It is now generally accepted that displaced midshaft clavicle fractures benefit from internal fixation. Plating and intramedullary fixation have become the accepted methods of fixation. The purpose of this study was to see if one method of fixation of clavicle fractures has a lower complication rate and higher union rate compared to the other.

Materials and Methods:

Over the last 9 years the senior author internally fixed 430 midshaft clavicle fractures. 255 of these were with intramedullary fixation using a Rockwood pin and 175 were with plate fixation ranging from a DCP plate to an anatomical plate. All patients were assessed until union looking at scarring and paraesthesia, range of motion, function, and return to normal activity. Any complications were documented and the 2 methods were compared.

Results:

All fractures eventually healed. The intramedullary pins had the higher complication rate. 2 of the pins had a deep infection requiring removal and eventual plate fixation. Other complications included 5 cases of capsulitis, 3 cases of refracture after removal of the pin, non-union requiring revision plating 15/255(6%), and a 10% incidence of irritation from the end of the pin. Of those with plate fixation there were 2 non unions out of 175(1%). There was one bent plate 5 weeks post-op due to football requiring revision plating surgery. There were 2 plates with some backing out of screws and mild plate elevation laterally. Both united with conservative management and no loss of function. There were no deep infections. Patients with plate fixation regained range of motion quicker and earlier normal function compared to the pins.

Conclusion:

Both methods of fixation had a high union rate with plate fixation showing a statistically significant lower rate of non union compared to pinning. The overall complication rate was higher with intramedullary fixation. Plate fixation provided an earlier return to normal function, range of motion and a more predictable result. Plate fixation was possible with all forms of clavicle fractures whereas intramedullary fixation was limited in comminuted fractures, small clavicle canals and osteoporotic bone. This series and patient feedback has changed the way I manage clavicle fractures.

Displaced Mason type II fractures of the radial head are often treated non-operatively. However it has been our experience that a number of patients with these injuries have an unsatisfactory result due to a malunion or nonunion of the radial head. The literature however does not address whether it is worthwhile to perform an osteotomy and reduce anatomically established non-unions or mal-unions of the radial head. Our aim was to assess whether operative management of late presenting displaced fractures of the radial head will improve patients pain and function.

Materials and Methods

We retrospectively reviewed thirty-three consecutive patients who presented late to the senior author’s practice between 2001 and 2008 with isolated symptomatic Mason type II fractures of the radial head. Presentation was between 3 weeks and 10 months post injury. All patients had an obvious malunion or established nonunion of the radial head. These patients then underwent an osteotomy, elevation and anatomical reduction, and internal fixation with or without bone grafting to the radial head. We then evaluated these patients for pre and post-operative pain, elbow range of movement, and function.

Results

In this series there was a statistically significant improvement of elbow range of movement and reduction in elbow pain after the surgical procedure. All radiographs showed established union and the deformity or step in the radial head was improved in all cases. 2 cases required a second arthroscopic procedure post internal fixation. All patients had improved function and were glad they had undergone surgery.

Conclusion

Patients often present late following an injury to the radial head. A non-united or malunited articular fracture with a step or gap with a mechanical block can cause a dilemma regarding whether there will be a benefit in operating at a late stage. There have been no studies addressing this in the literature. Our study suggests that osteotomy, elevation and internal fixation of late radial head fractures can improve patients function, range of motion and decrease their overall pain.

Methods: Over the last 6 months the authors has fixed 35 clavicle fractures in adolescents and females using an anatomical clavicle plate, through a small incision usually adopted for intramedullary devices. The technique involves an incision inferior to the clavicle and about half the size of the plate. As the plate is anatomical the clavicle can generally be reduced onto the plate and the skin elevated on either side of the plate. Follow up was made on all patients until union.

Results: All 35 patients went onto clinical and radiological union within 8 weeks. All scars were between 3.5 and 4.5cm. No significant paraesthesia was noticed. Full range of motion was achieved between 3 to 6 weeks. No plates have been removed due to irritation. Contact sports were allowed at between 6 to 8 weeks. No complications occurred.

Conclusion: That clavicle fractures can be stabilized through a limited incision technique due to new low profile anatomical plates. The incision is also made below the clavicle to decrease irritation under the skin. With this new technique range of motion and function is achieved quickly and reproducibly. This technique has also now been adopted for more complex clavicle fracture patterns.

