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ORIGINAL ARTICLE

Anterior Versus Superior Plating Of Fresh Displaced  Midshaft Clavicular Fractures

 Santosh Venkatachalam*,Chellappan K Sivaji**,Allison Shipton***,Greg J Packer#

* Registrar Trauma and Orthopaedics,Southend University Hospital, Essex, UK
** Associate Specialist, Trauma and Orthopaedics,Southend University Hospital, Essex, UK
***Senior Physiotherapist,Southend University Hospital, Essex, UK
#Clinical Director and Consultant Orthopaedics,Southend University Hospital, Essex, UK

Address for Correspondence:

Mr Santosh Venkatachalam
42 Leafield Close
Birtley,
County Durham,UK,
DH3 1RX

J.Orthopaedics 2007;4(4)e1
 

Introduction:

Clavicle fractures are common in young active adults.  They constitute 2.6% of all adult fractures [1] of which 80% occur in the midshaft of the clavicle [2]. Fractures of the middle third of the clavicle show a rotatory posterosuperior angular displacement of the medial fragment whereby the trapezuis muscle is penetrated and soft tissue interposition prevents fragments from contaction each other. Also, overlap in multiple fragment fractures results in a shortening of the shoulder girdle at the fracture site which leads to poor cosmetic and functional results [3]. In an Allman I [4] fracture, the distal fragment is pulled distally and medially due to the influence of the weight of the upper extremity and the pectorals major muscle, while the proximal fragment is elevated due to the force of the sternocleidomastoid.

 The incidence of non-union in midclavicular fractures is usually quoted as being 0.1-0.8% [5] with non-operative treatment. More recent data, based on detailed classification of fractures, suggest that the incidence of non union in displaced midshaft clavicular fractures is between 10-15% especially in those with an initial shortening of >20 mm [6]. This resulted in unsatisfactory patient outcome in 31% of the study group treated with non operative treatment [7]. There have been many papers published on treatment of established malunion of clavicular fractures and their complications [8]. Previously this was described only as a cosmetic deformity. Malunion with shortening and rotational deformity does not remodel in adults. This can be debilitating for the patient and challenging for the surgeon. Emphasis in literature has been more on non union until Eskola [3] reported that patients with a shortening of greater than 15 mm had statistically significantly more pain. Recent papers have analysed the results of plating of fresh clavicle fractures [9, 10].  

The purpose of this study was to compare the results of anterior versus superior plating of freshly displaced clavicular fractures with an initial shortening of >20mm

Material and Methods :

This is a non randomised retrospective study from 2000-2004. Patients with an acute non-pathological fracture of the midshaft of the clavicle treated surgically at Southend District General Hospital were considered. Inclusion criteria were (i) closed midshaft fracture (ii) Age between 16 to 65 years (iii) Shortening of more than 20 mm measured on initial radiographs. Exclusion criteria were (i) floating shoulder (ii) pathological fracture (iii) Unfit for general anaesthesia (iv) Associated neurovascular injuries. 

 The choice of surface for plating the clavicle was based on the surgeon operating. One of the authors (GJP) preferred to place the reconstruction plates anteriorly. The other consultants plated the clavicle superiorly. 

The timing of the operation was 3.6 days post injury on an average. It was performed under general anaesthesia with patient in beach chair position. A longitudinal incision along the superior border of the clavicle was made. Large branches of the supraclavicular nerves were protected. The fracture was plated with the aim of restoring the clavicular length. Lag screw was used to fix large butterfly fragments. Reconstruction plate was used to fix the fracture with the intention of getting altleast 6 cortices on either side of fracture. They were contoured to the three dimensional anatomy of the clavicle. Post operatively, the limb was kept in a sling and mobilised within pain limits. Patients were discharged by the next day and were followed up at two weeks for wound check, six weeks, three months and six months.  

Continuous normally distributed data was analysed using Chi-square test, T-test, Fisherís exact test using SPSS 10.0 software (SPSS Inc.Chicago Illinois, USA). P value <0.05 was considered significant for the purpose of this study.

Results :

Forty nine patients were included in the study. There were 22 patients in the anterior group (Fig 1) and 27 in the superior group (Fig 2). The mean age in the anterior group was 36.3 years (Range 17-64) and in the superior group was 37.6 years (Range 16-65). There were no demographic differences in the two groups (Table 1). The follow up varied between six months to 24 months. The outcomes were assessed based on complications, Constant score and patient satisfaction questionnaire. 

