5-Year Radiographic and Functional Outcomes of Nonoperative Treatment of Completely Displaced Midshaft Clavicular Fractures in Teenagers.

BACKGROUND: Optimal treatment of completely displaced midshaft clavicular fractures in adolescents remains controversial, with some favoring surgical management and others favoring a nonoperative approach. Few studies have comprehensively assessed longer-term nonoperative outcomes. PURPOSE: To prospectively assess patient-reported outcomes (PROs) and radiographic remodeling ≥5 years after injury in teenagers undergoing nonoperative treatment of completely displaced clavicular fractures. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Adolescent patients previously enrolled in a prospective study from a single institution with nonoperatively treated, completely displaced midshaft clavicular fractures ≥5 years from injury were eligible for the study. Patients were clinically evaluated for scapular dyskinesia and strength deficits. Bilateral clavicular imaging assessed residual shortening, displacement, and angulation. PROs included the American Shoulder and Elbow Surgeons (ASES), the shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH), Marx Shoulder Activity Scale, cosmesis, and return to sports data. RESULTS: A total of 24 patients were available for the follow-up, of whom 17 (71%) consented to additional imaging. The mean cohort age at the time of injury was 14.5 ± 1.1 years, with 88% being male. At a mean follow-up of 6.1 years, all fractures had healed, with no patient requiring secondary interventions. Significant remodeling was observed across all measurements, with improvements of 70% in shortening (22.8 to 6.8 mm; P < .001), 73% in superior displacement (13.4 to 3.6 mm; P < .001), and 83% in angulation (10.4° to 1.8°; P < .001). Thirteen patients (72%) had a >2-cm initial shortening, and all remodeled to <2 cm. PROs were almost universally excellent, with mean ASES, QuickDASH, and Marx activity scores of 99 ± 3, 1 ± 3, and 20 ± 1, respectively, with 79% of patients reporting perfect scores in all 3 domains. Most patients (58%) were completely satisfied with their shoulder appearance, 38% were more satisfied than not, 1 patient (4%) was neither satisfied nor dissatisfied, and no patients were dissatisfied. All patients except 1 who were interested in sports returned to sporting activities. PROs were not associated with bony remodeling (P > .05). CONCLUSION: Teenaged patients with completely displaced clavicular fractures treated nonoperatively can expect excellent radiographic and clinical outcomes 5 years after injury.

Clinical effect of nice knot-assisted minimally invasive titanium elastic nail fixation to treat Robinson 2B midshaft clavicular fracture.

BACKGROUND: The treatment of completely displaced midshaft clavicle fractures is still controversial, especially Robinson 2B fractures. Titanium elastic nail (TEN) fixation is a good option for simple fractures, but no reports exist on its use in complex fractures. This study aimed to present a surgical method using the Nice knot-assisted TEN fixation to treat Robinson 2B midshaft clavicular fractures. METHODS: A retrospective analysis of 29 patients who underwent fixation with TEN and had a 1-year postoperative follow-up between 2016 and 2020 was performed. The fractures were classified as Robinson type 2B1 in 17 cases and type 2B2 in 12 cases. Length of the incision, postoperative shoulder function Disability of Arm Shoulder and Hand (DASH) score and Constant score, complications rate, and second surgical incision length were recorded. RESULTS: The length of the incision was 2-6 cm (average 3.7 cm). All incisions healed by first intention, and no infection or nerve injury occurred. The Constant score was 92-100 (average 96) and the DASH score was 0-6.2 (mean, 2.64). TEN bending and hypertrophic nonunion occurred in one case (3.4%) and implant irritation occurred in four cases (13.8%) Fixation implants were removed at 12-26 months (mean, 14.6 months) after surgery, and the length of the second incision was 1-2.5 cm (average 1.3 cm). CONCLUSIONS: Intramedullary fixation by TEN is approved as a suitable surgical technique in clavicular fracture treatment. Nice knot-assisted fixation provides multifragmentary fracture stabilization, contributing to good fracture healing. Surgeons should consider this technique in treating Robinson 2B midshaft clavicular fractures. TRIAL REGISTRATION: Retrospectively registered. This study was approved by the Ethics Committee of Wuxi Ninth People's Hospital (LW20220021).

Does plate position influence the outcome in midshaft clavicular fractures? A multicenter analysis.

