Plate Fixation Compared with Nonoperative Treatment for Displaced Midshaft Clavicular Fractures: A Multicenter Randomized Controlled Trial.

BACKGROUND: The use of operative treatment for clavicular fractures is increasing, despite varying results in previous studies. The aim of this study was to compare plate fixation and nonoperative treatment for displaced midshaft clavicular fractures with respect to nonunion, adverse events, and shoulder function. METHODS: In this multicenter, prospective, randomized controlled trial, patients between 18 and 60 years old with a displaced midshaft clavicular fracture were randomized between nonoperative treatment and open reduction with internal plate fixation. The primary outcome was evidence of nonunion at 1 year. Other outcomes were secondary operations, arm function as measured with the Constant shoulder score and Disabilities of the Arm, Shoulder and Hand (DASH) score, pain, cosmetic results, and general health status. Outcomes were recorded at 6 weeks, 3 months, and 1 year following trauma. RESULTS: One hundred and sixty patients were randomized. The rate of nonunion was significantly higher in the nonoperatively treated group than in the operatively treated group (23.1% compared with 2.4%; p < 0.0001), as was the rate of nonunion for which secondary plate fixation was performed (12.9% compared with 1.2%; p = 0.006). The rate of secondary operations was 27.4% in the operatively treated group (16.7% for elective plate removal) and 17.1% in the nonoperatively treated group (p = 0.18). Nineteen percent of the patients in the operatively treated group had persistent loss of sensation around the scar. No difference was found between the groups with respect to the Constant and DASH scores at all time points. CONCLUSIONS: For patients with a diaphyseal fracture of the clavicle displaced at least 1 shaft width, plate fixation improves the chances that the bone will heal; however, the rate of patients who need a second operation is considerable. In addition, the procedure does not improve shoulder function or general symptoms, and it does not decrease limitations compared with nonoperative treatment in a sling. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Measurement of clavicular length and shortening after a midshaft clavicular fracture: Spatial digitization versus planar roentgen photogrammetry.

PURPOSE: Clavicular shortening after fracture is deemed prognostic for clinical outcome and is therefore generally assessed on radiographs. It is used for clinical decision making regarding operative or non-operative treatment in the first 2weeks after trauma, although the reliability and accuracy of the measurements are unclear. This study aimed to assess the reliability of roentgen photogrammetry (2D) of clavicular length and shortening, and to compare these with 3D-spatial digitization measurements, obtained with an electromagnetic recording system (Flock of Birds). PATIENTS AND METHODS: Thirty-two participants with a consolidated non-operatively treated two or multi-fragmented dislocated midshaft clavicular fracture were analysed. Two observers measured clavicular lengths and absolute and proportional clavicular shortening on radiographs taken before and after fracture consolidation. The clavicular lengths were also measured with spatial digitization. Inter-observer agreement on the radiographic measurements was assessed using the Intraclass Correlation Coefficient (ICC). Agreement between the radiographic and spatial digitization measurements was assessed using a Bland-Altman plot. RESULTS: The inter-observer agreement on clavicular length, and absolute and proportional shortening on trauma radiographs was almost perfect (ICC>0.90), but moderate for absolute shortening after consolidation (ICC=0.45). The Bland-Altman plot compared measurements of length on AP panorama radiographs with spatial digitization and showed that planar roentgen photogrammetry resulted in up to 37mm longer and 34mm shorter measurements than spatial digitization. CONCLUSION: Measurements of clavicular length on radiographs are highly reliable between observers, but may not reflect the actual length and shortening of the clavicle when compared to length measurements with spatial digitization. We recommend to use proportional shortening when measuring clavicular length or shortening on radiographs for clinical decision making.

Posttraumatic midshaft clavicular shortening does not result in relevant functional outcome changes.

BACKGROUND AND PURPOSE: Shoulder function may be changed after healing of a nonoperatively treated clavicular fracture, especially in cases of clavicular shortening or mal-union. We investigated scapular orientations and functional outcome in healed clavicular fractures with and without clavicular shortening. PATIENTS AND METHODS: 32 participants with a healed nonoperatively treated midshaft clavicular fracture were investigated. Motions of the thorax, arm, and shoulder were recorded by standardized electromagnetic 3D motion tracking. The DASH score and Constant-Murley score were used to evaluate functional outcome. Orientation of the scapula and humerus at rest and during standardized tasks, and strength and function of the affected shoulders were compared with corresponding values for the uninjured contralateral shoulders. RESULTS: Mean clavicular shortening was 25 mm (SD 16). Scapula protraction had increased by mean 4.4° in rest position in the affected shoulders. During abduction, slightly more protraction, slightly more lateral rotation, and slightly less backward tilt was found for the affected shoulders. For anteflexion, the scapular orientations of the affected shoulders also showed slightly increased protraction, slightly increased lateral rotation, and slightly reduced backward tilt. Scapulohumeral kinematics, maximum humerus angles, and strength were not associated with the degree of clavicular shortening. All participants had excellent performance on the Constant-Murley score and DASH score. INTERPRETATION: Scapulohumeral kinematics in shoulders with a healed clavicular fracture differ from those in uninjured shoulders, but these changes are small, do not result in clinically relevant changes in outcome, and do not relate to the amount of clavicular shortening. These findings do not support routine operative reduction and fixation of shortened midshaft clavicular fractures based on the argument of functional outcome.

