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 Table of Contents  
A RETROSPECTIVE STUDY
Year : 2022  |  Volume : 5  |  Issue : 2  |  Page : 110-114

Functional outcome of mid-shaft clavicle fracture treated with precontoured superior plate placement: A retrospective study


Department of Orthopaedics, IGIMS, Patna, Bihar, India

Date of Submission12-Jan-2022
Date of Decision25-Feb-2022
Date of Acceptance06-Mar-2022
Date of Web Publication28-May-2022

Correspondence Address:
Ashish Kumar Arya
Department of Orthopaedics, IGIMS, Patna, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jodp.jodp_5_22

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  Abstract 


In the olden days, clavicle fractures have been treated with conservative management like strapping and bed rest. Fractures of the clavicle are one of the most common injures of the human skeleton. This study was undertaken to observe the rate of union, functional outcome and complications of fracture middle third clavicle treated with open reduction and internal fixation (ORIF) with precontoured superior plate placement. Methods: A total of 30 patients were operated with anatomical precontoured plates from December 2018 to December 2020 and functional outcomes were assessed through 6 months. Results: A total of 30 patients were included in the study. There were 27 males and 3 females. The mean age of the patient in the ORIF group was 31.03 years (age between 20 and 50 years). The mean time to union was 15 weeks. In our study, none of the patients had nonunion, implant failure and infection. Four patients developed scar hypertrophy, Three patients developed hypoesthesia below the incision site and one patient developed screw loosening. Conclusion: It is possible to obtain a good fracture union, less soft tissue stripping and good patient satisfaction with superior plate placement for fracture middle third clavicle.

Keywords: Clavicle fracture, middle third, open reduction and internal fixation, precontoured, superior placement


How to cite this article:
Chandan K, Kumar S, Arya AK, Kumar R, Verma PK. Functional outcome of mid-shaft clavicle fracture treated with precontoured superior plate placement: A retrospective study. J Orthop Dis Traumatol 2022;5:110-4

How to cite this URL:
Chandan K, Kumar S, Arya AK, Kumar R, Verma PK. Functional outcome of mid-shaft clavicle fracture treated with precontoured superior plate placement: A retrospective study. J Orthop Dis Traumatol [serial online] 2022 [cited 2022 Jul 3];5:110-4. Available from: https://jodt.org/text.asp?2022/5/2/110/346219




  Introduction Top


Clavicle fracture is a common fracture and constitutes approximately 4% of all fractures in adults.[1] They are common injuries in young, active individuals, especially those who participate in activities or sports where high-speed falls (bicycling, motorcycles) or violent collisions (football, hockey) are frequent.[2] Clavicle fracture is a common traumatic injury around the shoulder girdle due to their subcutaneous position. It accounts for approximately up to 44%–66% of injuries to the shoulder girdle.[3] About 70%–80% of these fractures are in the middle third of the bone and less often in the lateral third (12%–15%) and medial third (5%–8%). Fractures of the clavicle have been conventionally treated nonoperatively. [4,5] Although many methods of closed reduction have been described, it is recognized that reduction is practically impossible to maintain and a certain amount of deformity and disability is expected in adults. In the past few years, several publications have described poor outcomes like malunion and nonunion after conservative treatment of severely displaced clavicular fractures. Operative fixation of a displaced fracture of the clavicle shaft results in improved functional outcomes and a lower rate of malunion and nonunion compared with nonoperative treatment.[6],[7] The goal of the treatment was to obtain a healed, well-aligned fracture, pain-free with functional range of motion of the shoulder while minimizing complications. The purpose of this study was to assess the functional outcome of midshaft clavicle fracture treated with precontoured superior plate placement.


  Methods Top


After the institution's Ethics Committee approval and patient consent, a retrospective study was conducted. A total of 30 patients were enrolled in this study, who were operated between December 2018 and December 2020 and reviewed for 6 months and functional outcomes were assessed. The material for this study comprised patients with closed displaced middle third fracture clavicle (Robinson's Type 2B[8]) of age between 20 and 50 years without any neurovascular deficit or floating shoulder seen in emergency department and outpatient department (OPD). Immediately, after admission and investigation, all patients were operated within 1 week of trauma. In this study Robinson's classification was followed. Radiographs were taken to determine fracture type, postoperative assessment of fracture reduction, implant position, and fracture union.