PURPOSE: To date, it remains unclear whether superior or anterior plating is the best option for treating midshaft clavicular fractures. The aim of this study was to compare both techniques with regard to the incidence of implant removal due to implant irritation, risk of complications, time to union, and function. METHODS: In this retrospective cohort study, all midshaft clavicular fractures treated operatively between 2017 and 2020 in two hospitals in Switzerland were analyzed. The participating hospitals differed with regard to their standard practice; one offered superior plating only, while the other predominantly employed an anterior plate. The primary outcome was the incidence of implant removal for irritation. Secondary outcomes were time to union, complications, re-interventions, and range of motion during the follow-up period of at least 6 months. RESULTS: In total, 168 patients were included in the study of which 81 (48%) received anterior plating and 87 (52%) superior plating. The overall mean age was 45 years (SD 16). There was no significant difference between anterior and superior plating with regard to implant removal (58.5% versus 57.1%, p = 0.887), infection (5.7% versus 1.8%, p = 0.071), and time to union (median 48 weeks versus 52 weeks, p = 0.643). Data on range of motion were available in 71 patients. There was no significant difference in anteflexion (median 180 degrees anterior versus 180 degrees superior) and abduction (median 180 degrees anterior versus 180 degrees superior) between the two groups. CONCLUSION: This retrospective cohort study did not find sufficient evidence to recommend one implant position over the other for midshaft clavicular fractures with regard to removal due to irritation. Time to union was similar and Infections were equally rare in both groups. Notably, a considerable number of patients in both groups had their implants removed due to irritation. Larger prospective studies are needed to determine how much plate position contributes to the occurrence of irritation and whether other patient or implant-related factors might play a role. Until this is clarified, implant position should be based on surgeons preference and experience.

A critical evaluation of the external and internal maneuvers for resolution of shoulder dystocia.

In the management of shoulder dystocia, it is often recommended to start with external maneuvers, such as the McRoberts maneuver and suprapubic pressure, followed by internal maneuvers including rotation and posterior arm delivery. However, this sequence is not based on scientific evidence of its success rates, the technical simplicity, or the related complication rates. Hence, this review critically evaluates the success rate, technique, and safety of different maneuvers. Retrospective reviews showed that posterior arm delivery has consistently higher success rates (86.1%) than rotational methods (62.4%) and external maneuvers (56.0%). McRoberts maneuver was thought to be a simple method, however, its mechanism is not clear. Furthermore, McRoberts position still requires subsequent traction on the fetal neck, which presents a risk for brachial plexus injury. The 2 internal maneuvers have anatomic rationales with the aim of rotating the shoulders to the wider oblique pelvic dimension or reducing the shoulder width. The techniques are not more sophisticated and requires the accoucher to insert the correct hand (according to fetal face direction) through the more spacious sacro-posterior region and deep enough to reach the fetal chest or posterior forearm. The performance of rotation and posterior arm delivery can also be integrated and performed using the same hand. Retrospective studies may give a biased view that the internal maneuvers are riskier. First, a less severely impacted shoulder dystocia is more likely to have been managed by external maneuvers, subjecting more difficult cases to internal maneuvers. Second, neonatal injuries were not necessarily caused by the internal maneuvers that led to delivery but could have been caused by the preceding unsuccessful external maneuvers. The procedural safety is not primarily related to the nature of the maneuvers, but to how properly these maneuvers are performed. When all these maneuvers have failed, it is important to consider the reasons for failure otherwise repetition of the maneuver cycle is just a random trial and error. If the posterior axilla is just above the pelvic outlet and reachable, posterior axilla traction using either the accoucher fingers or a sling is a feasible alternative. Its mechanism is not just outward traction but also rotation of the shoulders to the wider oblique pelvic dimension. If the posterior axilla is at a higher sacral level, a sling may be formed with the assistance of a long right-angle forceps, otherwise, more invasive methods such as Zavanelli maneuver, abdominal rescue, or symphysiotomy are the last resorts.

Clavipectoral plane block performed in the emergency department for analgesia after clavicular fractures.

Clavicle fractures are common injuries in the Emergency Department (ED). Adequate pain control with oral or intravenous medications is the central aspect of treatment. The ultrasound-guided clavipectoral plane block (CPB), previously described in anesthesia literature, offers complete analgesia of the clavicle with a low adverse effect profile. In this case series, we describe the first reported utilization of the CPB for analgesia for acute clavicular fractures in the ED. We performed the CPB for distal and midshaft clavicular fractures on patients who suffered from a variety of traumatic accidents including bicycle accidents, motorcycle accidents, and motor vehicle accidents. All patients experienced significant reductions in their reported pain without any reported complications. Given the need to provide patients with appropriate pain control in the ED, the CPB offers an effective, simple method for providing analgesia without known significant risks, including without the risks associated with high-dose systemic analgesia.