Reliability of the Robinson classification for displaced comminuted midshaft clavicular fractures.

This study aimed to assess the reliability of the Robinson classification for displaced comminuted midshaft fractures. A total of 102 surgeons and 52 radiologists classified 15 displaced comminuted midshaft clavicular fractures on anteroposterior (AP) and 30-degree caudocephalad radiographs twice. For both surgeons and radiologists, inter-observer and intra-observer agreement significantly improved after showing the 30-degree caudocephalad view in addition to the AP view. Radiologists had significantly higher inter- and intra-observer agreement than surgeons after judging both radiographs (κmultirater of 0.81 vs. 0.56; κintra-observer of 0.73 vs. 0.44). We advise to use two-plane radiography and to routinely incorporate the Robinson classification in the radiology reports.

Online radiographic survey of midshaft clavicular fractures: no consensus on treatment for displaced fractures.

The choice of treatment for midshaft clavicular fractures is not straightforward, but depends on fracture characteristics such as comminution, angulation and displacement. An online survey was conducted amongst trauma and orthopaedic surgeons to determine the preferred treatment for midshaft clavicular fractures, based on anteroposterior radiographs, for 17 randomly selected displaced or comminuted midshaft clavicular fractures. The background and experience of the respondents were documented. Data were analyzed using a Generalized Estimating Equations (GEE) model. The 102 respondents preferred non-operative treatment more frequently for displaced fractures than for comminuted fractures (OR 3.24, 95% CI 2.55-4.12). Locking plate fixation was more often preferred over other surgical modalities for comminuted than for displaced fractures (OR 1.50, 95% CI 1.17-1.91). In clinical practice, there is no consensus between surgeons on the choice of treatment for displaced or comminuted midshaft clavicular fractures. This lack of agreement calls for evidence-based treatment guidelines for these fractures.

Online radiographic survey of midshaft clavicular fractures: no consensus on treatment for displaced fractures.

The choice of treatment for midshaft clavicular fractures is not straightforward, but depends on fracture characteristics such as comminution, angulation and displacement. An online survey was conducted amongst trauma and orthopaedic surgeons to determine the preferred treatment for midshaft clavicular fractures, based on anteroposterior radiographs, for 17 randomly selected displaced or comminuted midshaft clavicular fractures. The background and experience of the respondents were documented. Data were analyzed using a Generalized Estimating Equations (GEE) model. The 102 respondents preferred non-operative treatment more frequently for displaced fractures than for comminuted fractures (OR 3.24, 95% CI 2.55-4.12). Locking plate fixation was more often preferred over other surgical modalities for comminuted than for displaced fractures (OR 1.50, 95% CI 1.17-1.91). In clinical practice, there is no consensus between surgeons on the choice of treatment for displaced or comminuted midshaft clavicular fractures. This lack of agreement calls for evidence-based treatment guidelines for these fractures.

Surgical treatment of Neer type-II fractures of the distal clavicle: a meta-analysis.

BACKGROUND AND PURPOSE: Type-II distal clavicle fractures according to the Neer classification are generally operated because of the high non-union rate after non-operative treatment. Several surgical techniques have been developed in order to reduce the non-union rate and improve functional outcome. This meta-analysis overviews the available surgical techniques for type-II distal clavicular fractures. METHODS: We searched the literature systematically. No comparative studies were found. 21 studies (8 prospective and 13 retrospective cohort studies) were selected for the meta-analysis. Data were pooled for 5 surgical outcome measures: function, time to union, time to implant removal, major complications, and minor complications. RESULTS: The 21 studies selected included 350 patients with a distal clavicular fracture. Union was achieved in 98% of the patients. Functional outcome was similar between the treatment modalities. Hook-plate fixation was associated with an 11-fold increased risk of major complications compared to intramedullary fixation and a 24-fold increased risk compared to suture anchoring. INTERPRETATION: If surgical treatment of a distal clavicle fracture is considered, a fixation procedure with a low risk of complications and a high union rate such as plate fixation or intramedullary fixation should be used. The hook-plate fixation had an increased risk of implant-related complications.

The relationship between trauma mechanism, fracture type, and treatment of midshaft clavicular fractures.

