Clavicle fractures: Are we overtreating?
Hitesh Gopalan U
Editor, www.orthopaedicprinciples.com
In the Blog @ Orthopaedic Principles
It has been well described that we need to fix clavicle fractures that are open, those that are at risk for impending skin compromise, associated neurovascular injuries, floating shoulder. But the entire scenario changed when the COTS (Canadian Orthopaedic Trauma Society), RCT was published in 2007. The study concluded “Operative fixation of a displaced fracture of the clavicular shaft results in improved functional outcome and a lower rate of malunion and nonunion compared with nonoperative treatment at one year of follow-up”. They added up indications like more than 2 cm shortening or displacement as yet ‘another indication’ for surgery. Now this is a level 1 study from a reputed group. And suddenly there has been a global explosion of clavicle surgeries. Every implant company has an anatomic plate for superior as well as antero inferior plating.
Leroux and colleagues,(JBJS A, July 2014), again from Toronto, looked at 1350 patients who were operated for clavicle fractures. One in four patients (24.6%) underwent at least one clavicle reoperation. The most common reoperation was isolated implant removal (18.8%).A reoperation secondary to nonunion, deep infection, and malunion occurred in 2.6%, 2.6%, and 1.1% of the patients after a median of six, five, and fourteen months, respectively. Incidence of major complications included nonunion (2.6%), deep infection (2.6%), pneumothorax, (1.2%), and malunion (1.1%). Risk of reoperation was increased in female patients and in those with major medical comorbidities. Surgeon inexperience was another risk factor for reoperation.
One of the authors of the COTS Trial, once said, that he gets calls from colleagues such as “I fixed an 87 year old lady with clavicle fracture, and she did not perform very well”. The author says that this is a clear extrapolation of indications and one should not create “myownindications”( a precursor for myorthoindications.com) . What the COTS trial wanted to say was that you can justify operating a clavicle fracture in a young man with 2 cm or more displacement!! But probably the COTS never knew that they are gonna create “fixallclavicle” surgeons.
The study by Leroux is a must read for all surgeons who operate on clavicle fractures. It is imperative to understand that surgery for a clavicular nonunion is no different from surgery on an acute clavicle fracture and you can always treat a nonunion when u detect it. On the other hand you can always justify your surgery using the term “shared decision making”, where you can discuss the pros and cons of surgery with the patient at lengths. !
Are you a Trauma surgeon? Write your comments below.
Ref
1. http://www.ncbi.nlm.nih.gov/pubmed/17200303
2.http://www.ncbi.nlm.nih.gov/pubmed/24990977
I think surgical indication for fracture clavicle are well mentioned by u. The displacement of more than 2 cm is difficult to calculate, and it should be measured after applying the clavicular brace. By and large clavicle fracture can be reduced and maintained till union by conservative means in more than 90 % cases.
However unless there is impending skin compromise, associated neurovascular injuries, or floating shoulder, I would prefer to conserve. If fracture goes in nonunion and if it is symptomatic the I will operate. This strategy I have been following last 45 years & recent inclination towards fixation of fracture has not changed my ideas.
Prof Sudhir Babhulkar
Nagpur
Another level 1 paper in JBJS A 2013 by CM Robinson, http://jbjs.org/content/95/17/1576
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“Open reduction and plate fixation reduces the rate of nonunion after acute displaced midshaft clavicular fracture compared with nonoperative treatment and is associated with better functional outcomes. However, the improved outcomes appear to result from the prevention of nonunion by open reduction and plate fixation. Open reduction and plate fixation is more expensive and is associated with implant-related complications that are not seen in association with nonoperative treatment. The results of the present study do not support routine primary open reduction and plate fixation for the treatment of displaced midshaft clavicular fractures.”
Yes
I totally agree with Dr Babhulkar. I have been following the same methodology since 40yrs. Absolute surgical indications are well described in Campbell operative book.
Those who are treating this fracture surgically routinely, I am afraid they have other motive
The situation in clavicle fractures can be compared to shoulder dislocation. There are reports that we can reduce the incidence of recurrent dislocation of shoulder by operating on all the primary shoulder dislocation. But we all know that is not justified. Not all dislocations go on to become recurrent and not all clavicle fracture become “symptomatic nonunions”. Operating on all clavicle fractures amounts to overkill. The real benefits of surgery for clavicle fractures should be weighed against the risks of surgery in general, the complications of surgery and the potential need for implant removal. Conservative treatment is usually more cosmetic and easy for the patient and the surgeon
Dr Ravi Mittal,
Professor,
AIIMS, New Delhi