Dr. David Sheps (biography and disclosures)
What I did before
During my residency training (Saskatchewan 1997 – 2002), the traditional teaching around mid-shaft clavicle fractures was that these fractures were best left alone, as surgical management was felt to be fraught with complications and poor outcomes. It was only the rare open fracture, or fracture with a risk of skin compromise, that was treated surgically. The most common method of treatment was benign neglect, and for the most part these patients only reappeared when a non-union of the fracture was clearly established, which historically was felt to occur less than 1% of the time.1, 2
What changed my practice
As I began my own shoulder practice in 2006, it was becoming apparent that a number of shoulder and trauma surgeons had begun to question whether benign neglect was indeed appropriate for a fracture that commonly had both displacement and shortening, and when healed, often left an individual with a cosmetic and potentially functional deformity. Furthermore, review of prospective studies of the non-operative treatment of these fractures demonstrated higher rates of non-union (15% to 20%), objective shoulder strength loss (18% to 33%), and higher rates of residual sequelae at six months post-injury (42%) then originally thought.4-6 Theoretically, when one thinks about how the position of the scapula changes with a mal-united and shortened clavicle (it becomes more protracted), reestablishing the length of the clavicle may have the same impact on function as restoring the length of a distal radius in the setting of a shortened distal radius fracture.
Mid-shaft clavicle fractures are most common in young, active males, and a rapid return to function and early union are seen as a priority when treating this fracture. As a result, operative osteosynthesis had the potential to achieve these aims, while minimizing the potential for either nonunion or symptomatic malunion.3 The question then arises, when a patient with a displaced mid-shaft clavicle fracture presents to you, is there a need to consider a referral for surgical management, or can you continue to treat these patients non-operatively as has been done for many years.
Between 2007 and 2010, six randomized clinical trials comparing the non-operative and operative treatment of mid-shaft clavicle fractures were completed.7-12 These studies were assessed as part of a meta-analysis completed in 2012, which included 412 patients.3 All of the included patients had completely displaced mid-shaft clavicle fractures, and there was a preponderance of young (25-41), male patients. The risk of complications was higher in the non-operative group compared to the operative group, as was the risk of a non-union or symptomatic mal-union. One of the six studies demonstrated significantly better pain scores at five, nineteen, and thirty three days post-injury, and a return to moderate function at sixteen days in 80% of the operative group compared to 55% on the non-operative group.10 The meta-analysis concluded that the operatively treated group had a significantly lower rate of non-union and symptomatic mal-union and an earlier functional return.3
In addition to the clinical data supporting operative management, a recent study compared the economic impact of operative treatment of mid-shaft clavicle fractures. Although one would assume that operative treatment is more costly than non-operative treatment, when considering the overall economic impact, Althausen et al. demonstrated that operative management lead to an earlier return to work, less consumption of pain medication, and required less physiotherapy. Despite a higher hospital bill in an American setting, operative treatment resulted in an average cost saving of just over five thousand dollars per patient compared to non-operative treatment.13
What I do now
Operative management of mid-shaft clavicle fractures is not for every patient, and it remains important to discuss the risks and benefits of the treatment alternatives with the patient. Non-operative management continues to be an appropriate alternative, and can lead to a positive outcome in a number of patients. When selecting non-operative treatment, it is important to immobilize the shoulder in a sling until early fracture union is apparent (roughly three to six weeks). However, with the continued refinement of clavicle-specific implants, operative management of the displaced and shortened mid-shaft clavicle fracture may give a superior outcome in the carefully selected patient. As a primary care or emergency physician, awareness of the alternatives, and the potential benefits of the operative alternative, is important in the management of this common injury.
Resource:
Archived webinar: Highlights from WorkSafeBC’s 2012 Physician Education Conference: Common Shoulder Conditions with Dr. David Sheps: view recording
References: (links may require login with CPSBC or UBC)
- Neer CS 2nd. Nonunion of the clavicle. J Am Med Assoc. 1960;172:1006-11. (Request from CPSBC)
- Rowe CR. An atlas of anatomy and treatment of midclavicular fractures. Clin Orthop Relat Res. 1968;58:29-42. (Request from CPSBC)
- McKee RC, Whelan DB, Schemitsch EH, McKee MD. Operative versus nonoperative care of displaced midshaft clavicular fractures: a meta-analysis of randomized clinical trials. J Bone Joint Surg Am. 2012;94:675-84. (View with UBC or Request from CPSBC)
- 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;79:537-9. (View article)
- McKee MD, Pedersen EM, Jones C, Stephen DJ, Kreder HJ, Schemitsch EH, Wild LM, Potter J. Deficits following nonoperative treatment of displaced midshaft clavicular fractures. J Bone Joint Surg Am. 2006;88:35-40. (View with UBC or Request from CPSBC)
- Nowak J, Holgersson M, Larsson S. Sequelae from clavicular fractures are common: a prospective study of 222 patients. Acta Orthop. 2005;76:496-502. (View article)
- Canadian Orthopaedic Trauma Society. Non-operative treatment compared with plate fixation of displaced mid-shaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am. 2007;89:1-10. (Request from CPSBC)
- Virtanen KJ, Paavola MP, Remes VM, Pajarinen J, Savolainen V, Bjorkenheim JM. Non-operative versus operative treatment of mid-shaft clavicle fractures: a randomized controlled trial. Read at the 75th Annual Meeting of the AAOS; 2010 Mar 9-12; New Orleans, LA. Paper no 331.
