Mini-Invasive Intramedullary Fixation of Displaced Midshaft Clavicle Fractures with an Elastic Titanium Nail.

BACKGROUND: The treatment of completely displaced midshaft clavicle fractures is still controversial, but surgical treatment provides a shorter recovery period and higher union rates than nonoperative treatment with a sling1-5. Even though the literature does not clearly support surgery for these fractures, surgery is becoming more frequent6. Elastic stable intramedullary nailing (ESIN) with a titanium nail is a well-documented mini-invasive procedure with functional outcomes comparable with those of plate fixation after 1 year but a high rate of implant removal of up to 80%6-8. The ideal injury for ESIN is a fracture without comminution that is available for surgery within a couple of days. ESIN is also a good option for fractures with comminution, but a somewhat slower functional recovery during the first 6 months should be expected. DESCRIPTION: The patient is placed in beach-chair position with the fluoroscope placed on the injured side or cranially in relation to the fracture. The surgeon pushes the skin gently with his/her index finger at the jugular fossa before incising it. This places the skin incision inferior to the implant. A 1 to 2-cm incision down to the bone is then placed about 1 to 2 cm lateral to the sternoclavicular joint. A unicortical entry hole is made at the medial end with a 2.5-mm drill bit and then widened and directed laterally with an awl. Two reduction forceps are placed percutaneously and used by the assistant to align the main fragments. The nail is passed with oscillating movements until it is secured into the lateral fragment. If it is not possible to obtain a closed reduction, an open reduction is performed. The nail is cut short down to the bone, and the myocutaneous layer and skin are closed with sutures. Five to 10 mL of bupivacaine is injected into the fracture area for postoperative pain management. The arm is placed in a simple sling for comfort. A non-weight-bearing active range of motion of <90° is encouraged. ALTERNATIVES: Closed completely displaced midshaft clavicle fractures can be treated operatively or nonoperatively with a sling. Superior plate fixation is well documented, but use of anterior or several mini-fragment plates is also an option. There are several intramedullary implant techniques, but most require an open reduction. RATIONALE: Most intramedullary implant methods are open procedures, whereas closed reduction and internal fixation is possible with ESIN. This ensures preservation of the fracture hematoma and no periosteal stripping, in contrast with the open intramedullary techniques. The nail enters the fracture medially, which decreases the chance of perioperative pulmonary or neurovascular injury. The procedure is less time-consuming than plate fixation, the result is cosmetically superior, and the functional outcomes after 1 year are equal. When ESIN is used for fractures without intermediary fragments, the functional recovery time is equal to that after plate fixation, although it is longer when used for fractures with intermediary fragments8.

Calcar screws and adequate reduction reduced the risk of fixation failure in proximal humeral fractures treated with a locking plate: 190 patients followed for a mean of 3 years.

BACKGROUND: Fixation of proximal humeral fractures (PHF) with locking plates has gained popularity over conservative treatment, but surgery may be complicated with infection, non-union, avascular necrosis (AVN) of the humeral head and fixation failure. Failure to achieve structural support of the medial column has been suggested to be an important risk factor for fixation failure. The aims of this study were to examine the effect of calcar screws and fracture reduction on the risk of fixation failure and to assess long-term shoulder pain and function. METHODS: This was a single-centre retrospective study of 190 adult PHF patients treated with a locking plate between 2011 and 2014. Reoperations due to fixation failure were the primary outcome. Risk factors for fixation failure were assessed using the Cox regression analysis. Postoperative shoulder pain and function were assessed by the Oxford Shoulder Score (OSS). RESULTS: Thirty-one of 190 (16%) patients underwent a reoperation: 14 (7%) due to fixation failure, 10 (5%) due to deep infection and 2 (1%) due to AVN. The absence of calcar screws and fixation with residual varus malalignment (head-shaft angle < 120°) both increased the risk of fixation failure with an adjusted hazard ratio (95% CI) of 8.6 (1.9-39.3; p = 0.005) and 4.9 (1.3-17.9; p = 0.02), respectively. The median (interquartile range) OSS was 40 (27-46). CONCLUSION: The use of calcar screws, as well as the absence of postoperative varus malalignment, significantly reduced the risk of fixation failure. We, therefore, recommend the use of calcar screws and to avoid residual varus malalignment to improve the medial support of proximal humeral fractures treated with a locking plate.