Dual Mini-Fragment Plate Fixation of Midshaft Clavicle Fractures Reduces Risk of Reoperation Compared With Single-Plate Fixation Techniques.

BACKGROUND: Recent studies have highlighted dual plating as a method of reducing high rates of postoperative complication after operative management of displaced midshaft clavicular fractures. However, few studies have reliably characterized reoperation rates and magnitude of risk reduction achieved when using dual versus anterior and superior single-plate techniques. HYPOTHESIS: There would be lower rates of reoperation among patients who underwent open reduction and internal fixation (ORIF) of displaced midshaft clavicular fractures via dual plating. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This was a retrospective analysis of patients who underwent ORIF for a displaced midshaft clavicular fracture between 2010 and 2021 at a level 1 trauma center with a minimum 12-month follow-up. Patients were separated into 3 cohorts based on fixation type: (1) orthogonal dual mini-fragment plate fixation, (2) superior plate fixation, and (3) anterior plate fixation. Data on patient characteristics, fracture pattern, and reoperations were documented. All-cause reoperation rates and hazard ratio (HR) estimates of dual, superior, and anterior plating were calculated using a multivariate multilevel mixed-effects parametric survival model. Significant confounders including high-risk fracture morphology and smoking status were controlled for in the final model. RESULTS: A final cohort of 256 patients was identified with mean follow-up of 4.9 ± 3.8 years. In total, 101 patients underwent superior plating, 92 underwent anterior plating, and 63 underwent dual plating. Overall, 31 reoperations took place (18 in superior, 12 in anterior, 1 in dual plating) among 22 patients. Major contributors to reoperation included symptomatic hardware (n = 11), nonunion (n = 8), deep infection (n = 7), and wound dehiscence (n = 2). Superior plating revealed the highest reoperation rate of 0.031 per person-years, followed by anterior plating with 0.026 per person-years and dual plating with 0.005 per person-years. Overall, single plating (either anterior or superior placement) had a nearly 8-fold greater risk of reoperation than dual plating (HR, 7.62; 95% CI, 1.02-56.82; P = .048). Further broken down by technique, superior plating had an 8-fold greater risk of reoperation than dual plating (HR, 8.36; 95% CI, 1.10-63.86; P = .041), but anterior plating did not demonstrate a statistically significant difference compared with dual plating (HR, 6.79; 95% CI, 0.87-52.90; P = .068). CONCLUSION: Dual-plate fixation represents an excellent treatment for displaced midshaft clavicular fractures, with low rates of nonunion and reoperation. When compared with single locked superior or anterior plate fixation, dual mini-fragment plate fixation has a nearly 8-fold lower risk of reoperation.

The deformities of acute diaphyseal clavicular fractures: a three-dimensional analysis.

BACKGROUND: Although minimally invasive surgeries have gained popularity in many orthopaedic fields, minimally invasive approaches for diaphyseal clavicular fracture have not been widely performed, which is attributed to difficulties in performing a closed reduction of fracture deformities of a curved bone in a three-dimensional space. The goal of this study was to investigate the radiographic parameters of fracture deformities in a three-dimensional space and to identify the risk factors for deformities. METHODS: The computed tomography images of 100 patients who sustained a clavicle fracture were included. Five parameters were used to analyze the deformities: change in clavicle length, fracture displacement, and fragment rotation around the X, Y, Z axes. The change in length was assessed using the length of the endpoint line. The displacement was assessed using the distance between the fracture midpoints. The rotation deformities were assessed using the Euler angles. The correlation between the parameters was evaluated with the Pearson correlation coefficient. The risk factors were evaluated using univariable analysis and multiple regression analysis. RESULTS: The average change in length was - 5.3 ± 8.3 mm. The displacement was 11.8 ± 7.1 mm. The Euler angles in the Z-Y-X sequences were -1 ± 8, 1 ± 8, and - 8 ± 13 degrees. The correlation coefficient between the change in length and the displacement was - 0.724 (p < 0.001). The variables found to increase the risk of shortening and displacement were right-sided fracture (p = 0.037), male sex (p = 0.015), and multifragmentary type (p = 0.020). The variables found to increase the risk of rotation deformity were the number of rib fractures (p = 0.001) and scapula fracture (p = 0.025). CONCLUSIONS: There was a strong correlation between shortening and displacement. The magnitude of anterorotation around the X axis was greater than the magnitude of retraction around the Z axis and depression around the Y axis. The risk factors for shortening and displacement included right-sided fracture, male sex, and multifragmentary type. The risk factor for retraction around the Z axis was the number of rib fractures, and the risk factor for depression around the Y axis was scapula fracture. These results could be useful adjuncts in guiding minimally invasive surgical planning for diaphyseal clavicular fractures.

