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AAOS Now

Published 6/1/2015
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Terry Stanton

Treatment Questions on Clavicle Fractures

OTA presenters offer possible answers

At the 2015 Specialty Day meeting of the Orthopaedic Trauma Association (OTA), two presentations addressed issues in the management of clavicle fractures. Andrew H. Schmidt, MD, discussed various considerations for surgical treatment, and Alexandra K. Schwartz, MD, presented information on the use and possible advantages of inferior plating in surgical treatment situations.

Dr. Schmidt, of the Hennepin County Medical Center and the University of Minnesota, explained that clavicle fractures were traditionally treated nonsurgically, with “surgery limited to relatively rare circumstances,” until a 1997 paper from the University of Omaha initiated a change in thinking. The study looked at a consecutive series of fractures over a 3-year period in patients who did not undergo surgery and found poor outcomes in nearly a third of those who had initial shortening of more than 2 cm.

Traditional indications for surgery—open fracture, tenting of the skin, associated brachial plexus injury, and severe displacement with ptosis of the shoulder—continue to apply, but for less complicated midshaft fractures, the choice to treat with surgery or in closed fashion is not so clear-cut.

“To answer the question of whether to fix displaced clavicle fractures,” Dr. Schmidt said, “you really need to know whether the ultimate function will truly be better. What are the risks of surgery, and how do they balance against the potential benefits? Is the surgery cost-effective?”

Dr. Schmidt reviewed the literature addressing these questions. He noted that a paper from the Canadian Orthopaedic Trauma Society reporting on a randomized clinical trial documented better outcomes, with fewer malunions and nonunions, in patients with displaced fractures who were treated with plate fixation compared to those treated with a sling. A 2012 Finnish paper found that outcomes were the same at 1 year for patients treated surgically and nonsurgically, “but surgery made a dramatic difference in basically eliminating the nonunions, whereas patients treated nonsurgically had a 20 percent nonunion rate.”

Prior to these studies, the classic literature had mostly reported low rates of nonunions with nonsurgical management.

In 2013, a Scottish paper reported nonunion rates of 26 percent in patients treated nonsurgically and 1 percent in those treated surgically, but, Dr. Schmidt noted, “half the nonunions were asymptomatic, and, with the nonunions excluded, there were no differences in function.”

Also in 2013, the Cochrane Collaboration looked at eight randomized trials involving 555 participants and concluded that the degree of improvement in surgical patients was neither clinically nor statistically significant. “Limited evidence is available from randomized controlled trials on the relative effectiveness of surgical versus conservative treatment for acute middle third clavicle fractures,” the report stated. “Surgery may not result in a significant improvement in upper arm function at 1 year or more follow-up.”

Turning to complications, Dr. Schmidt explained that a British study found that smoking and comminution “are factors that can make the nonunion rate appreciably high.” A Canadian study analyzing the risk factors for reoperations reported that, over an 8-year period, one in four patients had had a reoperation, most—19 percent of total patients—for removal of hardware. Other causes were infection (2.6 percent), nonunion (2.6 percent), malunion (1.1 percent), pneumothorax (1.2 percent), and neurovascular injuries (<0.4 percent).>

In terms of the cost-effectiveness of the two approaches, “expenses for surgery are vastly greater,” Dr. Schmidt said. A recent paper in the Journal of Orthopaedic Trauma presented a decision tree model to predict the expected cost of either surgical or nonsurgical treatment. The model included the risk and expenses of reoperation in both groups. It showed that the expected cost in the group treated with immediate surgery was $14,000 versus $3,000 for the group initially treated nonsurgically, for a cost savings of $11,000 per case with initial nonsurgical management.

Yet the cost advantage of nonsurgical management may not be as overwhelming as the raw dollar figures portray. “That study just looked at the payer perspective,” Dr. Schmidt said. “Another study, which considered the costs of at-home care and days off work, and noted a dramatic loss in income. These researchers concluded that surgery is more cost-effective because patients return to function, including work, sooner.” Taking these factors into account, the overall cost for treatment of a fracture and recovery was about $13,000 for surgical patients and $18,100 for nonsurgical patients.

