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ORIGINAL ARTICLE
Year : 2015  |  Volume : 15  |  Issue : 1  |  Page : 31-36

Fracture clavicle: Operative versus conservative management


1 Department of Orthopaedics, AIIMS, New Delhi, India
2 Department of 1Orthopaedics, Burdwan Medical College and Hospital, Burdwan, India
3 Department of Physiology, Burdwan Medical College and Hospital, Burdwan, India
4 Department of Pathology, Burdwan Medical College and Hospital, Burdwan, India
5 Department of Orthopedics, RGKar Medical College, Kolkata, India
6 Department of Orthopedics, National Medical College, Kolkata, West Bengal, India

Date of Web Publication19-Jan-2015

Correspondence Address:
Arunima Chaudhuri
Krishnasayar South, Borehat, Burdwan - 713 102, West Bengal
India
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DOI: 10.4103/1319-6308.149531

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  Abstract 

Background: Clavicle fractures are common injuries in active individuals, and it is becoming increasingly apparent that clavicular malunion is a distinct clinical entity with radiographic, orthopedic, neurologic, and cosmetic features. Aims: To analyze the outcome of managements of nonoperative and operative procedures in fracture clavicle in an urban population of eastern India. Materials and Methods: This prospective observational study of 30 cases with fracture of the clavicle was conducted in a tertiary care hospital of eastern India in a time span of 1 year after taking institutional ethical clearance and informed consent of the patients. Injuries were classified according to the AO classification scheme. Patients were treated either conservatively or operatively and followed-up at 6 weeks and 3, 6, and 12 months, then every 6 months. Results: The mean time for fracture healing was significantly shorter in the operative group (15.73 ± 0.70 weeks) than nonoperative group (27.47 ± 0.74 weeks). The difference is statistically highly significant (P < 0.000). Patients in the operative group were more satisfied with the appearance of the shoulder (P < 0.05*). There was no statistically significant difference between two groups with respect to flexion, extension, abduction, internal rotation and external rotation movements with P = 0.532, 1.00, 0.344, 0.052 and 0.056 respectively. Patients in the operative group had better range of Shoulder adduction movement than nonoperative group (P = 0.015). Conclusion: Operative fixation of the clavicle fracture results in improved functional outcome, shorter time for union compared with nonoperative treatment at 1 year of follow-up and primary operative intervention in clavicle fracture in active adults may be of immense importance.

  Abstract in Arabic 

كسر الترقوة - العلاج التحفظ و الجراحي
خلفية: تعدّ كسور الترقوة إصابات شائعة في الأفراد النشطاء، وقد أصبح من الواضح بشكل متزابد أن سوء الالتحام الترقوي يظهر في الفحص السريري و الإشعاعي و العظمي والعصبي والتجميلي .
الأهداف : تحليل نتائج علاج كسور الترقوة الجراحي وغير الجراحي في المجتمعات الحضرية في شرقي الهند.
منهج الدراسة: أجريت هذه الدراسة على 30 من حالات كسور الترقوة في أحد مستشفيات الرعاية الصحية شرقي الهند على مدى عام كامل بعد اتخاذ الإجراءات الأخلاقية وأخذ موافقة المرضى. وقد خضع المرضى لعلاج جراحي أو تحفظي وتمت متابعتهم لمدة 6 أسابيع و 3و6و12 شهرا ثم لمدة ستة أشهر.
النتائج: أظهرت الدراسة أن زمن العلاج في مجموعة العلاج الجراحي كان أقل من مجموعة العلاج التحفظي 15.73+-0.70 اسبوعا بالمقارنة ل 27.47±0.74- اسبوعا
و يعد الفرق الإحصائي ذا أهمية بالغة p<000 وكانت مجموعة العلاج الجراحي أكثر رضى عن مظهر الكتف P< 0.05 ولم تظهر الدراسة فروقا إحصائية بين المجموعتين في حركات ثني الكتف وبسطه وتبعيده والدوران الداخلي والخارجي وأظهرت مجموعة العلاج الجراحي تحستنا في حركة التقريب أكثر من مجموعة
الاستنتاجات : اظهرت نتيجة التثبيت الجراحي لكسر الترقوة تحسنا فى المردود الوظيفي والتحام الكسر في وقت أقصر مقارنة بالعلاج غير الجراحي بعد سنة واحدة من المتابعة، ويعد التدخل الجراحي الأولي في كسر الترقوة عند البالغين ذا أهمية بالغة.