Table 1- Demographic data

TABLE 1

 

 

Parameter

Anterior group(N=22)

Superior group(N=27)

Male

16

20

Female

6

7

Mean age (yrs)

36.3

37.6

Dominant Arm

17/22 (77.3%)

21/27 (77.7%)

Mech of Injury

 

 

     RTA

14 (63.6%)

21 (77.7%)

    Fall

4 (18.2%)

2 (7.1%)        

    Assault

3 (13.6%)

2 (9.1%)        

    Sports

1 (4.5%)

2 (7.4%)

Employment

 

 

     Light

12 (54.5%)

15 (55.5%)

     Heavy manual

 9 (40.9%)

11 (40.7%)

     Unemployed

1 (4.5%)

1 (3.7%)

Fig.1

Fig.2

Fig.3

Any adverse event or complication was defined as any event necessitating another operative procedure or medical treatment (Table 2). Out of the six patients in whom the plates were removed, five were superiorly placed plates (P value 0.032) and one was anterior. Two patients (P value 0.041) in the superior group had a broken implant (Fig 3) which was replated anteriorly. Two wounds-one in each group, had superficial infection (P value 0.693). The wounds were dressed regularly and healed in two weeks. One patient in the superior group developed deep infection, for which the metal work had to be removed (P value 0.869). The clavicle was replated anteriorly once the infection settled. There were no non-unions/delayed unions/ neurovascular complications/ pulmonary injury /shoulder droop in either group. 

Table 2- Complications

TABLE 2

Anterior group(N=22)

Superior group (N=27)

P value

Hardware removal

5

1

0.032

Hardware failure

0

2

0.041

Superficial infection

1

1

0.693

Deep infection

0

1

0.869

Table 3- Patient satisfaction

TABLE 3

Anterior group(N=22)

Superior group (N=27)

Patient questionnaire

 

 

Scar

 

 

     Excellent

17

20

     Good

2

3

     Fair

1

3

     Poor

2

1

Return to work

22

25

Patient satisfaction

21

26

The results were analysed by a Physiotherapist as a neutral observer with a Biodex machine. Constant score, shoulder range of movements and patient satisfaction with function and scar were assessed. Constant score was used to assess outcome in 37 patients. Since it was impossible to allocate a preinjury score, the injured side was compared to the uninjured side. Among them, 19 patients in the superior group had mean Constant score of 87. The remaining 18 patients in the anterior group had a mean score of 89 (P value 0.784). Rest of the patients were assessed for outcome based on clinical case notes and telephonic questionnaire as they were unable to come for the appointment. 

Patients were asked specific questions about the scar, satisfaction with the operation, level of activity and return to work (Table 3). Three patients (6%) considered the scar as poor out of which one had a scar hypertrophy. Forty seven patients (96%) thought that the operation helped them get back to their work and activities of daily living while two thought the contrary( one from each group) of which one of them had a claim going through. Forty seven patients (Anterior group-21, Superior group-26) felt that they would have the operation on the opposite side if their clavicle fractured.

Discussion :

In this retrospective assessment, we have compared the results of anterior versus superior placement of the plate on the clavicle. Fractures of the clavicle account for 35-45% of shoulder girdle injuries [11]. According to Allman, midshaft fractures are the commonest type of clavicle fractures accounting for 80%. They occur at the site of lowest resistance of the bone, when it passes from a prismatic cross-section to a flattened one.

 

The clavicle does have several important functions, each of which can be expected to alter in non-union and malunion. In treating fractures of middle third of clavicle, several factors should be considered: the patientís age and general condition, sex, fracture comminution, occupation, personality of the patient and other concomitant injuries [12]. Neersí[5] non-union rate of 1% is misleading in that the patient population was mixed with regard to age, clavicular fracture site and severity of fracture. In Robinsonís series [12] the non-union rate was between 4.5-9.5% for type 2B1/2 fractures while in Hillís series [6] 15% developed non-union.  

Shortening of clavicle exceeding 17mm can result in abduction weakness due to a restriction of the scapula in the adducted position by the shortened clavicle [3, 13]. Potential drawbacks of conservative management can be overcome by surgical treatment with the recovery of a normal anatomic profile. 

Displaced fractures of clavicle with shortening of 20mm or more should not be treated the same way as undisplaced or minimally displaced fractures. It is very rare to achieve success with conservative treatment of such fractures. The deforming force of sternocleidomastiod is very strong [14] and cannot be overcome by external supports. 

The use of open reduction in the treatment of fresh fractures remains controversial; with wide geographical and institutional variation in the choice of treatment. There is still a reluctance to treat fresh clavicle fractures with primary internal fixation in significant number of institutions due to problems with operative treatment like operative scar, infection, implant failure and implant removal [15]. 

