Fig. 1 Preoperative (A) and postoperative (B) radiographs of a displaced clavicle fracture.
Courtesy of Samir Mehta, MD

AAOS Now

Published 2/1/2015
|
Jennie McKee

Has the Pendulum Swung to Surgery for Clavicle Fractures?

Recent data find surgical intervention may yield better outcomes

Research performed in the 1960s set the precedent for how orthopaedists treat clavicle fractures. The era’s researchers found that clavicle fractures should be treated conservatively, because patients who underwent surgery had a higher rate of nonunion.

But much has changed since that precedent was established, noted Samir Mehta, MD, of the Orthopaedic Trauma and Fracture Service at the University of Pennsylvania. Dr. Mehta compared historic and recent data on clavicle fracture treatment at the 2014 annual meeting of the Society of Military Orthopaedic Surgeons (SOMOS). Current data suggest that carefully selected patients with acute midshaft clavicle fractures may have significantly better outcomes with surgery, he asserted. Furthermore, recent evidence finds that several risk factors—such as sustaining a shortened, comminuted, or displaced fracture—may increase the risk of poor outcomes for patients who receive conservative treatment.

Past to present data
Five decades ago, surgery was performed primarily on patients with the “worst of the worst” clavicle fractures: those with open fractures, segmental bone loss, and/or vascular injuries. According to Dr. Mehta, this is why data from studies conducted during the 1960s showed higher rates of nonunion in patients who underwent surgery, leading to the belief that conservative treatment should be used, when possible.

“There was a therapeutic bias then,” said Dr. Mehta. “We need to challenge that historic data because recent data suggest a much higher nonunion rate for nonsurgically treated fractures.”

The circumstances surrounding clavicle fractures are quite different today. Modern-day safety features of vehicles, such as seatbelts and airbags, are more effective at protecting motorists during high-speed vehicle accidents. Emergency response systems have also been improved.

“Patients who would have died on impact during a car accident in the 1960s are today being brought to hospital emergency departments with significant fractures,” he noted. “Patients are surviving roll-over vehicle accidents as well as falls from height, because first responders are able to do more sooner, and have greater access to trauma network hospitals. As a result, we’re seeing more high-energy, displaced, comminuted clavicle fractures than previously.” (Fig. 1)

According to Dr. Mehta, current research suggests that malunion is more common in nonsurgically treated fractures. Additionally, commonly used clinical outcomes scores, such as the Disabilities of the Arm, Shoulder and Hand (DASH) and the Short-Form 36 (SF-36), show objective and subjective deficits in patients treated nonsurgically.

“We’re starting to understand that maybe these patients don’t do nearly as well as we thought they did,” said Dr. Mehta.

Another factor that helped “swing the pendulum” from nonsurgical to surgical treatment was a randomized, controlled trial conducted by the Canadian Orthopaedic Trauma Society (COTS) and published in 2007. Although the study found that many patients with clavicle fractures generally have good outcomes after surgery, said Dr. Mehta, surgery may not always be warranted.

“If you read the COTS article in detail, you find out that patients do well with surgical repair, unless there’s a complication,” said Dr. Mehta. “If you don’t surgically repair the fracture and it heals, the patient does well also. Poor outcomes result from complications after surgical repair and delayed healing or nonunions.”

Examining the data
Data on outcomes for patients with acute displaced midshaft clavicle fractures treated either surgically or nonsurgically range from “randomized, controlled trials to systematic reviews to anecdotal case series,” said Dr. Mehta.

One systematic review comparing plating versus nonsurgical treatment included a total of 2,144 clavicle fractures from two prospective cohort studies; three randomized, controlled trials; three retrospective cohort studies; and 14 case series published from January 1975 to April 2005. Data were also extracted from the Cochrane Database, PubMed, and other sources. The 2007 COTS study was not included.

Patients treated nonsurgically had a 15.1 percent nonunion rate, while those in the surgical group had a 2.2 percent nonunion rate.

“Researchers found that the relative risk reduction of using a plate to decrease the risk of nonunion was 86 percent,” Dr. Mehta explained. “That’s a tremendous number when you think about risks and complications.”

Healing time and risk factors
Another study found a significantly quicker time to union among patients who underwent surgical intervention.

“This multicenter, randomized, controlled trial of 132 clavicle fracture patients found that nonsurgical patients had a time to union of 28 weeks, while surgical patients had a time to union of 16 weeks,” noted Dr. Mehta. “Nonsurgical patients had a 14 percent nonunion rate, while surgical patients had a 3 percent nonunion rate.”

According to Dr. Mehta, recent research has found that factors such as displacement, comminution, and female sex can increase the risk of nonunion.

“A 2004 study in which investigators prospectively observed 208 patients with clavicle fractures found decreased recovery with fracture displacement, comminution, and greater number of fragments,” said Dr. Mehta.

“Again, we see poor outcomes with fractures resulting from high-energy injuries, as well as with fractures with significant displacement and shortening,” he noted. Dr. Mehta also acknowledged the wide range of evidence levels regarding factors that increase the risk of nonunion.

Drawing conclusions

  • After considering all currently available data, Dr. Mehta finds that “surgical treatment of displaced fractures often leads to better outcomes when compared to nonsurgical treatment.

“Patients whose fractures are shortened, comminuted, or displaced are at greater risk of poor outcomes following nonsurgical treatment, as are females and older patients,” he added.

More data are still needed, however, in many areas, including how much displacement significantly benefits from plate fixation and whether different modes of fixation have similar outcomes. In addition, more studies should be conducted to analyze the factors that put patients at higher risk for poor outcomes after nonsurgical treatment.

“Based on the current data, however, we can conclude that surgical fixation may be a better choice in the correctly selected patient,” said Dr. Mehta.

Dr. Mehta’s disclosure information, including potential conflicts of interest, can be viewed at www.aaos.org/disclosure

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

Bottom Line

  • Five decades ago, researchers concluded that clavicle fractures should usually be treated conservatively, because patients who underwent surgery—ie, only those with the most severe fractures—had poor outcomes.
  • Recent data suggest that acute displaced midshaft clavicle fractures may have a much higher nonunion rate when treated conservatively, rather than surgically.
  • Clinical outcomes scores indicate objective and subjective deficits in patients with acute, displaced, comminuted clavicle fractures treated nonsurgically.
  • The data now suggest that factors such as fracture shortening, displacement, or comminution, as well as female sex and advanced age, can increase the risk of nonunion.
  • Based on current evidence, surgical fixation may be a better choice for patients with shortened, displaced or comminuted fractures.

References
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 Jan;89(1):1-10.