“Are we operating on too many patients?” asked Dr. Schmidt. “It depends on which patients undergo surgery. I think the best evidence is that fixation essentially eliminates both nonunions and malunions. Surgically treated patients get back to work more quickly. Determining cost-effectiveness is more difficult. Certainly surgical care is more expensive initially, but with all considerations factored in, the conclusion may be different.”

In general, he said, candidates for surgery would be active patients who desire a more rapid return to function and who are educated about the risks of surgery. Also warranting consideration are patients with a high risk of nonunion, as well as those patients with the traditional indications for surgery.

Patients can be informed that delaying surgery for a few weeks does not seem to affect outcomes and that plate irritation is common; plates are removed in approximately 20 percent of patients.

Surgery may be warranted in correctly selected patients, Dr. Schmidt said, but “you cannot justify surgery, at this stage, with arguments that ultimate function is going to be better.”

Technical tips
When surgery is the chosen course of treatment, anteroinferior plating may offer advantages to the more commonly performed superior placement, said Dr. Schwartz, of the University of California, San Diego. The superior plate position has the advantage of attaching to the tension side and is more familiar to surgeons, but, she said, “Superior plating has historically had problems with prominent hardware, requiring hardware removal in up to 74 percent of patients. This is in itself problematic because the refracture rate after a hardware removal can be as high as 7 percent.” Superior plating also uses shorter bicortical screw length than anteroinferior plating and has a trajectory toward the lungs and neurovascular structures.

Anteroinferior plating, on the other hand, may offer less hardware prominence and a lower risk of neurovascular injury. It provides improved construct stiffness in the early postoperative period.

The anteroinferior procedure may be performed with the patient supine on a radiolucent table or on a beach chair setup. “I like placing a bump under the scapula,” she said. “And it is important to tilt the head away from the operative side and tape the endotracheal tube away so it doesn’t interfere with the implants.”

Prepping and draping the entire arm is advised in case longitudinal traction is needed. The incision is longitudinal. “It can be centered over the clavicle, but for inferior clavicle plating, it is best to place the incision inferior to the clavicle, which results in less scar tissue and is possibly more cosmetic,” said Dr. Schwartz. “It is important to remove the supraclavicular nerves. I advise every patient of subsequent numbness over the anterior chest wall. It is very important to minimize the soft-tissue stripping and to handle soft tissue gently.”

Dr. Schwartz prefers to have 2 mm screws available for comminuted fragments. She also prefers using pointed reduction clamps because “they are a little bit more soft-tissue–friendly.” She advises planning ahead for the type of plate needed, based on the fracture pattern. “Even though these plates are precontoured, they do not always fit anatomically, so it is important to have plate benders available,” she recommended.

In plating clavicle fractures, surgeons must be mindful of nearby neurovascular structures, particularly the brachial plexus and the subclavian artery and vein. According to one study, said Dr. Schwartz, with the arm in neutral, neurovascular structures were 16 mm to 20 mm away from the screw tip; abduction of that arm increased the distance by about 5 mm.

“These authors concluded there were no safe zones for placement, and caution should be exercised when instrumenting midshaft clavicle fractures regardless of where the plate is placed,” she said.

Dr. Schwartz also reviewed results that have been reported. In one study of 80 patients, the union rate was 93 percent, and just 3 percent of patients desired hardware removal. Another comparative study of superior and inferior plating placements involving 105 patients found similar times to union and the same union rate. “However, the superior plates had a trend toward longer operative time, higher malunion rate, higher implant failure, and more need for hardware removal,” she noted. “There was one subclavian vein injury.”

One study addressed plate size, comparing 2.7 mm and 3.5 mm anteroinferior plating. It reported no difference in time to union, outcome scores, or hardware removal. But a statistically significantly (P = 0.03) better rate of cosmetically acceptable reconstruction (95 percent versus 50 percent) was seen with the 2.7 mm plate.