A recent meta-analysis showed that operative fixation compared to conservative treatment reduces the relative risk of non-union by 86% [9].  Operative fixation allows earlier rehabilitation with a high level of patient satisfaction with respect to shoulder function. Pain relief is faster and there is no problem of immobilisation with shoulder straps. Rigid internal fixation may also allow patients to return to certain occupations and driving earlier.   

The choice of surface for plating of clavicle fractures is not clearly defined.  Conventionally the clavicles are plated on its superior surface. Anterior plating of the clavicle makes the metal work less prominent due to better soft tissue cover. As a result, the need for removal of prominent hardware becomes less. Also the risk of injuring the important neurovascular structures is less while drilling the screw holes from anterior to posterior compared to superior to inferior direction.

We accept that this is a retrospective study and a relatively small series. Further studies to compare surface of choice for clavicular plating in a prospective randomised manner would be useful to substantiate these results. 

In our study, the union rate was 100%. The p values did not reach significance with respect to Constant scores and infection. Majority of patients in both groups were satisfied with the scar as the location of the scar was the same in both groups irrespective of whether the clavicle was plated anteriorly or superiorly. 

The superior group had significantly higher number of hardware failures and hardware removal compared to the anterior group. Placement of the plate anteriorly rather than superiorly on the clavicle yielded better results with regards to these two factors. Hence we recommend anterior plating as a better method of fixation of midshaft clavicular fractures.

Reference :

1. Neer C. Fractures of the clavicle. In: Rockwood CA Jr, Green DP, editors. Fractures in adults. 2nd ed. Philadelphia: Lippincott; 1984. p707-13.

2. Crenshaw AH. Fractures of the shoulder girdle arm and forearm. In: Crenshaw AH, editor. Campbellís operative orthopaedics. 8th ed. St.Louis: Mosby Year book; 1992.p 989-1053.

3. Eskola A, Vaininpaa S. Surgery of ununited clavicle fracture. Acta Orthop Scand 1986; 57:300-70.

4. Allman Jr FL. Fractures and ligamentous injuries of the clavicle and its articulation.  J Bone Joint Surg [Am] 1967; 49-A: 774-84.

5. Neer CS. Nonunion of the clavicle. JAMA 1960:172:1006-11.

6. 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-B: 537-9.

7. McKee MD, Schemitsch EH, Stephen DJ, Kreder HJ, Yoo D, Harrington J. Functional outcome following clavicle fractures in polytrauma patients. J Trauma. 1999; 47:616.

8. Chan KY, Jupiter JB, Leffert RD, Marti R. Clavicle malunion. J Shoulder Elbow Surg. 1999; 8:287-90.

9.Zlowodzki M, Zelle BA, Cole PA, Jeray K, Mckee MD; Evidence-Based Orthopaedic Trauma Working group. Treatment of midshaft clavicle fractures: systematic review of 2144 fractures: on behalf of Evidence-Based Orthopaedic Trauma Working group. J Orthop Trauma. 2005; 19:504-7

10. Nonoperative Treatment Compared with Plate Fixation of Displaced Midshaft Clavicular Fractures. A Multicenter Randomised Clinical Trial By the Canadian Orthopaedic Trauma Society. J Bone Joint Surg Am. 2007; 89:1-10.       

11. Robinson CM. Fractures of the clavicle in the adult. Epidemiology and classification.  J Bone Joint Surg [Br] 1998; 80-B: 476-84.

12. Robinson CM, Court-Brown CM, Mcqueen MM, Wakefield AE. Estimating the risk of non-union following nonoperative treatment of clavicular fracture. J Bone Joint Surg AM. 2004; 86:1359-65.

13. Mckee MD, Pedersen EM, Jones C, Stephen DJ, Kreder HJ, Schemitsch EH, Wild LM, Potter J. Deficits following non-operative treatment of displaced clavicular fractures. J Bone Joint Surg Am. 2006; 88:35-40.

14. Poigenfurst J, Rappold G, Fischer W. Plating of fresh clavicular fractures: results of 122 operations. Injury 1992; 23(4):237-41.

15. Bostman O, Manninen M, Pihlajamaki H. Complications of plate fixation in fresh displaced midclavicular fractures. J Trauma. 1997; 43:778-783.

 

This is a peer reviewed paper 

Please cite as : Santosh Venkatachalam : Anterior Versus Superior Plating Of Fresh Displaced  Midshaft Clavicular Fractures

J.Orthopaedics 2007;4(4)e1

URL: http://www.jortho.org/2007/4/4/e1

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