Keywords: Clavicle fracture, operative versus conservative management, outcome


How to cite this article:
Vaithilingam A, Ghosh S, Chaudhuri A, Datta S, Gupta G, Dugar N, Dutta S. Fracture clavicle: Operative versus conservative management. Saudi J Sports Med 2015;15:31-6

How to cite this URL:
Vaithilingam A, Ghosh S, Chaudhuri A, Datta S, Gupta G, Dugar N, Dutta S. Fracture clavicle: Operative versus conservative management. Saudi J Sports Med [serial online] 2015 [cited 2019 Oct 23];15:31-6. Available from: http://www.sjosm.org/text.asp?2015/15/1/31/149531


  Introduction Top


The clavicle or collarbone is the only long bone in the body that lies horizontally. Clavicle fractures are common injuries in active individuals, especially those who participate in activities where collisions are common (e.g, road traffic accident [RTA], sports). In the axial projection, the clavicle is noted to have both medial and lateral flat expanses, linked by a thin, tubular middle. This central transitional area represents a weak link in clavicular structure. The midclavicle, therefore, is the most common site of fracture. [1],[2],[3],[4]

It is becoming increasingly apparent that clavicular malunion is a distinct clinical entity with radiographic, orthopedic, neurologic, and cosmetic features. Increasing reports of complications associated with nonoperative management like symptomatic malunion, nonunion, shortening, droopy shoulder, have stirred towards operative management of clavicle fractures. Internal fixation restores the anatomical continuity of the clavicle, early return to functional activity, the shorter period of immobilization, and less complications. [5],[6],[7],[8],[9],[10] Hence, the present study was conducted to analyze the outcome of managements of nonoperative and operative procedures in fracture clavicle. A number of such studies have been undertaken for the western population, but studies in Indian setup are less.


  Materials and methods Top


This prospective observational study of 30 cases with fracture of the clavicle was conducted in the Department of Orthopedic surgery in a tertiary care hospital of eastern India in a time span of 1 year after taking institutional ethical clearance and informed consent of the patients. Simple random sampling (systematic allocation) was done. First case was managed by nonoperative method, second case was managed by operative method and this order was maintained in the rest of the study.

Inclusion criteria

Patients aged above 15 years with fracture of the clavicle.

Exclusion criteria

Patients with pathological fractures, open fractures, fractures associated neurovascular injury with objective neurological findings on physical examination, associated head injury, and medical contraindication to surgery and/or anesthesia.

The patients were subjected to proper history taking and clinical examination. Clinical examination was done to assess the skin condition over the clavicle, swelling, abnormal prominence, distal neurovascular status of the involved side upper limb. Examination of the head, neck, chest, abdomen, spine and the other limbs was done to rule out associated injuries. After stabilizing the patient, the girdle was immobilized in clavicle brace (CB)/modified figure of eight (MFO8) bandage/strappings and sling.

Routine investigations were done. The clinical diagnosis was confirmed by the antero-posterior radiograph of the chest showing both clavicles. In this study, injuries were classified according to the AO classification scheme. The clavicle fractures were further divided into the medialmetaphyseal, diaphyseal and lateral metaphyseal fractures.

After proper preanesthetic check-up of the operative group patients, surgery was performed.

Among 15 patients under nonoperative care, 11 patients received commercial figure of eight bandage (CB), and 4 patients received MFO8 bandage [Figure 1]. Patients were encouraged to move joints as tolerable as possible from day 1. From 14 days onwards passive circumduction exercises with the arm at the side (pendulum exercises) and elbow range-of-movement exercises were permitted. From 6 weeks, onwards resistive exercises were encouraged after removal of the brace. Patients with associated rib fractures were encouraged for deep breathing exercises with an incentive spirometer.
Figure 1: Patient with clavicle brace

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Surgical steps

Anesthesia

General anesthesia was given to all operative group patients, and the endotracheal tube is taped to the normal side. Patient positioning and preparation: The patients were positioned in a beach-chair semi-sitting position\modified beach-chair position. The involved shoulder was prepared and draped. The arm was usually padded and strapped to the patient's side except in lateral one-third clavicle fractures where the arm was free draped [Figure 2].
Figure 2: Modified beach-chair position of the patient

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Superior approach

An oblique incision was made centered superiorly over the fracture site.

