Raffy Mirzayan, MD

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July 18, 2006

Editorial Collaboration

Medscape &

The clavicle links the upper extremity to the appendicular skeleton and is stabilized by a series of strong ligaments medially and laterally. In the United States, clavicle fractures account for 5% of fractures seen in emergency departments. Approximately 80% of fractures are in the middle third; 15% are in the lateral third; and 5% involve the medial third. Historically, clavicle fractures have been treated nonoperatively with good functional outcomes. Nonoperative management usually includes a figure of 8 brace or a sling. Surgical intervention was reserved for certain limited situations, including open fractures, tenting of the skin by a sharp clavicle edge, neurovascular injury, and in association with a glenoid/scapula fracture ("floating arm").

There have been studies reporting a high dissatisfaction rate with outcomes of the nonoperative treatment of clavicle fractures.[1,2] In addition, there have been advances made in the fixation of clavicle fractures, including anatomic precontoured plates, locking plates, and intramedullary rods. As a result, there has been a renewed interest in fixing clavicle fractures in order to allow for early return to activities and to obtain higher patient satisfaction.

Operative vs Nonoperative Therapies

At the American Academy of Orthopaedic Surgeons 2006 Annual Meeting, March 22-26, Chicago, Illinois, Hall and coworkers[3] presented a paper entitled "A Multicenter Prospective Randomized Clinical Trial of Non-operative Versus Operative treatment of Midshaft Clavicle Fractures." The study authors compared patient-oriented outcomes scores following nonoperative vs operative treatment of displaced midshaft clavicle fractures. The patients were randomized through a sealed envelope. Nonoperative treatment was with a sling. The sling was continued until the patients' symptoms resolved. The operative patients were treated with open reduction and internal fixation with small fragment plates and screws. Constant Shoulder Score; Disability of the Arm, Shoulder, and Hand (DASH) score; and SF-36 scores were collected at 6 weeks and 3, 6, and 12 months. Seventy-two of 120 patients had at least 1 year of follow-up. There were 25 men in the nonoperative group (N = 35) with an average age of 32. There were 14 dominant fractures in this group. There were 23 men in the operative group (N = 37) with an average age of 34.5 years. There were 21 dominant fractures in this group. The Constant Shoulder Score and DASH scores were statistically better in the operative group at all measured time points (P = .001 and P = .021, respectively). Complications in the nonoperative group included a patient with reflex sympathetic dystrophy, 2 with symptomatic malunions, and 6 patients with nonunions requiring open reduction internal fixation. In the operative group, 2 patients complained of plate irritation and 1 patient had a late wound dehiscence. The study authors concluded that operative treatment provided statistically significant clinical and functional improvement over nonoperative treatment of displaced midshaft clavicle fractures.

Impact of Delayed Repair

Another study presented sought to determine whether a delayed repair of displaced clavicle fractures negatively affected shoulder strength or outcomes. J. Potter, MD, and colleagues[4] presented a paper entitled "Immediate Fixation Versus Delayed Reconstruction of Displaced Midshaft Fractures of the Clavicle." The patients all had completely displaced midshaft clavicle fractures. They were closed and isolated fractures. Fifteen patients underwent open reduction and internal fixation with a compression plating technique. The surgery was performed at a mean of 0.6 months after the injury. Another 15 patients underwent delayed reconstruction with open reduction and compression plating for nonunion or malunion at a mean of 58 months after the injury. At a mean of 25 months post operation, an assessment, including the DASH, Constant scores, and objective muscle strength and endurance testing, was performed. There were no significant differences between acute fixation and delayed reconstruction groups with regard to shoulder abduction (P = .75), strength of shoulder flexion (P = .56), internal rotation (P = .87), or external rotation (P = .29). However, there was a trend for improved Constant scores (P = .12) and DASH scores (P = .10) in the group that underwent acute fixation. In a subset of each group tested for endurance, delayed fixation led to a significant decrease in muscle endurance with regard to shoulder flexion (P = .007). The study authors concluded that late reconstruction of nonunion or malunion following displaced midshaft clavicle fractures resulted in the restoration of objective muscle strength similar to that seen with acute fixation. However, there was a significant loss in muscle endurance as well as a trend toward a decrease in outcomes scores (DASH, Constant) following late reconstruction.

Treating Humeral Shaft Fractures

Much like clavicle shaft fractures, controversy exists over operative vs nonoperative treatment of distal third humeral shaft fractures. Nonoperative treatment is the accepted means of treatment.[5] However, functional bracing can be associated with skin problems and varying degrees of angular deformity. Healing, motion, and function are usually excellent. Operative treatment achieves more predictable alignment and potentially quicker return of function, but risks for iatrogenic radial nerve injury and reoperation rates. Operative indications include open fractures, radial nerve palsy occurring after a closed reduction, nonunions, and malunions. Radial nerve palsy is the most common complication seen in distal third humeral shaft fractures.