Intramedullary nailing versus plating fixation for the treatment of midshaft clavicular fractures: A meta-analysis of randomized controlled trials.

PURPOSE: This study was to test the hypothesis that intramedullary (IM) nailing fixation of midshaft clavicle fractures could result in better clinical outcomes and lower complications rates than plating fixation. METHODS: PubMed, Embase, and the Cochrane Library database were used to search all English language published randomized controlled trials (RCTs) of midshaft clavicle fractures using plating versus IM nailing. The characteristics of the study participants were collected. Outcomes of postoperative shoulder functional measurements, operative data and complications rates were meta-analyzed. RESULTS: Eight hundred and ninety-five patients in ten RCTs and three quasi-RCTs were involved in the meta-analysis. The results of meta-analysis of these studies showed that the functional outcome evaluated by the Constant Shoulder and Disabilities of the Arm, Shoulder and Hand (DASH) scores after accepting IM nailing was significantly better than that of plating fixation at one year post-operatively (P < 0.01), with the heterogeneity of 43% and 91%, respectively. Sensitivity analyses of the pooled results of Constant and DASH scores displayed that the functional advantage of IM nailing fixation comes from the subgroup of locked IM nailing. Further, regarding the operative statistics, operative time, blood loss and wound length were significantly less in the IM nailing group than the plating group (P < 0.001). The rates of infection, major complications and complications-related revision surgery were significantly higher in the plating group than the IM nailing group; however, there were no significantly statistical differences in other complications, e.g., nonunion, refracture after hardware removal, implant failure, symptomatic hardware, etc. (P > 0.05). CONCLUSION: The observations in this review suggested that IM nailing, especially locked IM nailing, could provide better shoulder functional outcome at one-year follow-up. Moreover, IM nailing fixation could effectively reduce operative time, blood loss, rates of infection, major complications, and revision surgery than plating. Further high-quality clinical trials with large samples and consistent designs are still needed to verify the long-term functional advantage of locked and unlocked IM nailing for midshaft clavicle fractures. LEVEL OF EVIDENCE: Level II.

Fracture edge features of diaphyseal clavicular fractures: a morphologic study.

BACKGROUND: Previous researchers used transverse fractures centered over the midpoint of the clavicle as the diaphyseal clavicular fracture models. However, as a result of shear stress concentration in sigmoid-shaped structures, most diaphyseal clavicular fractures have coronal fracture edges and are located distal to the midpoint. The purpose of this study was to quantify the morphology and utilize these parameters to establish clinically relevant fracture models. METHODS: The computed tomographic DICOM data of 100 consecutive patients were included. We investigated the morphologic characteristics of the fracture edges after virtual fracture reduction. The fracture orientation was determined based on the normal vectors of the best-fit plane of the fracture edges. The fracture location was measured by the extreme points of the edges. The fracture configuration was evaluated using fracture maps. RESULTS: There were 28 simple, 43 wedge, and 29 multifragmentary types. Coronal oriented fracture edges accounted for more than 70% of the simple, wedge, and multifragmentary types. The most proximal point of the proximal edge was located at 46.7% (42.0%-56.5%), 47.6% (42.5%-50.1%), and 46.3% (42.0%-49.3%) of the endpoint line in the simple, wedge, and multifragmentary types, respectively (P = .548). The most distal point of the distal edge was located at 72.2% (68.4%-75.0%), 73.2% (69.5%-76.9%), and 74.0% (69.6%-77.1%) of the endpoint line (P = .353). The longest proximal main fragments occurred in the simple types at 71.9% (66.3%-75.4%) of the endpoint line (P < .001), and the shortest distal main fragments occurred in the multifragmentary types at 55.8% (49.8%-59.3%) of the endpoint line (P = .001). The heatmaps showed a high concentration of anteriorly distributed wedge fragments (88%; n = 38/43) and coronally distributed multifragmentary fragments (62%; n = 18/29). CONCLUSIONS: We showed that typical diaphyseal clavicular fractures have coronal fracture edges and are located within the distal half of the diaphyseal segment. The fractured fragments were initiated anteriorly in the wedge types and then propagated coronally in the multifragmentary types. The features of these fracture edges could be useful in designing osteotomy models and provide different perspectives of anterior and superior plating techniques.