The subcutaneous tissue and platysma muscle were kept together as one layer and extensively mobilized, especially proximally and distally. Care was taken to identify, isolate, and protect any visible, larger branches of the supraclavicular nerves, smaller branches were sacrificed. Themyofascial layer over the clavicle was incised and elevated in one contiguous layer. Care was taken to preserve the soft tissue attachments to any major fragment [Figure 3]. The fracture site was identified, and the fracture was reduced and fixed with a precurved clavicle plate on the superior surface of the bone [Figure 4]. Ten patients were managed with precurved clavicle plate and screws; two patients with 3. 5-mm reconstruction plates and screws; two patients with titanium elastic nail system (TENS) nail and one patient with coraco-clavicular screw and stainless steel wire.
Figure 3: Fracture end being held with bone holding forceps before reduction

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Figure 4: Clavicle fracture after reduction with precurved locking plate

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Reconstruction plates were contoured to the patient clavicle with the help of plate benders. Lag screw was used for reduction if big comminuted fragments were seen, and care was taken to preserve soft tissue attachments. If the fragments were too small to accept fixation, they were loosely sutured into place with number-1 absorbable suture or positioned under the plate. The deltotrapezial fascia was closed with interrupted number-1 absorbable sutures as a distinct layer, followed by skin closure. No drains were used.

Anterior (minimally invasive plate osteosynthesis) approach

Through mini incisions, 2 cm lateral to the sternoclavicular joint and 2 cm medial to the acromioclavicular joint were made. By tunneling technique (minimally invasive plate osteosynthesis), muscular attachments from the anterior surface of the clavicle were stripped subperiosteally. The recon plate was curved to the shape of clavicle and fixed with screws.

Intramedullary nailing technique

Patient was positioned on a radiolucent table in a semi-sitting position, with an image intensifier on the ipsilateral side. By rotating the image 45° caudal and cephalic, orthogonal views of the clavicle were obtained. A small incision was made over the postero-lateral corner of the clavicle 2-3 cm medial to the acromioclavicular joint. The posterior clavicle at this point was identified, and the canal breached with a drill. A reduction of the clavicle is performed through a small open incision. After reduction 2 mm TENS introduced from lateral to medial, just 1 cm away from sternoclavicular joint (under C-ARM guidance) [Figure 5]. Distal end was bend lightly and cut with cutter and skin closed.
Figure 5: Intramedullary nailing under C-ARM guidance

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Postoperative rehabilitation

A shoulder arm pouch was used for comfort. From 2 nd postoperative day, passive movements of the shoulder, elbow, and wrist permitted as tolerable till suture removal. Sutures were removed at the interval of 10-14 days. From 14 days onwards passive circumduction exercises with the arm at the side (pendulum exercises) and elbow range-of-movement exercises were permitted. From 6 weeks, onwards active-assisted shoulder range-of-motion exercises and unrestricted range of movements were allowed. Patients with associated rib fractures are encouraged for deep breathing exercises with Incentive spirometer. Physically active patients were allowed to return to general fitness training, including running, and noncontact sports at 12 weeks, but were advised to avoid competitive collision activities until 16 weeks after the injury.

Follow-up

The patients were seen at 6 weeks and at 3, 6, and 12 months, then every 6 months and following factors were assessed.

  • Time taken for functional recovery
  • Time taken for fracture healing (radio-graphically judged by obliteration of fracture site by cortical bridging)
  • Range of motion of the shoulder joints.
  • Any specific complaints
  • Disability of the Arm, Shoulder and Hand (DASH) score.


Statistical analysis

Statistical analysis was performed using SPSS software version 16.


  Results Top


There was no significant difference in age between the two groups (34.33 ΁ 10.38 years and 31.47 ΁ 10.66 years P = 0.462). In nonoperative group, 12 cases were male, and 3 cases were female. In operative group, 13 cases were male, and 2 cases were female. There was no significant difference between proportions of males in the two groups (Z = 0.00 P = 0.998). There was no significant difference between the proportions of females between the two groups (Z = 0.00 P = 0.998). Maximum patients (19 cases) (63.33%) had clavicle fracture following RTA with direct impact on the shoulder girdle, followed by fall on out stretched hand in 9 cases (30%), physical assault by fist in 1 case (3.33%) and fall of the object from side in one case (3.33%). All 30 patients had right upper limb as Dominant arm. Maximum patients (17 cases-56.66%) were affected on the left side clavicle (nondominant side) and remaining (13 cases-43.33%) on the right side clavicle. Associated Injuries noted in this study were rib fractures following RTA (13.33%), abrasions following RTA and fall of the object from side (13.33%), fracture both bone leg following RTA (6.66%), scaphoid fracture following fall on an outstretched hand (3.33%), glenoid neck fracture following RTA (3.33%) and tibial plateau fracture following RTA (3.33%). Abrasions were managed with regular antiseptic dressing and a course of antibiotic. One fracture both bone leg was managed by interlocking intramedullary nailing and another both bone leg fracture by external fixator due to open wound. One case with associated glenoid neck fracture was opened reduced and internally fixed with recon plate and screws. One case with associated tibial plateau fracture (type I) was managed conservatively. Patient with associated scaphoid fracture were managed conservatively.

