Sat., 10/6/12 Upper Extremity Injuries, PAPER #85, 10:44 am OTA-2012
Minimally Displaced Clavicle Fracture on Initial Trauma Survey: A Benign Injury?
John Riehl, MD; Bill Athans, MD; Mark Munro, MD; Joshua Langford, MD;
Stanley Kupiszewski, MD; George J. Haidukewych, MD; Kenneth J. Koval, MD;
Orlando Regional Medical Center, Orlando, Florida, USA
Purpose: Minimally displaced clavicle fractures are often considered to be a benign injury. However, it has been our experience that minimally displaced clavicle fractures on initial chest radiograph in patients sustaining high-energy trauma may displace during the early follow-up period and therefore warrant close radiographic follow-up. This study was performed to evaluate subsequent fracture displacement in patients sustaining high-energy trauma when a supine chest radiograph on initial trauma survey revealed a well-aligned clavicle fracture.
Methods: This was a retrospective review of patients treated at a Level I trauma center from 2005–2010. Inclusion criteria consisted of: (1) trauma alert patient, (2) patient age ≥18 years, (3) a midshaft clavicle fracture (AO/OTA type 15-B) present on initial survey supine chest radiograph, (4) initial fracture displacement <100% of the clavicle shaft width, and (5) follow-up radiographs between 2 days and 6 weeks of injury clearly showing the clavicle. Initial analyses were performed to determine the rate of fracture displacement >100% of the shaft width on follow-up radiographs. Secondary analyses evaluated those fractures that had initial displacement ≤3 mm who later displaced >100%. This definition of displacement was based on previous work that showed displacement of 100% to be predictive of nonunion.
Results: 95 clavicle fractures met the inclusion criteria. On follow-up, 57 of 95 fractures (60%) had displacement >100% of the shaft width. Of these 57 patients, 12 (21%) had subsequent surgical stabilization. 31 of 95 patients (33%) had initial fracture displacement ≤3 mm (group A) while the remaining 64 had displacement >3 mm but <100% of the clavicle shaft width (group B). In group A, 10 of 31 fractures (32%) had displacement >100% of the shaft width on follow-up radiographs. This displacement was evident at 7 days in 7 of 10 patients, and in all 10 patients by 3 weeks. The subsequent displacement of these fractures from initial to follow-up radiographs averaged 15 mm (range, 8-25 mm). Three of ten patients in group A (30%) had subsequent surgical stabilization. In group B, 47 of 64 fractures (73%) had fracture displacement >100% of the shaft width on follow-up radiographs. This displacement was evident at 7 days in 31 of 47 patients (66%), and in 44 of 47 patients (94%) by 3 weeks. 9 of 47 patients in group B (19%) underwent subsequent surgical stabilization.
Conclusion: Clavicle fractures in patients who sustain a high-energy injury have a high propensity to displace on follow-up radiographs, even when initially minimally displaced. 60% of minimally displaced fractures on initial supine chest radiograph had >100% displacement on early follow-up. One-third of fractures with initial displacement ≤3 mm had subsequent displacement >100%. This displacement may change subsequent fracture management in order to provide optimal patient outcomes. We recommend close follow-up of all clavicle fractures to evaluate for subsequent fracture displacement.
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• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing. Δ OTA Grant.