Five-Year Follow-up Results of a Randomized Controlled Study Comparing Intramedullary Nailing with Plate Fixation of Completely Displaced Midshaft Fractures of the Clavicle in Adults.

BACKGROUND: Surgical management of completely displaced midshaft fractures of the clavicle is becoming more frequent, although long-term follow-up with Level-I evidence is scarce. Plate fixation (PF) of comminuted fractures provides faster functional recovery than elastic stable intramedullary nailing (ESIN). The 12-month follow-up of this randomized controlled trial, published previously, found no clinical differences at that time on the group level, but subtle differences on the subgroup level indicated that the results after closed ESIN were better than those after open ESIN. The primary aim of the study reported here was to compare the long-term clinical outcomes and sequelae after open reduction with those after closed reduction and to help surgeons develop a treatment strategy of either PF or ESIN for selected patients. METHODS: At a median follow-up of 66 months (range, 49 to 89 months), the 123 patients in the original study were invited to an online secure survey. We used the survey results to compare the PF and ESIN treatment arms and to perform predetermined subgroup analyses of closed compared with open ESIN in relation to Disabilities of the Arm, Shoulder and Hand (DASH) score, pain assessment, and implant removal. RESULTS: The questionnaire was completed by 114 (93%) of the 123 patients. There were no differences between the 2 treatment arms with regard to the DASH score (ESIN, 3.1 ± 7.0 and PF, 3.7 ± 7.5; p = 0.9). The 27 patients who had been treated with closed ESIN had a significantly superior DASH score compared with the 27 patients who had been treated with open ESIN (closed, 0.7 ± 1.4 and open, 5.2 ± 8.9; p = 0.015) and compared with the patients who had been treated with PF (closed ESIN, 0.7 ± 1.4 and PF, 3.9 ± 7.5; p = 0.002). Patients who had been treated with closed ESIN also reported fewer sequelae than patients who had been treated with open ESIN or PF. CONCLUSIONS: The results of this study, combined with those of our prior 1-year follow-up of the same patients, indicate that it seems to be advantageous to perform closed ESIN. The long-term results after PF were similar to those after open ESIN, but PF resulted in faster functional recovery and fewer patients needing to have the implant removed. Therefore, if open reduction is necessary for a comminuted fracture, it seems that the advantages of the minimally invasive ESIN procedure are lost, and the surgeon should consider conversion to PF. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Radiological and functional outcomes 2.7 years following conservatively treated completely displaced midshaft clavicle fractures.

OBJECTIVES: It is unclear whether all completely displaced midshaft clavicle fractures require primary surgical intervention. The aim of this study was to elucidate the radiological and clinical outcomes after conservative treatment, and to identify subgroups at risk of an inferior outcome. DESIGN: Retrospective case series. SETTING: Level II trauma center. PATIENTS: Between 2005 and 2008, 122 patients were conservatively treated for a completely displaced midshaft clavicle fracture of whom 92 were eligible for inclusion in this study. Of these, 59 completed the study after a median of 2.7 years after the fracture (min-max, 1.1-4.9). INTERVENTION: The patients received the standard treatment administered at our institution at the time: nonsurgically with a sling without physiotherapy. Patients with painful nonunions were subsequently offered surgery. MAIN OUTCOME MEASUREMENTS: At follow-up, the patients' Disabilities of Arm, Shoulder, and Hand (DASH) and the Constant scores were evaluated. Radiographs were taken at follow-up and compared to those taken acutely. RESULTS: Nonunion was found in 9 of the 59 (15.3%) patients. Twenty-four (24%) patients reported a fair-to-poor DASH score (i.e. >20). Patients with fractures that were vertically displaced by more than 100% (one bone width) were significantly less satisfied than those with fractures vertically displaced at 100% (p = 0.04). Initial shortening of more than 15 mm was not associated with a worse outcome or nonunion. The odds ratio of developing a nonunion increased with age (p = 0.04). CONCLUSIONS: By treating completely displaced midshaft clavicle fractures conservatively with a sling and offering plate fixation for eventual painful nonunions, we found a 24% risk of a fair or poor clinical result with a DASH score over 20. A vertical displacement of more than 100 % between the main fragments on the initial radiograph was associated with an inferior clinical outcome in this study. LEVEL OF EVIDENCE: IV.