A. Jawa, MD, and colleagues[6] presented a paper entitled "Distal Third Diaphyseal Humerus Fractures: Operative vs. Non-operative Treatment" to compare the treatment of distal third diaphyseal humerus fractures with either functional bracing or plate and screw fixation. Thirty-four consecutive patients with closed, extra-articular fractures of the distal one third of the humeral shaft were extracted from a prospective trauma database. Seventeen were treated with functional bracing and 17 were treated with plate and screw fixation. The patients in the 2 groups were comparable in regard to their demographic data, with the main difference being the preference of the treating surgeon. Pretreatment radial nerve palsy was present in 5 patients treated operatively and 2 patients treated with functional bracing. All of the injury-related radial nerve palsies recovered completely in both groups. In the surgically treated group, 1 patient had early loosening of fixation and 1 had nonunion. Both patients healed after repeat plate fixation and bone grafting. Two new postoperative radial nerve palsies developed and had not recovered. One of these patients was treated with tendon transfers. One new postoperative ulnar nerve palsy developed but resolved without intervention. All fractures ultimately healed in anatomic or near-anatomic alignment with full or near-full range of motion of the elbow. Among patients treated nonoperatively, all fractures healed. Only 1 patient had greater than 30° of malalignment in any plane. One patient developed skin breakdown during treatment and completed treatment in a sling. Only 1 patient lost greater than 10° of elbow or shoulder motion. The study authors concluded that operative treatment achieves more predictable alignment and a potentially quicker return of function, but has higher risks for iatrogenic nerve injury and reoperation. Functional bracing can be associated with skin problems and varying degrees of angular deformity, but healing, motion, and function are usually excellent.

The Challenge of Intra-articular Fractures

Unlike extra-articular distal humerus fractures, intra-articular fractures can be challenging fractures to treat. The standard of care is to perform open reduction and internal fixation of these fractures in order to achieve anatomic reduction of the articular surfaces to prevent premature arthrosis. The majority of studies report excellent or good short-term results of open reduction and internal fixation of intra-articular (AO Type C) distal humerus fractures. Reports on long-term results of operative treatment of complex intra-articular distal humerus fractures are limited. J. van Duijn, MD, and coworkers[7] presented a paper entitled "Intra-Articular Distal Humerus Fractures: 12-30 Years Follow-Up."

The objective of this study was to assess the long-term (12-30 years) clinical and radiologic outcomes of surgically treated intra-articular distal humerus fractures (type C) with standardized outcomes measures. A total of 31 patients were evaluated after an average of 19 years (range, 12-30 years). There were 19 men and 12 women with an average age of 35 years (range, 13-64 years). Eleven of 31 (36%) patients had polytrauma. After a standard posterior approach with (n = 20) or without (n = 11) olecranon osteotomy, internal fixation was achieved with unicolumnar or bicolumnar plates and screws, or isolated screws and/or Kirschner wires. None of the ulnar nerves were transposed during the index procedure. Patients were hospitalized for an average of 19 days (range, 1-99 days). After a mean follow-up of 19.4 years, the sagittal motion arc averaged 100° (range, 0°-140°). Forearm rotation arc averaged 165° (range, 140°-180°). The American Shoulder and Elbow Surgeons (ASES) score averaged 91 points (range, 69-100 points) with a reported satisfaction of 88% (range, 36% to 100%) at final follow-up. Mayo Elbow Performance Index (MEPI) scores averaged 91 points (55-100). All elbows were rendered stable at final follow-up. ASES pain scores averaged 22 points out of 50 (8-25) (0 = no pain). The mean DASH score was 7 points (range, 0-57 points). The categoric rating of the MEPI score was excellent in 19 patients (63%), good in 9 patients (30%), fair in 1, and poor in 1. These last 2 patients rated their pain as 21 and 34 points. Both of these patients had significant arthrosis. DASH scores were 66 and 22 points. Eighty-six percent of the patients had arthrosis. Arthrosis did not correlate with the reported pain. Ten patients had to have subsequent procedures. The study authors concluded that open reduction and internal fixation of type C intra-articular distal humerus fractures are safe and effective. After successful operative repair, satisfactory long-term results are to be expected. Arthrosis was present in the majority of cases but did not seem to impair function and did not attribute to subjective pain assessment.

References
  1. 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;79B:537-539.

  2. Lazarides S, Zafiropoulos G. Conservative treatment of fractures at the middle third of the clavicle: the relevance of shortening and clinical outcome. J Shoulder Elbow Surg. 2006;15:191-194.

  3. Hall J, McKee MD, Wild L, Schemitsch EH. A multicenter PRCT of non-operative versus operative treatment of midshaft clavicle fractures. Program and abstracts of the American Academy of Orthopaedic Surgeons 2006 Annual Meeting; March 22-26, 2006; Chicago, Illinois. Paper 068.

  4. Potter JM, McKee MD, Schemitsch EH, Wild L, Jones C. Immediate fixation versus delayed reconstruction of displaced mid-shaft fractures of the clavicle. Program and abstracts of the American Academy of Orthopaedic Surgeons 2006 Annual Meeting; March 22-26, 2006; Chicago, Illinois. Paper 069.

  5. Sarmiento A, Kinman PB, Galvin EG, Schmitt RH, Phillips JG. Functional bracing of fractures of the shaft of the humerus. J Bone Joint Surg Am. 1977;59A:596-601.

  6. Jawa A, Ring DC, McCarthy P, Harris MB. Distal third diaphyseal humerus fractures: operative vs. non-operative treatment. Program and abstracts of the American Academy of Orthopaedic Surgeons 2006 Annual Meeting; March 22-26, 2006; Chicago, Illinois. Paper 072.

  7. van Duijn JP, Doornberg JN, Kloen P, Raaymakers EL, Marti RK, Linzel DS. Intra-articular distal humerus fractures: 12-30 years follow-up. Program and abstracts of the American Academy of Orthopaedic Surgeons 2006 Annual Meeting; March 22-26, 2006; Chicago, Illinois. Paper 073.

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