Medical management of displaced mid-shaft clavicle fractures

Between 2010 and 2014 WorkSafeBC accepted 231 clavicle fracture claims, which resulted in claims costs of $13.7 million. Close to $8 million worth of those claims represented short-term disability costs. The majority of people suffered fractures from falls, motor vehicle incidents, or being struck by objects. 

Conservative versus surgical treatment
Historically, mid-shaft clavicle fractures were treated conservatively with benign neglect because surgical management was considered fraught with complications and poor outcomes. Only rare open fractures or ones with risk of skin compromise were treated surgically. Patients initially treated with benign neglect returned for follow-up treatment only on those infrequent occasions when a clear non-union of the fracture developed.[1,2]

In 2000 surgeons began to question whether benign neglect was, in fact, the best treatment for fractures that commonly had displacement and shortening and, when healed, left cosmetic and potentially functional deformities. For young, active males, who are the most likely to experience mid-shaft clavicle fractures, surgical osteosynthesis could potentially achieve the desired rapid return to function and early union, while minimizing nonunion and symptomatic mal-union.[3]

Prospective studies of conservative management of mid-shaft clavicle fractures revealed the following:
•     Nonunion rates of between 15% and 20%.
•     Objective shoulder strength loss between 18% and 33%.
•     Residual sequelae at 6 months postinjury of 42%.

All these numbers were higher than originally thought.[4-6] Theoretically, since the position of the scapula becomes more protracted with a mal-united and shortened clavicle, re-establishing the length of the clavicle would have a similar impact on function as restoring the length of a distal radius in the setting of a shortened distal radius fracture.

Meta-analyses: Discordant results
Since 2000 researchers have conducted many randomized clinical trials comparing surgical and conservative management, the goal being to determine the most appropriate treatment for displaced mid-shaft clavicle fractures. Discordant results led to meta-analyses and systematic reviews in an attempt to combine the data to establish the superior treatment method.3,[7-11] The six meta-analyses included 11 studies published between 2000 and 2013.[12-22]

Unfortunately, the meta-analyses came to discordant conclusions. Some suggested surgical management was superior; others favored conservative management. Consequently, authors of the most recently published systematic review of the meta-analyses used the Jadad decision algorithm[23] and concluded that the highest quality review was the Cochrane review published by Lenza and colleagues in 2013.[8] This review concluded that “Limited evidence is available from randomized controlled trials on the relative effectiveness of surgical versus conservative treatment for acute middle third clavicle fractures. 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.”

Lenza and colleagues found that surgical intervention was superior to conservative treatment in DASH score, constant score, symptomatic mal-union, overall treatment failure, deformity and asymmetry, asymptomatic mal-union, stiffness/restricted range of shoulder movement, number of patients returning to sport activities, and time to return to previous activities. There were no differences in function, UCLA score, pain, symptomatic nonunion, early mechanical failure, unsightly scar, total cosmetic problems, asymptomatic nonunion, skin and nerve problems (incisional numbness), refracture, and total adverse events. Conservative treatment was superior in hardware irritation and prominence, infection and dehiscence, and hardware irritation requiring removal.

With no clear answer on the benefits of surgical management you should discuss the risks and benefits of each type of management with each patient and tailor the management based on each individual’s expectations and acceptance of risk.

Personal experience
As a subspecialty shoulder surgeon in clinical practice, I have seen consistently good outcomes with surgical management, with low rate of hardware irritation and need for hardware removal. While my results are anecdotal, newer second-generation clavicle plating systems are lower profile than first-generation systems. When combined with careful surgical technique, the need for secondary surgery for plate removal is low. Further studies are required to evaluate whether second-generation systems demonstrate reduced rates of secondary surgery for removal.

In my own clinical practice I have found that surgical management of displaced mid-shaft clavicle fractures results in more rapid return to activity and function with high patient satisfaction. Because of this experience, and after reviewing the risks and benefits of both surgical and conservative management with each patient, I continue to choose surgical stabilization to manage the majority of displaced mid-shaft clavicle fractures, particularly in young, active patients.