Comparative analysis of arthroscopic-assisted Tight-rope technique and clavicular hook plate fixation in the treatment of Neer type IIB distal clavicle fractures.

BACKGROUND: The aim of the present study was to compare the clinical efficacy of arthroscopic-assisted fixation using the Tight-rope system and clavicular hook plate fixation in the treatment of Neer IIB distal clavicle fractures. METHODS: We enrolled 48 consecutive patients with Neer IIB distal clavicle fractures who were treated at our institution from February 2016 and August 2020. These patients were divided into 2 groups based on the fixation method (16 cases with Tight-rope system and 32 cases with clavicular hook plate), and demographics and clinical characteristics of patients in different groups were compared. RESULTS: All 48 patients had functional outcome scores of the affected shoulder available at a mean of 23.8 ± 5.1 months, and there was a statistically significant improvement in the constant score, American shoulder and elbow surgeons (ASES) score, visual analogue scale (VAS) score at the end of follow-up (p < 0.001 respectively). However, the smaller length of skin incision, less estimated blood loss and shorter hospital stay were detected in the Tight-rope technique group patients than those of clavicular hook plate group patients (p < 0.001, respectively). Furthermore, the constant score, ASES score and VAS score were significantly improved in the Tight-rope technique group patients than those of clavicular hook plate group patients (p < 0.05, respectively). CONCLUSIONS: Both Tight-rope technique and clavicular hook plate fixation can provide satisfactory clinical and radiological results in the treatment of distal clavicular Neer IIB fracture. However, arthroscopic-assisted fixation using the Tight-rope technique showed better results in terms of length of hospital stay, surgical trauma, clinical scores, and diagnose and treat concomitant glenohumeral pathologies. LEVELS OF EVIDENCE: III, Case-control study Retrospective comparative study.

Isolated neonatal clavicular fracture is a risk factor for future shoulder dystocia.

OBJECTIVE: Shoulder dystocia (SD) is a risk factor for neonatal clavicular fracture (CF). Previous SD is a known risk factor for subsequent SD. It is unknown whether an isolated neonatal CF (one that is not associated with SD) increases the risk of future SD. We aimed to investigate this question. METHODS: A retrospective computerized database study conducted at Shaare Zedek Medical Center, a university-affiliated hospital, between 2005 and 2018. We included in the study all women that had a vaginal delivery without SD and had a subsequent vaginal delivery in our center between 2005 and 2018. Medical records of parturients who had a coded diagnosis of neonatal CF were retrieved. The first delivery with the neonatal diagnosis of an isolated CF was chosen as index delivery. Rates of SD at the subsequent delivery were assessed and compared between parturients with isolated neonatal CF (INCF) and parturients without neonatal CF or SD at the index delivery. To account for dependency between deliveries of the same individual parturient, we used generalized estimating equation (GEE) models. RESULTS: We identified 39,601 parturients that met the inclusion criteria. During the study period, 519 parturients with a diagnosis of INCF that had at least one subsequent delivery were identified (1.3%). Overall, 3.9% of parturients with isolated CF (20/519) had subsequent SD, as compared to 0.5% of parturients without CF or SD at the index delivery (190/39082; p < .01). Previous diagnosis of INCF was found to be independently associated with SD in a subsequent delivery after controlling for known risk factors for SD (aOR = 6.41, 95% CI = 3.92-10.61). Previous diagnosis of an INCF was also found to be independently associated with a subsequent event of SD in all subsequent deliveries of the same individual parturient (aOR = 3.42, 95% CI = 2.26-5.18). CONCLUSION: Women with previous INCF have an increased risk for SD in subsequent deliveries. Intervention efforts directed at this particular subgroup of women should be applied, with special attention to potentially modifiable risk factors to minimize the risk for future SD.

Is there a need for standardized postoperative X-rays after operative treatment of clavicular fractures?