In summary, Dr. Schwartz advised, “Anteroinferior plating is easily performed with the patient supine on a radiolucent table or a beach chair. Beware of the supraclavicular nerves. Have a good preoperative plan. Anteroinferior plates do have a trend for less hardware removal, and remember there is really no safe zone for screw placement.”

Details of the authors’ disclosure as submitted to the Orthopaedic Disclosure Program may be accessed electronically at www.aaos.org/disclosure

Terry Stanton is a senior science writer for AAOS Now. He can be reached at tstanton@aaos.org

Bottom Line

  • Studies indicate that clavicle fractures treated surgically have lower rates of malunion and nonunion, but surgery does not appear to improve functional outcome.
  • When factors such as home care and loss of income are considered, surgery may compare favorably in cost-effectiveness to nonsurgical management.
  • In addition to patients with clavicle fractures who meet traditional indications for surgery, patients who wish to return to function quickly and who understand the risks may also be candidates for surgery.
  • Anteroinferior plating has possible advantages over superior plating, including reduced hardware prominence and associated need for hardware removal and lowered risk of neurovascular injury.
  • Neurovascular structures to be avoided are the brachial plexus and the subclavian artery and vein.
  • The anteroinferior approach may yield a lower rate of malunion and hardware failure.

References

  1. Althausen PL, Shannon S, Lu M, O’Mara TJ, Bray TJ: Clinical and financial comparison of operative and nonoperative treatment of displaced clavicle fractures. J Shoulder Elbow Surg 2013;22(5):608-611. doi: 10.1016/j.jse.2012.06.006. Epub 2012 Sep 7.
  2. 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.
  3. Collinge C, Devinney S, Herscovici D, DiPasquale T, Sanders R: Anterior-inferior plate fixation of middle-third fractures and nonunions of the clavicle. J Orthop Trauma 2006;20(10):680-686.
  4. Evaniew N, Simunovic N, McKee MD, Schemitsch E: Cochrane in CORR®: Surgical versus conservative interventions for treating fractures of the middle third of the clavicle. Clin Orthop Relat Res 2014;472(9):2579-2585. doi: 10.1007/s11999-014-3643-5.
  5. Galdi B, Yoon RS, Choung EW, et al: Anteroinferior 2.7-mm versus 3.5-mm plating for AO/OTA type B clavicle fractures: A comparative cohort clinical outcomes study. J Orthop Trauma 2013;27(3):121-125. doi: 10.1097/BOT.0b013e3182693f32.
  6. 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.
  7. Leroux T, Wasserstein D, Henry P, et al: Rate of and Risk Factors for Reoperations After Open Reduction and Internal Fixation of Midshaft Clavicle Fractures: A Population-Based Study in Ontario, Canada. J Bone Joint Surg Am 2014;96(13):1119-1125.
  8. 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.
  9. 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.
  10. Robinson CM, Goudie EB, Murray IR, et al: Open reduction and plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures: A multicenter, randomized, controlled trial. J Bone Joint Surg Am 2013;95(17):1576-1584. doi: 10.2106/JBJS.L.00307.
  11. Virtanen KJ, Remes V, Pajarinen J, Savolainen V, Björkenheim JM, Paavola M: Sling compared with plate osteosynthesis for treatment of displaced midshaft clavicular fractures: A randomized clinical trial. J Bone Joint Surg Am 2012;94(17):1546-1553.
  12. Walton B, Meijer K, Melancon K, Hartman M: A cost analysis of internal fixation versus nonoperative treatment in adult midshaft clavicle fractures using multiple randomized controlled trials. J Orthop Trauma 2015;29(4):173-180. doi: 10.1097/BOT.0000000000000225.
  13. Werner SD, Reed J, Hanson T, Jaeblon T: Anatomic relationships after instrumentation of the midshaft clavicle with 3.5-mm reconstruction plating: An anatomic study. J Orthop Trauma 2011;25(11):657-660. doi: 10.1097/BOT.0b013e3182112d7b.