- Smith CA, Rudd J, Crosby LA. Results of operative versus non-operative treatment for 100% displaced mid-shaft clavicle fractures: a prospective randomized clinical trial. Read at the 16th Annual Open Meeting of the American Shoulder and Elbow Surgeons; 2000 Mar 18; Orlando, FL. Paper no 31.
- Witzel K. Intramedullary osteosynthesis in fractures of the mid-third of the clavicle in sports traumatology. Z Orthop Unfall. 2007;145:639-42. (View with UBC or Request from CPSBC)
- Judd DB, Pallis MP, Smith E, Bottoni CR. Acute operative stabilization versus non-operative management of clavicle fractures. Am J Orthop (Belle Mead NJ). 2009;38:341-5.
- Smekal V, Irenberger A, Struve P, Wambacher M, Krappinger D, Kralinger FS. Elastic stable intramedullary nailing versus non-operative treatment of displaced mid-shaft clavicular fractures-a randomized, controlled, clinical trial. J Orthop Trauma. 2009;23:106-12. (Request from CPSBC)
- Althausen PL, Shannon S, Lu M, O’Mara TJ, Bray TJ. Clinical and financial comparison of operative and non-operative treatment of displaced clavicle fractures. J Shoulder Elbow Surg. 2013 May;22(5):608-11. (Request from CPSBC)
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This was the way my cycling related clavicular # was handled. I am very satisfied with the result.
I guess I will be referring a lot more clavicular fractures to my Ortho colleagues to make this judgement call. Great article!
My original fracture (bike accident) was treated “conservatively”, with ORIF only done 8 months later after the inadequately healed fracture went POP while swimming backstroke 6 months post accident. Rehab after surgery was much easier and strength and ROM notably better after ORIF than after original conservative treatment. Even considering an unpleasant reaction to general general anaesthesia, I would much prefer to have had the ORIF right away.
very useful. Thank you
It would have been helpful if the article had been more clear on what indications might lead to a referral for operative treatment of a clavicular fracture.
I will definitely discuss all of the mid-shaft clavicular fractures I see in the ED with ortho. I also appreciate the responses by colleagues who have sustained this injury and found operative intervention worthwhile.
My general indications are 1 cm of shortening or displacement superiorly of the medial fragment greater than one width of the diameter of the clavicle. The other relative indication is unacceptable cosmetic shortening. I will often tell a patient to look in the mirror with their shirt off and if they do not like the appearance of their shoulder with the medial displacement due the shortening of the clavicle then that can be corrected with surgery (although they are trading a bump for a scar). Done well, the recovery is much quicker and I often have people back to medium work within two weeks and heavy work within four.
I disagree with the immobilization portion of this
I immobilize for comfort but not with any dreams that immobilization will improve repair. I tell patients if it hurts they shouldn’t do that yet. I give them some very basic shoulder movement exercises to do to keep the shoulder from becoming stiff. I do refer those with the indications listed as above I just try to be a minimalist with immobilization, except to treat discomfort.
As a community orthopedic surgeon I think this article is potentially misleading and doesn’t reflect the practice of most community orthopods who the readers will interact with.
The author is a sub specialist shoulder surgeon who, while he may do general call, likely sees a selective subset of patients who have failed non operative treatment. His use of the term benign neglect is misleading since it is not neglect but non operative treatment.
The evidence for operative intervention is not robust and essentially applies to significantly shortened (> 2 cm not 1 cm)) fractures. The complications related to operative treatment including hardware failure and infection are difficult to deal with and the rate of nonunion in nonoperative treatment is extremely low. Further, any patient who tells me he wants surgery to return to work or vigorous activity within 2-4 weeks is a red flag for treatment complications such as hardware failure and I would not treat him operatively.
Interesting article on a procedure that has usually not been readily available in most urban orthopaedic centres. The author mentions that one out of six studies noted significant pain relief in the operative group. Does this mean that the other 5 studies did not find this? Most clavicular fractures seem to do well with conservative (benign neglect?) treatment, but it can be difficult getting a consult on the cases that may need consideration of surgery
I appreciated the whole article. A patient of mine has had a bad outcome because of a missed, for a long time, dislocation of a sternal-clavicular joint in an over the handlebars bicycle accident. His shoulder hit the open car door which opened suddenly in front of him. He was assessed at the ER, xrays taken of the shoulder, but not the medial clavicle, and seen by myself and many visits to a physiotherapist before the dislocation was finally diagnosed. Language barriers may have played a small role in missing this. I had not ever heard of such a thing happening. Now the vascular and orthopedic surgeons are leery to operate, but it is a tragedy for this young athlete.