. Schmidt pointed to a Swedish study that found that lack of bone contact on the initial radiograph and, specifically, fracture comminution with a transverse fragment were the strongest predictors of long-term sequelae.

Another study found that factors such as comminution, smoking status, and amount of fracture displacement could be used to predict the risk of nonunion. “This is important because surgery can effectively mitigate nonunion,” Dr. Schmidt said.

He added that studies have shown that early ORIF reduces the nonunion rate from 15 percent to 2 percent or less and also reduces the symptomatic malunion rate from 20 percent to 2 percent 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.

Disclosure information: Dr. Schmidt—Acumed LLC, Bone Support AB, Medtronic, St. Jude Medical, Twin Star Medical, Conventus Orthopaedics, Epien, Epix VAN, International Spine and Orthopaedic Institute, Thieme, Inc., Journal of Orthopaedic Trauma, Journal of Knee Surgery, Orthopaedic Trauma Association.

Maureen Leahy is assistant managing editor of AAOS Now. She can be reached at leahy@aaos.org

Bottom Line

• Initial surgical treatment for displaced midshaft clavicle fractures is increasing.
• Most fractures treated nonsurgically heal without functional problems.
• Surgery should be performed when nonunion is likely.
• ORIF decreases healing time in high-demand patients and is a consideration in the worker or athlete.

References

1. 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(4):537-539.
2. McKee MD, Pedersen EM, Jones C, et al: Deficits following nonoperative treatment of displaced midshaft clavicular fractures. J Bone Joint Surg Am 2006;88(1):35-40.
3. Canadian Orthopaedic Trauma Society: Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures: A multicenter, randomized clinical trial. J Bone Joint Surg Am 2007;89(1):1-10.
4. 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;13(5):479-486.
5. Murray IR, Foster CJ, Eros A, Robinson CM: Risk factors for nonunion After nonoperative treatment of displaced midshaft fractures of the clavicle. J Bone Joint Surg Am 2013;95(13):1153-1158. doi: 10.2106/JBJS.K.01275