Upper Limb
Historically mid-shaft clavicle fractures have by and large been managed conservatively. In the 1960’s Neer1 and Rowe2 reported nonunion rates of 0.1% and 0.8% respectively with conservative management of mid-shaft clavicle fractures. In the decades since no other studies have replicated the low nonunion rates popularised by Neer and Rowe and widely accepted by the Orthopaedic community.
In more recent times, the high-energy mid-shaft clavicle fracture associated with shortening and/or comminution has been recognised as a separate entity which has clinical outcomes dissimilar to its low-energy, minimally displaced counterpart.
Mid-shaft clavicle fractures with significant shortening, have now been shown to have a higher nonunion rate of 15%.3,4 Symptomatic mal-union due to pain, neurological symptoms, thoracic outlet syndrome, and reduced function has also been recognised but its rate remains unknown.3 Significant shortening results in medialisation of the shoulder girdle and asymmetry which may be unacceptable to patients.5
The publication of a randomised trial comparing plating vs conservative management in 2007 challenged the status quo in clavicle fracture management and has stimulated debate.6 There has been a proliferation of literature on this topic since, with several recent randomised trials. In 2011 a meta-analysis of randomised trials concluded that plating was associated with improved treatment effects when compared to conservative management.7 More recently in 2012 a systematic review of available randomised trials concluded that there was no difference in functional outcome or complications after plate fixation or intramedullary fixation.8 None of these papers make a clear distinction between shortening and displacement.
So has the pendulum swung? There does appear to be recognition that in displaced mid-shaft clavicle fractures, operative management is superior. Despite the plethora of recent evidence several questions remain. Do shortened fractures behave differently to those that are displaced without shortening? What amount of shortening is acceptable? What is the most practical, repeatable, and reliable means of measuring shortening? What is the best method of operative management? There is the need for a large, multi-centre, well powered, study that can answer these questions definitively.
Mr Nicholas A. Ferran, Specialist Registrar, University Hospitals of Leicester NHS Trust, Leicester, UK
References
1. NEER CS 2nd. Nonunion of the clavicle. J Am Med Assoc 1960;172:1006-11.
2. Rowe CR. An atlas of anatomy and treatment of midclavicular fractures. Clin Orthop Relat Res 1968;58:29-42.
3. 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-B:537-9.
4. Zlowodzki M, Zelle BA, Cole PA, Jeray K, McKee MD. Evidence-Based Orthopaedic Trauma Working Group. Treatment of acute midshaft clavicle fractures: systematic review of 2144 fractures: on behalf of the Evidence-Based Orthopaedic Trauma Working Group. J Orthop Trauma 2005;19:504-7.
5. McKee MD, Pedersen EM, Jones C, et al. Deficits following nonoperative treatment of displaced midshaft clavicular fractures. J Bone Joint Surg [Am] 2006;88-A:35-40.
6. 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-A:1-10.
7. Duan X, Zhong G, Cen S, Huang F, Xiang Z. Plating versus intramedullary pin or conservative treatment for midshaft fracture of clavicle: a meta-analysis of randomized controlled trials. J Shoulder Elbow Surg 2011;20:1008-15.
8. Houwert RM, Wijdicks FJ, Steins Bisschop C, Verleisdonk EJ, Kruyt M. Plate fixation versus intramedullary fixation for displaced mid-shaft clavicle fractures: a systematic review. Int Orthop 2012;36:579-85.