PURPOSE: In most hospitals, acquiring postoperative X-rays after operative treatment of a fracture is the standard. Its value, however, after operative treatment for clavicular fractures is questionable. The aim of this study was to evaluate how often there is a change in treatment plan due to the postoperative X-ray after operative treatment of clavicular fractures when intra-operative images were acquired. METHODS: This was a retrospective cohort study performed in a level I trauma center. All consecutive patients treated surgically for clavicular fractures between 2014 and 2018 were included. The primary outcome was any deviation from the standard postoperative protocol resulting from the routine postoperative X-ray taken within the first 72 h after surgery. Secondary outcomes included all other complications and re-interventions performed during follow-up of patients with at least 6-month follow-up. RESULTS: In total, 241 patients were included in the study with a mean age of 42 years (SD 17). Only one patient had an abnormality on postoperative X-ray necessitating additional CT-scanning. No additional re-interventions or deviations from standard postoperative protocol were required. For secondary analyses, 187 patients were available. Seven patients had a late implant associated infection: one was detected at the time of implant removal and six during revision for non-union. Six patients had aseptic complications: four with non-union and two with implant failure. One-hundred and seven patients had an implant removal due to irritation after consolidation. CONCLUSION: Routinely performing postoperative X-rays after osteosynthesis for clavicular fractures seems unnecessary. Refraining from performing unnecessary radiographs will decrease exposure to radiation and likely have a beneficial effect on costs, length of hospital stay as well as healthcare consumption. This study was performed in a single center; therefore, it remains to be seen whether the findings are reproducible in another setting.

Clavicular Fractures in Newborns: What Happens to One of the Commonly Injured Bones at Birth?

Introduction The clavicle is one of the most commonly injured bones during the birth process. The objective of this study was to determine the frequency and outcome of fractured clavicle amongst neonates born in a five-year period at a Secondary Hospital setting and to determine the Maternal and Neonatal Characteristics involved in such cases and compare them with a control group and determine the significance of any factors. Methods All cases of fractured clavicle were retrospectively reviewed in a Secondary care hospital setting during a five-year period from July 2015 to June 2020. Maternal and neonatal factors were determined and then compared to a control group. Results Out of 21,435 live births at our center during the study period, 92 infants were diagnosed to have clavicle fractures, giving an incidence of 4.29 per 1,000 live births (0.43%). 89% cases (n=82) were detected before discharge and 11 % cases (n=10) on routine follow-up visit after discharge. Physical examination identified 77% cases (n=71) whereas 23% cases (n=21) were recognized incidentally on X-ray. All babies with fracture including 3 with Erb's palsy recovered completely without any complications. On logistic regression analysis, spontaneous vaginal delivery, prolonged second stage, vertex presentation, vitamin D deficiency in mothers, birthweight, macrosomia, all were significant risk factors. Conclusion Neonatal clavicular fracture appears to be a transient yet unpredictable and unavoidable event with an overall good prognosis. Only the birth weight was identified as the common risk factor affecting clavicular fracture. Parental concerns and anxiety can be decreased with proper counselling and reassurance.

Interventions to decrease complications after shoulder dystocia: a systematic review and Bayesian meta-analysis.

OBJECTIVE: This study aimed to evaluate the outcomes associated with the implementation of simulation exercises to reduce the sequela of shoulder dystocia. DATA SOURCES: Electronic databases (Ovid MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature database, and Scopus) were initially queried in June 2020 and updated in November 2020. The following 3 concepts were introduced and refined using the controlled vocabulary of the database: vaginal birth, shoulder dystocia, and simulation training. There were no limitations to the year of publication as part of the search strategy. STUDY ELIGIBILITY CRITERIA: We included all studies that reported on the frequency of shoulder dystocia and the associated complications before and after the implementation of interventional exercises to improve outcomes. METHODS: Two authors independently assessed the abstracts and full-text articles of all studies for eligibility and evaluated the quality of the included studies using the Newcastle-Ottawa Scale. Any inconsistencies related to study evaluation or data extraction were resolved by a third author. The coprimary outcomes of this systematic review and meta-analysis were neonatal brachial plexus palsy diagnosed following deliveries complicated by shoulder dystocia and persistence of brachial palsy at 12 months or later. The secondary outcomes were the frequency of shoulder dystocia and cesarean delivery. Study effects were combined using a Bayesian meta-analysis and were reported as risk ratios and 95% credible intervals (Crs). RESULTS: Of the 372 articles reviewed, 16 publications, which included 428,552 deliveries with 217,713 (50.8%) deliveries during the preintervention and 210,839 (49.2%) deliveries during the postinterventional period, were included in the meta-analysis. The incidence of neonatal brachial plexus palsy after shoulder dystocia decreased from 12.1% to 5.7% (risk ratio, 0.37; 95% Cr, 0.26-0.57; probability of reduction 100%). The overall proportion of neonatal brachial plexus palsy decreased, but with less precision, from 0.3% to 0.1% (risk ratio, 0.53; 95% Cr, 0.21-1.26; probability of reduction 94%). Two studies followed newborns with brachial plexus palsy for at least 12 months. One study that reported on persistent neonatal brachial plexus palsy at 12 months among 1148 shoulder dystocia cases noted a reduction in persistent neonatal brachial plexus palsy from 1.9% to 0.2% of shoulder dystocia cases (risk ratio, 0.13; 95% confidence interval, 0.04-0.49). In contrast, the study that reported on persistent neonatal brachial plexus palsy at 12 months for all deliveries noted that it did not change significantly, namely from 0.3 to 0.2 per 1000 births (risk ratio, 0.77; 95% confidence interval, 0.31-1.90). Following the implementation of shoulder dystocia interventional exercises, the diagnosis of shoulder dystocia increased significantly from 1.2% to 1.7% of vaginal deliveries (risk ratio, 1.39; 95% Cr, 1.19-1.65; probability of increase 100%). Compared with the preimplementation period, the cesarean delivery rate increased postimplementation from 21.2% to 25.9% (risk ratio, 1.22; 95% Cr, 0.93-1.59; probability of increase 93%). We created an online tool (https://ccrebm-bell.shinyapps.io/sdmeta/) that permits calculation of the absolute risk reduction and absolute risk increase attributable to the intervention vis-à-vis the incidence of shoulder dystocia, neonatal brachial plexus palsy, and cesarean deliveries. CONCLUSION: Introduction of shoulder dystocia interventional exercises decreased the rate of neonatal brachial plexus palsy per shoulder dystocia case; the data on persistence of neonatal brachial plexus palsy beyond 12 months is limited and contradictory. Implementation of the interventions was associated with an increase in the diagnosis of shoulder dystocia and rate of cesarean deliveries.

