Operative outcome of displaced medial-end clavicle fractures in adults

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