Surgical technique

After all preoperative investigations and anesthesia clearance, the patient was positioned supine with one towel in between the scapula under general anesthesia. About 8–10 cm incision was made in the anterior aspect centring over the fracture site [Figure 1]. The skin subcutaneous tissue and platysma were divided. The supraclavicular nerves were looked for. The overlying fascia and periosteum were divided. The bony ends were freed from surrounding tissue. Minimal soft tissue and periosteum dissection was done [Figure 2].
Figure 1: Skin incision

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Figure 2: Fracture site exposed

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Fracture fragments were reduced and fixed with Indian made precontoured Titanium plate over the superior aspect of the clavicle and fixed with screws [Figure 3]. Wound was closed in layers without suction drain. Postoperatively, wound dressing was done on the 2nd and 5th postoperative days. All patients were discharged after 5 days of surgery with arm sling pouch and suture removal done on the 12th postoperative day days on OPD review [Figure 4].
Figure 3: Fracture fixed with precontoured plate

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Figure 4: Postoperative wound condition

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  Results Top


A total of 30 patients were included in the study of which 27 patients were male and three patients were female. The mean age of the patient was 31.03 years (Age between 20 and 50 years).

The most common mode of injury was RTA (41.50%). 16 patients had left sided and 14 patients had right sided fracture of clavicle. In this study, Robinson's classification[8] was followed. The most common fracture type was Type 2B1 (56.6%) [Figure 5]. All patients were operated as early as possible after stabilizing the patients. The mean time to treatment from injury was 5.4 days. All the patients with fracture midshaft clavicle were fixed with a 3.5 mm titanium anatomical precontoured plate placed over the superior surface of the clavicle and fixed with locking screws. Six hole plate was used in the majority (46.42%) of the patients followed by 7 hole plate (28.57%) [Figure 6]. Mean time of union was 15 weeks [Table 1].
Figure 5: Preoperative X-ray

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Figure 6: Immediate postoperative X-ray

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Table 1: Studies where duration of union were compared

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Four patients developed scar hypertrophy; one patient presented with screw prominence due to loosening of a single screw and three patients developed mild sensory paraesthesia at the incision site. There was no implant breakage, implant pull out, deep infection, and septic loosening in any patients in this study.

The functional outcome is assessed wby Constant and Murley score[9] at 6 months. About 85.71% of patients had excellent and 14.28% of patients had good outcomes.


  Discussion Top


Traditionally, clavicle fractures were usually treated conservatively. In a study conducted by Neer[4] in 1960, he reported nonunion in only 3 out of 2235 patients with middle third fracture clavicle treated by closed methods. He also suggested a higher nonunion rate with operative care. However, more recent studies have shown that the union rate for displaced midshaft fracture of the clavicle may not be as favorable as once thought. Our study showed that all fractures united well. Robinson et al.,[8] reported a nonunion rate of 21% for the displaced, comminuted midshaft fracture when managed conservatively. A randomized controlled trial by the Canadian orthopedic trauma society[6] showed that early primary plate fixation of completely displaced midshaft clavicular fractures results in improved patient-oriented outcomes, earlier return to function and decreased rates of nonunion and malunion. In our study, it was noticed that 85.71% of patients had excellent and 14.3% of patients had good result at 6 months follow-up [Table 2]. In the study done by the Canadian orthopedic trauma society[6] and Virtanen et al.[7] following observations were made on the duration of the union [Table 1].
Table 2: Master chart

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Patients managed nonoperatively were more likely to have symptomatic malunion and this factor increased very significantly with severely displaced and comminuted fractures (Robinson Type 2B2 fracture).[10] Hill et al.[11] published an unsatisfactory outcome rate of 31%.

In contradistinction to earlier case series, recent studies on primary plate fixation of acute midshaft clavicular fractures have described high rates of successful results with rates of union ranging from 94% to 100%.[12] In the present study, all fractures united with the meantime taken for bony union was 15 weeks [Figure 7].
Figure 7: X-ray after 6 months

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Figure 8: Scar hypertrophy

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Figure 9: Screw loosening

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In terms of functional outcome “Constant and Murley scores[9]” for patients receiving surgery were significantly better at the 6 months of follow-up [Table 2]. In a study conducted by Kulshrestha et al.,[13] the operative group had significantly superior Constant shoulder scores at all time points.

In our study, the following complications were seen which were compared with various other studies and the following observation were made.