Latarjet fracture treated with a single endobutton: A case presentation.

BACKGROUND: Avulsion fracture of the coracoclavicular ligament accompanied by upward displacement of the medial fragment of the clavicle represents a unique fracture pattern, first described by Latarjet and colleagues in 1975. Due to the function of the underlying articulations and the ligaments found in the area, this fracture pattern results in a combination of horizontal and vertical instability that must be taken into consideration when treating. Several surgical techniques have been proposed but none has been proven superior. CASE SUMMARY: Herein, we present a Latarjet fracture of the distal clavicle treated with a single endobutton. A 45-year-old male underwent open surgical stabilization of distal clavicular fracture 15 days after trauma. After stabilization of the fracture, we applied a single endobutton, passing through the medial fragment, inferior fragment and coracoid process. The patient was observed for 14 mo postoperative, during which time he achieved union in all three fragments of the fracture and an excellent functional clinical score. CONCLUSION: In Latarjet fracture treatment, augmentation of the coracoclavicular ligament is the most important parameter for a favorable result.

S-shaped titanium endomedullary nail reduces telescoping of comminuted midshaft clavicular fractures.

BACKGROUND: The surgical treatment of displaced midshaft clavicular fractures (DMCF) is clinically relevant and a much discussed topic. The axial stability of DMCF after intramedullary nailing (IMN) is still a matter of debate. OBJECTIVE: Our objective was to present a modification of IMN of DMCF with S-shaped titanium endomedullary nail (TEN) and determine fracture telescoping from day one after surgery to the time of fracture healing. METHOD: In a prospective analytic cohort study over a 6-year period (2012-2017) at a Level II trauma care centre, a total of 128 patients with DMCF were included and classified according to the AO/OTA classification system. Group I was AO/OTA type 15.2A/15.2B (N = 68) and group II was AO/OTA type 15.2C (N = 60). After a modified open stabilization technique of each DMCF with IMN (S-shaped TEN), the dynamics of radiological assessed telescoping until union and rate of surgical adverse events were measured. Significance was assumed for p < 0.05. RESULTS: One day after surgery, fractured clavicles were lengthened slightly in both groups compared to the unfractured clavicules (group I: 1.2%; group II: 0.9%). After osseus consolidation, the fractured clavicules were significantly shortened in both groups (group I: - 2.9%; group II: - 3.6%). Measurement of the clavicular shortening at one day postsurgically and at consolidation revealed a mean telescoping of - 3.99% in group I and of - 4.6% in group II. The difference between the two groups was not significant (P = 0.522). The overall rate of major surgical adverse events was 2.3%. CONCLUSION: The proposed operative technique of IMN (stabilization of the DMCF with a long, S-shaped, tight-fitting TEN) provides enough axial stability to prevent significant telescoping of the comminuted fractures. The rate of nonunion is low and the overall rate of major adverse events is similar to the reported events after plate fixation in the literature.

Fractures of the coracoid process: a systematic review.

