Abstract
Background
Clavicular fractures account for nearly 10 % of all fractures, and the majority of those fractures involve the midshaft. Historically, these fractures were treated nonoperatively; however, recent data suggest an increased risk of nonunion and symptomatic malunion for displaced, comminuted midshaft clavicular fractures treated conservatively. Surgical intervention via plate osteosynthesis or intramedullary fixation with pins, nails, or screws has been shown to reduce, but not eliminate, this risk. Identification of risk factors predictive of nonunion would improve the overall management of displaced, comminuted midshaft clavicular fractures.
Methods
The medical records of 337 consecutive patients who underwent Knowles pin fixation and supplemental cerclage for the treatment of displaced, comminuted midshaft clavicular fractures between April 2007 and March 2009 were retrospectively reviewed. The records of the mechanism of injury, side of injury, Robinson fracture classification, presence of associated injuries, cerclage material, and patient-related variables, including diabetes mellitus, hypertension and smoking, were analyzed. Variables were assessed by univariate and multivariate analysis to identify those factors significantly associated with the development of fracture nonunion.
Results
A total of 19 nonunions occurred. Increasing age and use of wire for supplemental cerclage fixation were significantly associated with an increased risk for fracture nonunion (p < 0.001). Although suggested as predictors of nonunion in other studies, female gender and fracture severity were not significantly associated with nonunion.
Conclusions
Nonunion remains a significant complication in the treatment of displaced, comminuted midshaft clavicular fractures even with intramedullary fixation. Use of absorbable suture in place of wire for cerclage fixation and careful selection of treatment strategy in the elderly may reduce the risk for nonunion.
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References
Kulshrestha V, Roy T, Audige L (2011) Operative versus nonoperative management of displaced midshaft clavicle fractures: a prospective cohort study. J Orthop Trauma 25(1):31–38
Smekal V, Oberladstaetter J, Struve P, Krappinger D (2009) Shaft fractures of the clavicle: current concepts. Acta Orthop Trauma Surg 129(6):807–815
Hillen RJ, Burger BJ, Pöll RG, de Gast A, Robinson CM (2010) Malunion after midshaft clavicle fractures in adults. Acta Orthop 81(3):273–279
Robinson CM (1998) Fractures of the clavicle in the adult. Epidemiology and classification. J Bone Jt Surg Br 80(3):476–484
Nordqvist A, Petersson CJ, Redlund-Johnell I (1998) Mid-clavicle fractures in adults: end result study after conservative treatment. J Orthop Trauma 12(8):572–576
Post M (1989) Current concepts in the treatment of fractures of the clavicle. Clin Orthop Relat Res 245:89–101
Smekal V, Deml C, Kamelger F, Dallapozza C, Krappinger D (2010) Corrective osteotomy in symptomatic midshaft clavicular malunion using elastic stable intramedullary nails. Arch Orthop Trauma Surg 130:681–685
Chu CM, Wang SJ, Lin LC (2002) Fixation of mid-third clavicular fractures with Knowles pins. Acta Orthop Scand 73(2):134–139
Zenni EJ Jr, Krieg JK, Rosen MJ (1981) Open reduction and internal fixation of clavicular fractures. J Bone Jt Surg Am 63(1):147–151
Robinson CM, Court-Brown CM, McQueen MM, Wakefield AE (2004) Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. J Bone Jt Surg Am 86-A(7):1359–1365
Brinker MR, Edwards TB, O’Connor DP (2005) Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture (letter). J Bone Jt Surg Am 87:676–677
Altamimi SA, McKee MD (2008) Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. Surgical technique. J Bone Jt Surg Am 90(Suppl 2 Pt 1):1–8
Lenza M, Belloti JC, Gomes Dos Santos JB, Matsumoto MH, Faloppa F (2009) Surgical interventions for treating acute fractures or non-union of the middle third of the clavicle. Cochrane Database Syst Rev (4):CD007428
McKee MD (2010) Clavicle fractures in 2010: sling/swathe or open reduction and internal fixation? Orthop Clin North Am 41(2):225–231
Zlowodzki M, Zelle BA, Cole PA, Jeray K, McKee MD, Evidence-Based Orthopaedic Trauma Working Group (2005) Treatment of acute midshaft clavicle fractures: systematic review of 2144 fractures: on behalf of the Evidence-Based Orthopaedic Trauma Working Group. J Orthop Trauma 19(7):504–507
