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Plate fixation deemed safe for acute dislocated clavicle fractures despite high complication rates

Wijdicks F. Arch Orthop Trauma Surg. 2011. doi:10.1007/s00402-011-1456-5.

Issue: April 2012

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A recent systematic review of plate fixation complications associated with treatment of displaced mid-shaft clavicle fractures showed the technique is useful in acute cases, but carries a risk for reoperation due to the implant material, according to a study in Archives of Orthopaedic and Trauma Surgery.

Researchers searched the EMBASE and PUBMED/MEDLINE computer databases for studies with review-reported complications of plate fixation. They found nonunion and malunion rates in those studies that met the inclusion criteria of less than 10% in all but one of the 11 studies they reviewed. Failure rates and plate irritation rates averaged between 9% and 64%. “The vast majority of complications seem to be implant related,” the investigators wrote in the abstract.

Although the technique proved safe for treating dislocated mid-shaft clavicle fractures, added research in the form of prospective trials is needed to better analyze how different plate types and positions affect the implant-related complication rates, the authors noted.

Surgical treatment of mid shaft clavicle fractures has increased recently. The Canadian Orthopaedic Society’s article comparing non operative with plate fixation of displaced mid shaft clavicle fractures was a key article in recent years favoring operative fixation (1). For years, these fractures were mostly treated non operatively. Now more are being treated with plate fixation. This article sought to review the complications associated with plate fixation of displaced mid shaft clavicle fractures (DMCF) by reviewing the current literature.

The articles on treatment of DMCF are of varying levels of evidence and difficult to discern the actual complication rate. The authors found 11 articles which met criteria for review. In all but 1 article, the occurrence of nonunion and malunion was under 10%. However, the hardware complications ranged from 9-64%. Many of these were second surgeries to remove the plate.

The paper brings to light key questions for consideration before jumping on the “Fix the Clavicle” bandwagon. Our patients must be truly informed of all complication rates and the problems with hardware removal and need for a second elective surgery. In addition, the best plate position to minimize hardware complications has not been evaluated in a recent high level evidence study. In addition, some surgeons choose precontoured locking plates. The question if this affects union rates has not been determined.

This article is a nice summary of the current studies and is thought provoking and provides ideas for future research.

References:

• 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 Jan;89(1):1-10.

— Lisa K. Cannada, MD
Associate Professor
Department of Orthopaedic Surgery
Saint Louis Univesity
St. Louis, MO
Disclosure: Cannada has no relevant financial disclosures.

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