Background: Although fracture of the coracoid process (CF) used to be considered rare, it is now more commonly encountered due to increased awareness and advances in imaging methods. This review aimed to analyze reported cases of CF to determine its mechanism and appropriate treatment. Methods: PubMed and Scopus were searched using the terms "scapula fracture" and "coracoid fracture." The inclusion criteria were English full-text articles concerning CF that described patient characteristics with appropriate images. The exclusion criteria included cases without appropriate images and those with physeal injury or nonunion. Citation tracking was conducted to find additional articles and notable full-text articles in other languages. Fractures were mainly classified using Ogawa's classification. Results: Ninety-seven studies were identified, including 197 patients (131 men, 33 women; average age 37.0±16.9 years). CF was classified as type I in 77%, type II in 19%, and avulsion fracture at the angle in 5%. Concurrent shoulder girdle injuries included acromioclavicular injury in 33%, clavicular fracture in 17%, acromion or lateral scapular spine fracture in 15%, and anterior shoulder instability in 11%. Among patients with type I CF, 69% had multiple disruptions of the superior shoulder suspensory complex. Conservative treatment was applied in 71% of isolated type I CF, while surgical treatment was applied in 76% of type I CF with multiple disruptions. Although the evaluation methods varied, 60% of patients were followed up for more than 6 months, and the outcomes were generally satisfactory for both conservative and surgical treatments. Conclusion: CF occurred commonly in the age group with higher social activity. The most common fracture type was type I. The possible mechanism of CF is violent traction of the attached muscles, except for avulsion fracture at the angle. Type I CF with multiple disruptions of the superior shoulder suspensory complex requires surgical treatment, whereas conservative care is recommended for isolated type I and type II CFs.

Risk factors for hardware removal following operative treatment of middle- and distal-third clavicular fractures.

BACKGROUND: The incidence of hardware removal (HWR) after operative fixation of clavicular fractures varies widely. Risk factors related to HWR remain incompletely understood. The aim of this study was to evaluate the incidence of and risk factors for HWR after plate fixation of middle- and distal-third clavicular fractures. We hypothesized that (1) the total HWR incidence would be <20%, (2) the HWR incidence of operatively treated distal- and middle-third clavicular fractures would not be statistically different, and (3) symptomatic implants would be the most common HWR indication. METHODS: We performed a multi-hospital retrospective study of skeletally mature patients who underwent plate fixation of middle- and distal-third clavicular fractures from November 2008 to November 2018. Data included patient demographic characteristics, mechanism of injury, operative records, hardware-related symptoms, subsequent HWR, and complications. RESULTS: A total of 103 patients (aged 16-75 years, 76.7% male patients) were included. Of the patients, 87 (84.5%) underwent plate fixation for midshaft clavicular fractures and 16 (15.5%) underwent plate fixation for distal-third clavicular fractures. HWR was performed in 13 patients (12.6%). A significantly higher percentage of HWR procedures were performed for distal clavicular fractures (50%) than for middle-third clavicular fractures (4.9%, P < .0001). An initial high-energy mechanism of injury was associated with HWR (P = .0025). The most common indication for HWR was symptomatic hardware (69.2%). The overall complication rate was 14.5%. CONCLUSION: The overall incidence of clavicular HWR was 12.6%. A distal fracture location was associated with a significantly higher incidence of HWR. An initial high-energy mechanism of injury was a significant risk factor for HWR. The primary indication for HWR was symptomatic hardware.

The relationship between the location of neonatal clavicular fractures and predisposing factors.

BACKGROUND: The aim was to investigate the maternal and fetal predisposing factors of clavicle fracture locations in newborns. METHODS: A retrospective evaluation was made of 77 clavicle fractures identified from a total of 33,480 live newborns between September 2016 and September 2018 at a single center in Turkey. Fractures were grouped according to the Allman classification: Group I mid third, Group II lateral distal third, Group III medial proximal third of the clavicle, respectively. Demographic features compared between the groups included maternal age, parity and height and infantile gestational age, gender, birth weight and length. Neonatal clinical features were also compared between the three groups and included mode of delivery, Apgar score, fracture laterality, time to diagnosis, mode of diagnosis, and presence of symptoms of brachial plexus palsy. RESULTS: There were no statistically significant differences between the three groups when the demographic characteristics of the mothers and newborns were compared. In terms of clinical characteristics Group 3 contained a higher proportion of patients with symptoms of brachial plexus palsy than Group 1 (61.5% versus 22%, p = 0.017). There was no statistically significant difference between Groups 2 and 3 and Groups 1 and 2. CONCLUSION: A significant association was found between the occurrence of brachial plexus palsy and fracture of the medial third of the clavicle (Allman type III).