In this study, AO classification was used. AO 15-B2 type with 15 cases (50%) followed by AO 15-B1 type with 5 cases (16.66%), AO 15-B3 type with 5 cases (16.66%), AO 15-A1 type with 3 cases (10%), AO 15-C1 type with 2 cases (6.66%). 11 cases (73.33%) were managed with CB and remaining 4 cases (26.66%) with MFO8 bandage. The mean time gap between injury and operation was 5.6 days in the operative group. Among 15 operative group patients, 12 cases (80%) operated by superior approach, 1 case (6.66%) by anterior approach and 2 cases (13.33%) by TENS through lateral entry. The patients in the operative group were treated with precurved plate and screws in 10 cases (66.66%), with Recon plate and screws in 2 cases (13.33%), with TENS in 2 cases (13.33%) and with coraco-clavicular screw in one case (6.66%). The mean time for functional recovery in the operative group was 4.40 ΁ 1.06 weeks while in the nonoperative group was 6.40 ΁ 1.55 weeks. The difference was statistically significant (P < 0.05).

The mean time for fracture healing was shorter in the operative group (15.73 ΁ 0.70 weeks) than nonoperative group (27.47 ΁ 0.74 weeks). The difference is statistically highly significant (P < 0.000).

Patients in the operative group were more satisfied with the appearance of the shoulder (P < 0.05*). There was no statistically significant difference between two groups with respect to flexion, extension, abduction, internal rotation and external rotation movements with P = 0.532, 1.00, 0.344, 0.052, and 0.056, respectively [Table 1]. Patients in the operative group had better range of shoulder adduction movement than nonoperative group (P = 0.015).
Table 1: Range of movements of the involved side shoulder

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Disabilities of the Arm, Shoulder and Hand scores in the operative group were significantly superior (i.e. lower values) than in the nonoperative group at all time-points till final follow-up. Complications observed in this study are shown in [Table 2].
Table 2: Complications

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  Discussion Top


A total of 30 cases with clavicle fractures were selected for the study. Of these 15 patients were managed by nonoperative methods and another 15 patients by operative methods. In this study, the average age of the patient was 32.90 years, with the youngest patient being 17 years and the oldest being 57 years old, among them, male predominance was present (83.33%) and female were 16.66%. Pearson et al. [2] have reported the average age of patients sustaining a clavicular fracture is 33 years. Postacchini et al. [1] reported that most patients were men (68%).

In this study, 63.33% developed clavicle fracture following RTA with direct impact on the shoulder girdle, followed by fall on out stretched hand in 30%, physical assault by fist in 3.33% and fall of an object from side in 3.33%. Zlowodzki et al. [4] and McKee et al. [3] described a fall or a blow to the shoulder, giving an axial compressive force on the clavicle, is the most common trauma mechanism of injury for any clavicular fracture.

In our study, 56.66% had clavicle fractures on the left side. Postacchini et al. [1] also described that the left side was involved in 61% of cases. Associated injuries commonly noted in this study were rib fractures(13.33%), abrasions (13.33%), fracture both bone leg (6.66%), scaphoid fracture (3.33%), glenoid neck fracture (3.33%) and tibial plateau fracture (3.33%). Associated injuries have been reported in different studies. [2],[3],[4],[5],[6],[7],[8]

In our series, 83.3% had mid-third fracture, 10% had medial third fracture, 6.7% had lateral third fracture. Mid-third fracture of the clavicle has been found to be more common in different studies. [5],[6],[7],[8],[9]

Patients in the operative group improved functionally and returned to normal activities earlier than nonoperative group. It is also statistically significant (P < 0.05). This factor is very important as patients today are more active and expect to return to pain-free function following a fracture. Patient satisfaction in the operative group is more than in the nonoperative group regarding appearance of the shoulder (cosmetic) and movements of the shoulder (P = 0.039). With conservative treatment for displaced and shortened mid-shaft clavicle fractures, Thyagarajan et al. [6] reported less satisfaction among patients. 23.5% (4/17) of the patients initially treated conservatively required operative treatment. As many as 41% of the patients in the conservative group had pain during daily activities.

The mean time for fracture healing (radiological union) was shorter in the operative group (15.73 weeks) than nonoperative group (27.46 weeks). McKee et al. [3] described the mean time for fracture healing were 14-16 weeks for operated patients and 24-28 weeks for nonoperated patients.