Adrian K. Low, MBBS, David G. Duckworth, FRACS, and Desmond J. Bokor, FRACS, Sydney, Australia

The results following nonoperative treatment of displaced, medial end clavicle fractures is often unsatisfactory; but no study has yet reported the outcome of operative fixation of these fractures. This study reports the results of open reduction and internal fixation on displaced, medial end clavicle fractures, in five adult patients (aged 25–52 years, mean 43) including 1 patient with a nonunion. The mean follow-up was 3.3 years (8 months-10.3 years). All fractures had united clinically and radiologically. No complications occurred, and no revision surgery was required. VAS pain scores averaged 0.75 (0-2) at rest, 0.75 (0-2) for normal activities, and 1.0 (0-2) for heavy activities. The mean DASH score was 9.0 (0-17), and all patients were very satisfied with the results of surgery (VAS 10). All patients had a full range of motion of their shoulder at final follow-up and were able to return to pre-injury occupational and activity levels. (J Shoulder Elbow Surg 2008;17:751­754.)

Fractures of the medial end of the clavicle in adults are uncommon, accounting for only 2-3% of all clavicle fractures. Traditionally, these fractures have been treated nonoperatively, even when significantly dis­placed, with operative intervention reserved for open fractures, neurovascular involvement, or threatened overlying skin. The literature is sparse on medial end fractures, but the results of available studies suggest that nonoperative treatment of displaced fractures is of­ten unsatisfactory. Some have reported that up to half of all patients are still symptomatic more than a year af­ter injury, while others have shown a nonunion rate approaching 15%. To our knowledge, no study to date has reported on the outcome of operative inter­vention specific for displaced, medial end clavicle frac­tures. This study reports on 5 patients who had open reduction and internal fixation (ORIF) of a displaced, medial end clavicle fracture.

MATERIALS AND METHODS

Adult patients who had ORIF of a displaced, medial end clavicle fracture between 1997 and 2007, were included in this study. A medial end fracture was defined as one which occurred in the medial one-third of the clavicle on radio­graphs. All were closed fractures associated with shortening and deformity. Typically, the lateral end of the clavicle was displaced both anteriorly and slightly superiorly, while the medial end remained within the sternoclavicular joint. Pa­tients with an open physis on radiograph were excluded, as children and adolescents may display different fracture patterns involving the medial growth plate.

A direct surgical approach, centered on the deformity, was used to expose the fracture fragments. The fracture was reduced and fixed primarily with a medial clavicle plate and screws in 4 cases, and stabilized in another only with a screw and sutures because of poor bone stock (Figure 1). Postoperatively, the extremities were immobi­lized in a sling for 2 to 4 weeks, after which gentle motion was allowed until fracture union occurred. In the first 2 to 4 weeks, patients were allowed to use the hand with their elbow by the side for simple daily tasks. The patients were reviewed postoperatively at approximately 1 and 6 weeks and then every 3 to 6 months until they were fully functional. Radiographs were taken until union was con­firmed.

Assessment of shoulder function was carried out postop­eratively. The patient’s pain profile was assessed using a vi­sual analogue scale (VAS), where 0 represented no pain and 10 the worst possible pain. They were asked to record their pain level at rest, with normal activities (such as self-grooming, driving), and with heavy activities (lifting ob­jects). They also rated their satisfaction with the results of their surgery using a VAS, where 0 represented not satis­fied at all and 10 completely satisfied. Functional outcome was evaluated using the DASH (disabilities of the arm, shoulder and hand) questionnaire, which is scored from 0-100, with a higher score representing a higher level of functional disability. Shoulder range of motion was docu­mented and fracture union assessed clinically and radio­graphically.

RESULTS

Five adult patients were identified who had opera­tive treatment for a displaced medial end clavicle frac­ture. All were male with a mean age of 43 (25–52) years. Three were right-hand dominant, and in 4, the injury affected their dominant side. The cause was typ­ically the result of a high energy injury (motorcycle 3, motor vehicle accident 1, rugby 1), and all were iso­lated injuries. Preoperative computed tomography (CT) scans were obtained in 2 patients to assess the amount of anterior displacement. The 3D reconstruc­tions were able to define the deformity accurately in these patients (Figures 1, B and 2, B).

Figure 1 Preoperative (A) x-ray and (B) CT scan. Postoperative (C) x-ray.

