Fixation better than sling for displaced clavicle shaft fractures

Surgery offers significantly better function after one year.

OTTAWA — Operative fixation yielded better outcomes than conventional sling treatment for completely displaced clavicle shaft fractures in a new Canadian study. The operation offered more rapid union and earlier return to function, the researchers said.

Jeremy A. Hall, MD, FRCS (C), St. Michael’s Hospital, University of Toronto, discussed the multicenter, prospective, randomized control trial at the Orthopaedic Trauma Association 21st Annual Meeting, here. Hall, lead investigator Michael D. McKee, MD, FRCS (C) and their co-authors compared outcomes of operative and non-operative treatment for displaced clavicle shaft fractures.

Hall cited modern literature showing a non-union rate of more than 15% for displaced clavicle shaft fractures, especially when associated with displacement, female gender and age. Open reduction and internal fixation cut the non-union risk by 86%, Hall said.

Researchers randomized their study patients using sealed envelopes. They included patients 16 to 60 years old and having completely displaced midshaft clavicle fractures. They excluded patients who were outside the age range, had pathological fractures, open fractures and fractures associated with neurological injury, and those who did not agree to participate.

Non-operative patients received standard care — a conventional sling. The operative patients underwent ORIF using small fragment plates and screws, Hall said.

The non-operative group comprised 49 patients averaging age 36, with 27 dominant clavicles. The operative group had 62 patients averaging age 35, with 34 dominant clavicles.

Researchers recorded Constant Shoulder Scores (CSS), Disability of the Arm, Shoulder and Hand (DASH) scores and SF-36 scores at six weeks, three months, six months, 12 months and two years. One-year results included 111 of 129 patients.

Fixation=higher CSS and DASH scores

The operative and non-operative groups’ CSS scores showed clear differences, Hall said.

“... At each of the time points ... there’s a significant improvement in the operative group compared to the non-operative group, and this continues out to the early data collected for the two-year patients, which suggests that the trend continues,” he said.

The groups’ DASH scores showed statistically improved scores in the operative group at the two-year mark, Hall said.

The surgical group had bony union at an average 16 weeks. The non-surgical group had union at an average 29 weeks, Hall said.

Complications among the non-operative group included one case of reflex sympathetic dystrophy, three symptomatic malunions, seven non-unions, one secondary compound fracture requiring ORIF and one open fracture. The operative group’s complications included four complaints of local plate irritation, three cases of late-wound dehiscence infection and one wound failure requiring revision fixation.

“Our conclusions were that early operative fixation of completely displaced midshaft clavicle fractures results in improved patient-oriented and surgeon-based outcomes, an earlier return to function and a decreased non-union rate,” Hall said. “This study supports early operative plate fixation of completely displaced midshaft clavicle fractures in young and active individuals.”

(Hall and McKee collaborated with the Canadian Orthopaedic Trauma Society. OTA, DePuy, Inc. and Zimmer, Inc. grants funded the study.)

For more information:
Hall J, McKee M, and the Orthopaedic Trauma Society. A multicenter randomized control trial of non-operative and operative treatment of displaced clavicle shaft fractures. #14. Presented at the Orthopaedic Trauma Association 21st Annual Meeting. Oct. 19-22, 2005. Ottawa.