Long-term patient-reported outcome after fractures of the clavicle in patients aged 10 to 18 years.

BACKGROUND: Fractures of the clavicle are common among adolescents and have traditionally been treated nonoperatively. Recent literature has demonstrated less satisfactory results than expected after conservative management of displaced fractures in adults. The purpose of this study was to evaluate the long-term patient-reported outcome after clavicle fractures in older children and adolescents. METHODS: Children aged 10 to 18 years who sustained a fracture of the clavicle between 2006 and 2008 were identified in our institution's computerized files. The radiographs were examined and the fracture patterns, degree of dislocation, and shortening were measured. Medical records were reviewed and the patient-reported outcome was assessed using the Oxford Shoulder score and the Quick version of the Disability of Arm, Shoulder, and Hand questionnaire, and specific and general satisfaction scores. RESULTS: A total of 185 patients (median age, 14.4 y) with 172 midshaft and 13 lateral fractures were included in the study. Sixty-five (37.8%) of the midshaft fractures were displaced, and 9 of these were operated. There was one case of nonunion and one delayed union. One hundred twenty-two (70.9%) of the patients with a midshaft fracture responded to the questionnaires on an average 4.7 years after injury. Overall results were good to excellent for the majority of nonoperatively treated patients; however, shortening of the fracture had a negative effect on the Oxford Shoulder score (P=0.02), the cosmetic satisfaction score (P=0.02), and the overall satisfaction score (P=0.01). CONCLUSIONS: The long-term patient-reported outcome after nonoperatively treated fractures of the clavicle in adolescents is good to excellent for the majority of the patients, and nonunion is rare. However, shortening of the fracture had a small negative effect on the outcome. Conservative management should remain the mainstay of management for fractures of the clavicle in this age group. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Fractures in children: epidemiology and activity-specific fracture rates.

BACKGROUND: Approximately one-third of pediatric fractures occur during sport or recreational activity. In this paper, we investigate the incidence and causes of pediatric fractures in our region and quantify the fracture rate per exposure time for the most common sport and recreational activities. METHODS: We prospectively evaluated all children younger than sixteen years who presented to our institution with a new fracture within a twelve-month period. Exposure time to the most common childhood activities was measured by means of interviewing random parents from the study population. The main outcome measures were the annual fracture incidence in the population and fracture rates per 10,000 hours of exposure to various sports and recreational activities. RESULTS: A total of 1403 fractures were included. The overall annual incidence was 180.1 fractures per 10,000 children younger than sixteen years. The distal part of the radius was most often fractured (436 fractures, 31.1%). Snowboarding was associated with the highest activity-specific fracture rate, estimated to be 1.9 (95% confidence interval [CI], 1.16 to 2.60) fractures per 10,000 hours of exposure. In comparison, the fracture rate per 10,000 hours of exposure was 0.79 (CI, 0.42 to 1.09) for handball, 0.44 (CI, 0.35 to 0.52) for soccer, and 0.35 (CI, 0.23 to 0.47) for trampolining. CONCLUSIONS: The distal part of the radius is the most common fracture site in childhood. Fracture rates differ between various physical activities. The fracture rate for snowboarding was four times higher compared with that for other common childhood sport and recreational activities in our region.