The complications were more in the nonoperative group like symptomatic malunion 7 cases (46.66%), shortening 3 cases (20%), muscle wasting 4 cases (26.66%), pressure necrosis 1 case (6.66%) and complex regional pain syndrome 1 cases (6.66%). The complications noted in the operative group were incisional numbness 1 case (6.66%) and hardware irritation 1 case (6.66%). Second surgery was done to remove irritating hardware. None of the operated patients had nonunion or malunion.

No infection was seen in the operative group. All surgical wounds healed between 8 and 12 postoperative days. Refracture and nonunion were seen in neither of the groups. McKee et al. [3] reported the rate of nonunion in the nonoperated patients 14-24%, and 3.2% in the operated group.

Iatrogenic neurovascular vascular injury is an imminent complication if proper operative techniques are not followed. Because major neurovascular structures like subclavian vein, subclavian artery and brachial plexus are near to the surgical field. [9],[10],[11],[12],[13] However, in this study, none of our operated patients developed any neurovascular injury. None of the patients in this study had pulmonary injury either following primary injury or iatrogenically.

Disability of the Arm, Shoulder and Hand scores in the operative group were superior (i.e. lower values) than in the nonoperative group at all time-points till final follow-up. The mean DASH score was 13.04.

The mean follow-up of both groups were 12.56 months. The mean follow-up of patients in the operative group was 14.20 months. The mean follow-up of patients in the operative group was 12 months. McKee et al. [3] followed-up their cases from 6 to 12 months duration.


  Conclusion Top


Operative fixation of the clavicle fracture results in improved functional outcome, shorter time for union compared with nonoperative treatment at 1 year of follow-up and primary operative intervention in clavicle fracture in active adults may be of immense importance.

 
  References Top

1.
Postacchini F, Gumina S, De Santis P, Albo F. Epidemiology of clavicle fractures. J Shoulder Elbow Surg 2002;11:452-6.  Back to cited text no. 1
    
2.
Pearson AM, Tosteson AN, Koval KJ, McKee MD, Cantu RV, Bell JE, et al. Is surgery for displaced, midshaft clavicle fractures in adults cost-effective? Results based on a multicenter randomized, controlled trial. J Orthop Trauma 2010;24:426-33.  Back to cited text no. 2
    
3.
McKee MD, Pedersen EM, Jones C, Stephen DJ, Kreder HJ, Schemitsch EH, et al. Deficits following nonoperative treatment of displaced midshaft clavicular fractures. J Bone Joint Surg Am 2006;88:35-40.  Back to cited text no. 3
    
4.
Zlowodzki M, Zelle BA, Cole PA, Jeray K, McKee MD. Treatment of acute midshaft clavicle fractures: Systematic review of 2144 fractures. J Orthop Trauma 2005;19:504-7.  Back to cited text no. 4
    
5.
Gille J, Schulz A, Wallstabe S, Unger A, Voigt C, Faschingbauer M. Hook plate for medial clavicle fracture. Indian J Orthop 2010;44:221-3.  Back to cited text no. 5
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6.
Thyagarajan DS, Day M, Dent C, Williams R, Evans R. Treatment of mid-shaft clavicle fractures: A comparative study. Int J Shoulder Surg 2009;3:23-7.  Back to cited text no. 6
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7.
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;89:1-10.  Back to cited text no. 7
    
8.
Garg AK, Mukhopadhyay KK, Shaw R, Roy SK, Banerjee K, Mukhopadhyay K. Displaced middle-third fractures of the clavicle-operative management. J Indian Med Assoc 2011;109:409-10.  Back to cited text no. 8
    
9.
Khan MA, Vakati SR. Management of clavicular non-union with plate fixation and bone grafting. Arch Int Surg 2013;3:49-51.  Back to cited text no. 9
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10.
Böhme J, Bonk A, Bacher GO, Wilharm A, Hoffmann R, Josten C. Current treatment concepts for mid-shaft fractures of the clavicle-results of a prospective multicentre study. Z Orthop Unfall 2011;149:68-76.  Back to cited text no. 10
    
11.
Stegeman SA, de Jong M, Sier CF, Krijnen P, Duijff JW, van Thiel TP, et al. Displaced midshaft fractures of the clavicle: Non-operative treatment versus plate fixation (Sleutel-TRIAL). A multicentre randomised controlled trial. BMC Musculoskelet Disord 2011;12:196.  Back to cited text no. 11
    
12.
Giorgi SD, Notarnicola A, Tafuri S, Solarino G, Moretti L, Moretti B. Conservative treatment of fractures of the clavicle. BMC Res Notes 2011;4:333.  Back to cited text no. 12
    
13.
Van der Meijden OA, Gaskill TR, Millett PJ. Treatment of clavicle fractures: Current concepts review. J Shoulder Elbow Surg 2012;21:423-9.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2]



 

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