Conservative Vs Operative Management of Displaced Midshaft Clavicle Fracture: A Comparative Study

Conservative Vs Operative Management of Displaced Midshaft Clavicle Fracture: A Comparative Study

Abstract

Background: Clavicle fracture is one of the common fractures accounting for 2.6-12% of all fractures and 44-66% of shoulder fractures with midclavicle fracture accounting for 80% of clavicle fractures. Most of the clavicles were treated conservatively in past but recently there has been an increasing tendency for operative management of clavicle fractures. With studies done showing varying results it is not clear whether primary surgical management provides any better results than conservative management. So, this study was carried out to compare the radiological and functional outcome following conservative management to that of operative management with plating for displaced midshaft clavicle fractures.

Methods: In a single center, prospective clinical trial, 60 patients with displaced midshaft fracture of the clavicle were systematically randomized (alternate patient) into either operative treatment with plate fixation or nonoperative treatment with clavicle brace and sling. Outcome was analysed in terms of functional outcome and radiological union by standard follow-up, Constant and Murley shoulder score and plain radiographs. All sixty patients completed sixmonth follow up and there was no difference between two groups with respect to patient demographics, mechanism of injury and fracture pattern.

Result: There was no significant difference in Constant shoulder score between the two groups. The mean time of union was 14.57 weeks in operative group compared to 16.04 weeks in nonoperative group (p value=0.191). There were two nonunion in nonoperative group compared to none in operative group. The complications in operative group were mainly hardware related (four had loosening of screw, two had implant failure and one had infection). At six months after surgery patient were more likely to be satisfied with the results in operative group compared to nonoperative group (p=0.02).

Conclusion: Six months after a displaced midshaft clavicular fracture, nonoperative treatment resulted in higher malunion and nonunion rate but similar functional outcome and union time compared to operative management. However, patients were more likely to be satisfied in operative group compared to nonoperative group.

Introduction

Clavicle acts as bony connection between thorax and shoulder girdle while contributing to movements around the shoulder [1]. It is one of the common bones to fracture accounting for 4-12% of all fractures and 44-66% fractures around shoulder. Of all clavicle fractures midshaft fractures contribute around 80% of cases [2]. In 94% of cases it follows direct trauma whereas rest cases occur due to fall on outstretched hand [3]. Midshaft fracture commonly occurs in young adult whereas lateral and medial end clavicle fracture is more common in elderly [4,5]. More than 200 methods of operative and nonoperative methods for management of clavicle fractures have been described [6]. These methods can be roughly divided into operative and nonoperative methods. Most commonly used nonoperative method is clavicle brace and an arm sling. It has advantage of being noninvasive and absence of exposure to anaesthesia. However, nonoperative methods are said to be associated with risk of non-union, residual deformity and patient dissatisfaction. Most clavicular fractures still are treated closed and heal uneventfully without serious consequences [7].

Nonoperative management was widely recommended for middle third fracture given higher union rate with nonunion of 0.03 to 6.2% [8,9] However, with recent studies showing nonunion rates up to 15% and patient dissatisfaction of up to 31%, there is increasing trend for operative management [10]. Three types of fixation are available for middle-third clavicle fractures: intramedullary devices, plates and external fixators [6]. Intramedullary fixation can be accomplished with smooth or threaded K- wires, Steinman pins, Knowles pins, Hagie pins, or cannulated screws (Figure 1). With intramedullary devices, there is less surgical dissection and soft tissue stripping with less hardware prominence. However, there is the possibility of pin migration and poor rotational control during overhead abduction of shoulder [6].

Figure 1: Follow up case of plating.

External fixation of the clavicle is indicated for severe open fractures with poor quality overlying skin. External fixation may also be indicated for treatment of clavicle fractures in the face of infection or infected nonunions following plate removal (Figure 2). Even in these cases, plate fixation should be considered first and used whenever possible [6]. Plating of acute clavicle fractures, when indicated, is advocated as the preferred fixation method by many authors. Biomechanically, plate fixation is superior to intramedullary fixation as it better resists the bending and torsional forces that occur during elevation of the upper extremity above shoulder level. Patients treated with plate fixation can be allowed full range of motion once their soft tissues have healed. Disadvantages of plate fixation include the necessity for increased exposure and soft-tissue stripping, potential damage to the supraclavicular nerves, which cross through the surgical field, slightly higher infection rates and the risk of refracture after plate removal (Figure 3). These complications can be reduced by careful soft tissue handling, minimal periosteal stripping and meticulous plate fixation [6]. We compare the conservative and operative management of midshaft displaced clavicular fracture.

Figure 3: 6 weeks follow up of plating.

Materials and Methods

The study was done at the tertiary care trauma centre between October 2014 to October 2016. There were 30 patients in each group. All the patients with isolated closed displaced traumatic midclavicular fractures without neurovascular involvement between age group 16-60 years were included in the study (Figure 4). Patients were enrolled from the emergency department and every alternat patient were enrolled between the two groups. Group A underwent conservative management and Group B underwent open reduction and internal fixation with a plate.

Result

Patient Demographics

In this study, the youngest patient was 17 years, and oldest patient was 59 years with the average age being 32.2years with a standard deviation of 11.656 (Figure 8). The majority of patients (55% of total cases) were below 30 years of age. The distribution of patients on two groups were similar on the basis of age with a mean age in a conservative group of 33.567 with a standard deviation of 12.445 and that in an operative group of 30.833 with a standard deviation of 10.847 and had no significant difference statistically (p value=.368).

Conclusion

Six months after a displaced midshaft clavicular fracture, nonoperative treatment resulted in higher malunion and nonunion rate but similar functional outcome and union time compared to operative management. However, patients were more likely to be satisfied in operative group compared to the nonoperative group. So, there is need to individualize the treatment as per the need and functional demand of the patient to give the optimum outcome. However, there is a need for multicentric trials with larger number of patients for a longer followup period, so that these findings could be further corroborated.

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