In 4 cases, the fracture was acute and fixed within 2 weeks of the injury. One patient, however, presented with a painful, hypertrophic nonunion 9 months after the injury. This fracture was stabilized after taking down the hypertrophic nonunion and fixing the frac­ture with a plate, screws, and local bone graft (Fig­ure 2).

The mean follow-up was 3.3 years (8 months-10.3 years). All fractures united clinically and radiographi­cally. No complications occurred, and 1 patient had a second surgery for voluntary hardware removal 6 months after surgery, despite being asymptomatic. All patients had a full range of motion in the shoulder at last review. The mean VAS pain scores were 0.75 (0-2) at rest, 0.75 (0-2) with normal activities, and

1.0 (0-2) with heavy activities. The mean DASH score was 9.0 (0-17), and all patients were very satisfied with the results of surgery (mean VAS 10). All patients had managed to return to their previous occupation and activity levels.

DISCUSSION

Indications for surgery on medial end clavicle frac­tures have traditionally only included open fractures, neurovascular involvement, or with a threat to the in­tegrity of the overlying skin, even in the presence of significant displacement. Unsatisfactory results follow­ing nonoperative treatment of displaced, medial end fractures have influenced some surgeons to include these fractures as an indication for internal fixation. However, due to the rarity of this fracture, only 1 study to date has reported solely on medial end clavicle fractures, and none is available with results following op­erative fixation.

Recently, Throckmorton et al reviewed 57 medial end clavicle fractures retrospectively in 55 patients that presented to a level 1 trauma center. Treatment was nonoperative, except in 4 where an open frac­ture was present. The majority was the result of high energy trauma, such as motor vehicle accidents, and this finding was supported by our study and others. Ninety percent of their patients sustained multisystem injuries with an associated 20% mortality rate. Medial end fractures comprised 9.3% of all their clavicle fractures, a higher incidence than that reported previously. This was accounted for by the higher use of CT scans in the trauma setting, where 22% of fractures were seen only on CT scans, but not on radiographs. CT scans can also be useful for determining the amount of displacement, espe­cially in the coronal plane, which may not be readily seen on chest x-rays alone (Figures 1 and 2). In their study, 44% of medial end fractures were minimally displaced (<2mm), 23% had 2-10 mm, and 33% had >10 mm of displacement. Disappointingly, after a mean of 15.5 months, the majority of patients still reported mild (25%), moderate (22%), or severe (6%) pain.

Figure 2 Nonunion. Preoperative (A) x-ray and (B) CT scan. Postoperative (C) x-ray.

The nonunion rate following nonoperative treat­ment of medial end fractures is difficult to determine, as studies have been limited by the small number of patients in reported series. However, most studies have suggested a poorer outcome when displaced medial end fractures are treated nonoperatively. In a prospective series of 222 consecutive clavicle frac­tures, fracture displacement was found to be the stron­gest radiographic risk factor for sequelae. The authors identified 4 (2%) medial end fractures, and af­ter 6 months, half of these (2 patients) still complained of weakness and pain at rest and with activity. One patient had a nonunion. In a prospective study of 868 consecutive clavicle fractures treated nonopera­tively, only 24 (2.76%) involved the medial end with the rate of nonunion higher for displaced (14.3%) than for nondisplaced fractures (6.7%). In contrast, one study reported good results with nonop­erative treatment. In 1000 consecutive clavicle frac­tures, all medial end fractures (n ¼ 28, 2.8%) united with only one requiring later surgery for a bony prom­inence. However, only 5 fractures had been consid­ered displaced. In both of these studies, the authors concluded that fracture displacement significantly in­creases the risk of delayed and nonunion for diaphy­seal and lateral end clavicle fractures, but the numbers were too small to make conclusions on me­dial end fractures.

The treatment of clavicle nonunions can be chal­lenging, and the literature is sparse in this area. In a se­ries of 20 clavicle nonunions,1 the only medial end nonunion healed after internal fixation with a lag screw and bone graft. However, the patient still com­plained of severe pain after 32 months. In our study, the patient who had fixation of a nonunion did very well after 8 months of follow-up. He complained of no pain other than with heavy lifting, had a full range of shoulder movement, and had returned to full-time work. In conclusion, although limited by the small number of cases, our study has shown that early fixation of dis­placed medial end clavicle fractures can result in ana­tomic reconstruction of the clavicle and a favorable outcome with minimal complications as measured us­ing VAS and DASH scores. Deformity is minimized