McKee RC, Whelan DB, Schemitsch EH, McKee MD (2012) Operative versus nonoperative care of displaced midshaft clavicular fractures: a meta-analysis of randomized clinical trials. J Bone Jt Surg Am 94(8):675–684
Neviaser RJ, Neviaser JS, Neviaser TJ, Neviaser JS (1975) A simple technique for internal fixation of the clavicle. A long term evaluation. Clin Orthop Relat Res 109:103–107
Lee YS, Lin CC, Huang CR, Chen CN, Liao WY (2007) Operative treatment of midclavicular fractures in 62 elderly patients: Knowles pin versus plate. Orthopedics 30(11):959–964
Lee YS, Huang HL, Lo TY, Hsieh YF, Huang CR (2008) Surgical treatment of midclavicular fractures: a prospective comparison of Knowles pinning and plate fixation. Int Orthop 32(4):541–545
Neer CS 2nd (1960) Nonunion of the clavicle. JAMA 172:1006–1011
McKee MD, Wild LM, Schemitsch EH (2004) Midshaft malunions of the clavicle. Surgical technique. J Bone Jt Surg Am 86-A(Suppl 1):37–43
Kim W, McKee MD (2008) Management of acute clavicle fractures. Orthop Clin North Am 39(4):491–505
Liu HH, Chang CH, Chia WT, Chen CH, Tarng YW, Wong CY (2010) Comparison of plates versus intramedullary nails for fixation of displaced midshaft clavicular fractures. J Trauma 69(6):E82–E87
Kitsis CK, Marino AJ, Krikler SJ, Birch R (2003) Late complications following clavicular fractures and their operative management. Injury 34(1):69–74
Pearson AM, Tosteson AN, Koval KJ, McKee MD, Cantu RV, Bell JE, Vicente M (2010) Is surgery for displaced, midshaft clavicle fractures in adults cost-effective? Results based on a mulitcenter randomized, controlled trial. J Orthop Trauma 24(7):426–433
Frigg A, Rillmann P, Perren T, Gerber M, Ryf C (2009) Intramedullary nailing of clavicular midshaft fractures with the titanium elastic nail: problems and complications. Am J Sports Med 37(2):352–359
Basamania CJ (1999) Claviculoplasty and intramedullary fixation of malunited shortened clavicle fractures. J Should Elbow Surg 8:540 (abstract)
Basamania CJ (2003) Treatment of clavicular fractures and malunions. In: Levine WN, Marra G, Bigliani LU (eds) Fractures of the shoulder girdle. Informa Healthcare, UK, pp 222–248
Ferran NA, Hodgson P, Vannet N, Williams R, Evans RO (2010) Locked intramedullary fixation versus plating for displaced and shortened mid-shaft clavicle fractures: a randomized trial. J Should Elbow Surg 19(6):783–789
Parker MJ, Raghavan R, Gurusamy K (2007) Incidence of fracture-healing complications after femoral neck fractures. Clin Orthop Relat Res 458:175–179
Bidula JC, Boehm C, Powell K, Barsoum W, Nakamoto C, Mascha E, Muschler GF (2006) Osteogenic progenitors in bone marrow aspirates from smokers and nonsmokers. Clin Orthop Relat Res 442:252–259
Chang IL, Lee TS, Ku MC (1994) Treatment of femoral fracture with nonunion. Kao-Hsiung i Hsueh Ko Hsueh Tsa Chih (Kaohsiung J Med Sci) 10(10):543–549
Solberg BD, Moon CN, Nissim AA, Wilson MT, Marqulies DR (2009) Treatment of chest wall implosion injuries without thoracotomy: technique and clinical outcomes. J Trauma 67(1):8–13
Noumi TK, Yokoyama K, Ohtsuka H, Nakamura K, Itoman M (2005) Intramedullary nailing for open fractures of the femoral shaft: evaluation of contributing factors on deep infection and nonunion using multivariate analysis. Injury 36(9):1085–1093
el Moumni M, Leenhouts PA, ten Duis HJ, Wendt KW (2009) The incidence of non-union following unreamed intramedullary nailing of femoral shaft fractures. Injury 40(2):205–208
Weiss JM, Graves S, Yang S, Mendelsohn E, Kay RM, Skaggs DL (2009) A new classification system predictive of complications in surgically treated pediatric humeral lateral condyle fractures. J Pediatr Orthop 29(6):602–605
O’Neill BJ, Hirpara KM, O’Briain D, McGarr C, Kaar TK (2011) Clavicle fractures: a comparison of five classification systems and their relationship to treatment outcomes. Int Orthop 35(6):909–914
Böhme JA, Bonk A, Bacher GO, Wilharm A, Hoffmann R, Josten C (2011) Current treatment concepts for mid-shaft fractures of the clavicle—results of a prospective multicentre study. Zeitschrift fur Orthopadie & Unfallchirurgie 149(1):68–76
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Wu, CL., Chang, HC. & Lu, KH. Risk factors for nonunion in 337 displaced midshaft clavicular fractures treated with Knowles pin fixation. Arch Orthop Trauma Surg 133, 15–22 (2013). https://doi.org/10.1007/s00402-012-1631-3
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DOI: https://doi.org/10.1007/s00402-012-1631-3