In an anatomical study, the subclavian artery in the medial half of the clavicle was the closest to the posterior cortex.[14] This is the reason why anteroinferior plate fixation can pose a great risk for neurovascular structures in the medial clavicular area. This may be considered a safe fixation method due to the reduction in the risk of a neurovascular injury caused by superior plate detection.[15] Neurovascular injury or other major complications were not detected in any of our patients in our study when super anatomical plate detection was used in surgical treatment [Table 3]. Some studies suggest that anteroinferior plate fixation techniques are better, suggesting that plate prominence is felt less often. However, more soft tissue dissection is required for this plate fixation.
Table 3: Comparison of complications with other similar studies [Figure 8], [Figure 9]

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  Conclusion Top


Treatment of fracture middle third clavicle with open reduction and internal fixation (ORIF) with precontoured plate provides anatomical reduction of the clavicle with no residual shortening of the affected clavicle, faster healing, low incidence of complications and early return to preinjury state. Patients with residual shortening which is only observed in conservatively treated patients had significant mal-union and poor functional outcomes mainly poor abduction endurance due to malposition of the scapula and weak tensile strength of abductors of the shoulder in comparison to ORIF patients.

Superior placement of plate is biomechanically more stable but subsequent prominence of the plate may necessitate its removal. The few considerable drawbacks in ORIF treatment seems to be the iatrogenic supraclavicular nerve injury, scar and its hypertrophy and need for second procedure to remove the implant.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Nowak J, Mallmin H, Larsson S. The aetiology and epidemiology of clavicular fractures. A prospective study during a two-year period in Uppsala, Sweden. Injury 2000;31:353-8.  Back to cited text no. 1
    
2.
Bucholz RW, Heckman JD, Tornetta P, McQueen MM, Ricci WM. Rockwood and Green's fractures in adults. InRockwood and Green's fractures in adults 2010 p. 1275.  Back to cited text no. 2
    
3.
Egol KA, Koval KJ, Zuckerman JD. Handbook of fractures. Lippincott Williams and Wilkins; 2010;5th ed. p. 135.  Back to cited text no. 3
    
4.
Neer CS. Nonunion of the clavicle. J Am Med Assoc 1960;172:1006-11.  Back to cited text no. 4
    
5.
Michael Robinson C., Brown Charles M. Court, McQueen Margret M, Estimating the Risk of Nonunion Following Nonoperative Treatment of a clavicular fracture, The Scientific Articles 2004, 86:1359-65.  Back to cited text no. 5
    
6.
By the Canadian Orthopaedic Trauma Society; Nonoperative Treatment Compared with Plate Fixation of Displaced midshaft Clavicular Fracture: A Multicentreric, Randomized Clinical Trial: J Bone Joint Surg (Am). 2007; 89:1-10. [Doi: 10.2106/JBJS. F.00020].  Back to cited text no. 6
    
7.
Virtanen KJ, Remes Ville, Pajarinen Jarkko, VesaSavolainen, Jan-Magnus Sling Compared with Plate Osteosynthesis for Treatment of Displaced Midshaft Clavicular Fractures A randomized clinical trial; J Bone Joint Surg Am. 94-A Number 17 2012; 94:1546-53.  Back to cited text no. 7
    
8.
Robinson C. M, Fractures of the clavicle in the adult Epidemiology and Classification, J Bone Joint Surg [Br] 1998; 80-B: 476-84.  Back to cited text no. 8
    
9.
Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clinical orthopaedics and related research. 1987;214:160-4.  Back to cited text no. 9
    
10.
McKee Michael D, Elizabeth M. P, Jones Caroline, Stephen David J.G, Kreder Hans J, Schemitsch Emil H, Lisa M. W. Deficits following nonoperative treatment of displaced midshaft clavicular fractures, J Bone Joint Surg (Am)January 2006;88:35-40 [doi:10.2106/JBJS.D.02795]  Back to cited text no. 10
    
11.
Hill James m, McGuire MH. Crosby Lynn a. Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg [Br] 1997;79-B:537-9.  Back to cited text no. 11
    
12.
De Giorgi S, Notarnicola A, Tafuri S, Solarino G, Moretti L, Moretti B. Conservative treatment of fractures of the clavicle. BMC research notes. 2011;1:1-7.  Back to cited text no. 12
    
13.
Kulshrestha V, Roy Tanmoy, Audige Laurent, Operative versus Nonoperative Management of Displaced Midshaft Clavicle Fractures: A Prospective Cohort Study, J Orthop Trauma: 2011:31-8.  Back to cited text no. 13
    
14.
Lo EY, Eastman J, Tseng S, Lee MA, Yoo BJ. Neurovascular risks of anteroinferior clavicular plating. Orthopedics. 2010;33:21–21.  Back to cited text no. 14
    
15.
Robinson L, Persico F, Lorenz E, Seligson D. Clavicular caution: An anatomic study of neurovascular structures. Injury 2014;45:1867-9.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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