OBJECTIVE: The debate on whether midshaft clavicular fractures should preferably be treated operatively or nonoperatively still continues. Several patient-related factors may influence this treatment decision. A retrospective study was carried out to determine the relation between fracture type and trauma mechanism, age and sex, and the influence of these factors on the choice of primary treatment. METHODS: Data on the trauma mechanism and treatment of 232 adult patients, who presented with a midshaft clavicular fracture in two hospitals in the Netherlands during the years 2006-2009, were collected. The extent of clavicular shortening, displacement, and fracture type on the primary radiograph were scored. RESULTS: Traffic accidents are the main cause of midshaft clavicular fractures. After correction for age, no relation was found between the trauma mechanism and the fracture type. Older age correlated with more comminuted and displaced fractures. Extensive shortening (>20 mm) was identified as the main clinical indication for primary surgery, whereas displacement and fracture classification seemed less relevant. Operative treatment was increasingly favored from 5% in 2006 to 44% in 2009, which could not be explained by an increase in more complex fractures or by age-related or trauma mechanism-related factors. CONCLUSION: Age has a major influence on the fracture type, whereas the trauma mechanism does not. The choice for the surgical treatment of midshaft clavicular fractures is primarily determined by the amount of axial shortening of the clavicle, rather than by the overall displacement or fracture type. Over the years, the choice of treatment seems to have been increasingly influenced by the patient's and surgeon's preferences.

The value of frozen section biopsy in diagnosing necrotizing fasciitis: proposal of a new grading system.

GOALS AND OBJECTIVES: Necrotizing fasciitis is a serious disease entity, with only limited pathognomic features. PURPOSE: In necrotizing fasciitis a rapid diagnosis is necessary in order to reduce morbidity and mortality. In this study the investigation focused on specific features in the frozen section biopsy for diagnosing necrotizing fasciitis. METHODS: A total of ten patients are described with final pathological examination of resected tissue. RESULTS: A new grading system is suggested for frozen section biopsy in patients with necrotizing fasciitis. In the herein reported study it was found that granulocytes were present in both the frozen section biopsy and in the definitive paraffin coupes, in the subcutis and fascia layer. CONCLUSION: Frozen section biopsy could be useful in diagnosing necrotizing fasciitis.

Displaced midshaft fractures of the clavicle: non-operative treatment versus plate fixation (Sleutel-TRIAL). A multicentre randomised controlled trial.

BACKGROUND: The traditional view that the vast majority of midshaft clavicular fractures heal with good functional outcomes following non-operative treatment may be no longer valid for all midshaft clavicular fractures. Recent studies have presented a relatively high incidence of non-union and identified speciic limitations of the shoulder function in subgroups of patients with these injuries. AIM: A prospective, multicentre randomised controlled trial (RCT) will be conducted in 21 hospitals in the Netherlands, comparing fracture consolidation and shoulder function after either non-operative treatment with a sling or a plate fixation. METHODS/DESIGN: A total of 350 patients will be included, between 18 and 60 years of age, with a dislocated midshaft clavicular fracture. The primary outcome is the incidence of non-union, which will be determined with standardised X-rays (Antero-Posterior and 30 degrees caudocephalad view). Secondary outcome will be the functional outcome, measured using the Constant Score. Strength of the shoulder muscles will be measured with a handheld dynamometer (MicroFET2). Furthermore, the health-related Quality of Life score (ShortForm-36) and the Disabilities of Arm, Shoulder and Hand (DASH) Outcome Measure will be monitored as subjective parameters. Data on complications, bone union, cosmetic aspects and use of painkillers will be collected with follow-up questionnaires. The follow-up time will be two years. All patients will be monitored at regular intervals over the subsequent twelve months (two and six weeks, three months and one year). After two years an interview by telephone and a written survey will be performed to evaluate the two-year functional and mechanical outcomes. All data will be analysed on an intention-to-treat basis, using univariate and multivariate analyses. DISCUSSION: This trial will provide level-1 evidence for the comparison of consolidation and functional outcome between two standardised treatment options for dislocated midshaft clavicular fractures. The gathered data may support the development of a clinical guideline for treatment of clavicular fractures. TRIAL REGISTRATION: Netherlands National Trial Register NTR2399.

Use of Cadaveric Donor Skin to Predict Success of a Definitive Split-thickness Skin Graft in Complicated Wounds.

UNLABELLED: Split-thickness skin grafts (STSG) are used for covering large wound beds. This procedure is sometimes postponed due to a positive culture swab. In those cases, prolonged antibiotic therapy is advised. The present study shows that if a temporary cadaveric donor skin has good take, antibiotic therapy is not necessary and a normal STSG can be performed directly with acceptable results. METHODS: Cadaveric donor skin was applied in 35 consecutive patients. If the cadaveric donor skin had a good take (adherence) to the wound bed, the patient was scheduled for a STSG. In cases where the cadaveric donor skin failed to take, the definitive skin graft procedure was postponed. In six consecutive cases the cadaveric donor skin was evaluated for possible pathological changes. RESULTS: In 25 out of 35 patients the cadaveric donor skin had full take. In 22 of these 25 patients a STSG was performed, which led to 91% complete graft take rate. These patients were not treated routinely with antibiotics and if they were treated, surgery was not postponed. CONCLUSION: Delaying STSG while waiting for swab culture results is not necessary if the cadaveric donor skin has good take 3 days after application; in such cases, the take (attachment) of a STSG in a complicated set of patients is > 90%. The cadaveric donor skin, with positive take, showed more granulocytic influx in the epidermal layer and more vitality than those with no adherence to the wound bed. Vascular in-growth was not noted in any of the cases .