More information and assistance
If you would like further information or assistance in choosing the appropriate treatment strategy for a worker patient with a displaced mid-shaft clavicle fracture, please contact a medical advisor in your nearest WorkSafeBC office.
—David Sheps, MD, MSc, MBA, FRCSC
WorkSafeBC Orthopaedic Consultant

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This article is the opinion of WorkSafeBC and has not been peer reviewed by the BCMJ Editorial Board.

References

1.    Neer CS 2nd. Nonunion of the clavicle. J Am Med Assoc 1960;172:1006-1011.
2.    Rowe CR. An atlas of anatomy and treatment of midclavicular fractures. Clin Orthop Relat Res 1968;58:29-42.
3.    McKee RC, Whelan DB, Schemitsch EH, et al. Operative versus nonoperative care of displaced midshaft clavicular fractures: A metaanalysis of randomized clinical trials. J Bone Joint Surg Am 2012;94:675-684.
4.    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;79:537-539.
5.    McKee MD, Pedersen EM, Jones C, et al. Deficits following nonoperative treatment of displaced midshaft clavicular fractures. J Bone Joint Surg Am. 2006;88:35-40.
6.    Nowak J, Holgersson M, Larsson S. Sequelae from clavicular fractures are common: A prospective study of 222 patients. Acta Orthop 2005;76:496-502.
7.    Xu CP, Li X, Cui Z, et al. Should displaced midshaft clavicular fractures be treated surgically? A meta-analysis based on current evidence. Eur J Orthop Surg Traumatol 2013;23:621-629.
8.    Lenza M, Buchbinder R, Johnston RV, et al. Surgical versus conservative interventions for treating fractures of the middle third of the clavicle. Cochrane Database Syst Rev 2013;6:CD009363.
9.    Xu J, Xu L, Xu W, et al. Operative versus nonoperative treatment in the management of midshaft clavicular fractures: A meta-analysis of randomized controlled trials. J Shoulder Elbow Surg 2014;23:173-181.
10.    Kong L, Zhang Y, Shen Y. Operative versus nonoperative treatment for displaced midshaft clavicular fractures: A meta-analysis of randomized clinical trials. Arch Orthop Trauma Surg 2014;134:1493-1500.
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12.    Smith C, Rudd J, Crosby L. Results of operative versus non-operative treatment for 100% displaced mid-shaft clavicle fractures: A prospective randomized trial. Proceedings from the 68th Annual Meeting of the American Academy of Orthopaedic Surgeons, San Francisco, CA, 2001.
13.    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.
14.    Witzel K. Intramedullary osteosynthesis in fractures of the mid-third of the clavicle in sports traumatology. Z Orthop Unfall 2007;145:639-642.
15.    Figueiredo EA, Neves EJ, Yoshizawa H, et al. Prospective randomized study comparing surgical treatments using anterior plate and non-surgical management of fractures of the middle third of the clavicle. Rev Bras Ortop 2008;43:419-425.
16.    Judd DB, Pallis MP, Smith E, et al. Acute operative stabilization versus nonoperative management of clavicle fractures. Am J Orthop (Belle Mead, NJ) 2009;38:341-345.
17.    Koch HJ, Raschka C, Tonus C, et al. The intramedullary osteosynthesis of the diaphyseal fracture of the clavicle compared to conservative treatment. Deutsche Zeitschrift fur Sportmedizin. 2008;59:91-94.
18.    Mirzatolooei F. Comparison between operative and nonoperative treatment methods in the management of comminuted fractures of the clavicle. Acta Orthop Traumatol Turc 2011;45:34-40.
19.    Smekal V, Irenberger A, Struve P, et al. Elastic stable intramedullary nailing versus nonoperative treatment of displaced midshaft clavicular fractures—A randomized, controlled, clinical trial. J Orthop Trauma 2009;23:106-112.
20.    Virtanen KJ, Remes V, Pajarinen J, et al. Sling compared with plate osteosynthesis for treatment of displaced midshaft clavicular fractures: A randomized clinical trial. J Bone Joint Surg Am 2012;94:1546-1553.
21.    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;95:1576-1584.
22.    Chen QY, Kou DQ, Cheng XJ, et al. Intramedullary nailing of clavicular midshaft fractures in adults using titanium elastic nail. Chin J Traumatol 2011;14:269-276.
23.    Jadad AR, Cook DJ, Browman GP. A guide to interpreting discordant systematic reviews. CMAJ 1997;156:1411-1416.