Session I - Upper Extremity

Operative Fixation of High-Energy Displaced Mid-Shaft Clavicle Fractures

Lisa K. Cannada, MD; Allen Deutsch, MD; Mehrun K. Elyaderani, MD; Roger G. Wilber, MD; John H. Wilber, MD, Metro Health Medical Center, Cleveland, OH

Purpose: We reviewed the results of operative treatment of 22 high-energy clavicle fractures in order to determine union and complication rates and perform a functional outcome assessment. Severely displaced fractures of the clavicle that are sustained during high-energy trauma can result in debilitating deformity that prevents normal shoulder function. These patients frequently suffer severe associated injuries to the chest, brachial plexus, head, and upper extremity. Prompt fixation of these clavicle fractures permits increased patient comfort, improved patient mobility, necessary access to thoracic injuries, and earlier rehabilitation. In cases with associated scapula fractures, fixation of the clavicle may provide reconstruction of shoulder mechanics leading to improved function.

The literature suggests that primary fixation of clavicle fractures carries a complication rate ranging between 12- 23% with a 5-17% nonunion rate. Nonoperative treatment of high-energy fractures of the clavicle with severe axial shortening is associated with a nonunion rate of 13-18% and a delayed union rate of 25%. Our experience with operative fixation of these high-energy injuries has demonstrated a low risk for complications and has aided the convalescence of these multiply injured patients.

Methods: Between 1992 and 1998, 22 adult patients with mid-shaft clavicle fractures were treated with plate fixation at a level 1 trauma center. The mechanism of injury was a motor vehicle or motorcycle accident (12 patients), traumatic sports accident (7), industrial accident (1), pedestrian struck (1), and fall from a height (1). The indications for operative intervention included high-energy clavicle fractures with ipsilateral shoulder girdle and thoracic injuries. Additional fractures demonstrated marked displacement, angulation, and comminution preventing closed reduction, which was suggestive of soft-tissue interposition. Associated thoracic injuries included 9 pneumothoraces, 14 pulmonary contusions, and rib fractures in 15 patients. There were 3 open fractures. There were 4 associated brachial plexus injuries. Eight patients had isolated clavicle fractures. Ipsilateral shoulder girdle injuries included 10 unstable scapular neck fractures, 1 proximal humerus fracture, 1 humeral shaft fracture, 3 glenoid articular fractures, and 1 scapulothoracic dissociation.

Clinical follow-up until union was available in 19 of 22 patients. Radiographs were reviewed in order to classify all fractures according to the OTA fracture classification and to evaluate fracture displacement and fixation technique. Physical examination and/or telephone interviews were conducted to assess shoulder function. Functional outcome and patient satisfaction were assessed with the American Shoulder and Elbow Surgeons' (ASES) shoulder form, the Constant Score, and the SF-36 health survey. Injury severity scores (ISS) were obtained along with the maximum Chest Abbreviated Injury Score (AIS) to indicate the ipsilateral trunk injury severity.

Results: There were 18 males and 4 females with an average age of 32 years (range, 19-50 years) and a mean follow-up of 30.3 months (range 2-80 months). Patients had an average ISS score of 17 (range, 9 - 45) and 13 patients had severe chest trauma as indicated by an AIS score of 3 or greater. Classification of the clavicle fractures included (2) 06-A1and A3, (3) 06-A2, (8) 06-B.2 and (7) 06-B.3. Radiographs demonstrated an average of 1.4 cm (range, 0.5-4.5 cm) of axial shortening and 125% displacement. Our surgical technique emphasizes careful elevation of the platysma muscle for later reattachment. Special attention is directed at preservation of all soft tissue attachments to the fracture fragments. Osteosynthesis was carried out with the use of plate fixation in all patients; a 3.5 reconstruction plate in 17 patients and a LCDC plate in 5 patients. A minimum of 3 screws were placed in the proximal and distal fragments in all but 2 patients. The operative procedure was performed at an average of 5 days post-injury in all but 2 patients. Of the 10 patients with associated scapular neck fractures none had operative fixation of the scapula. Two patients had operative fixation of a humerus fracture, and 2 of a glenoid articular fracture. Time to union as determined by radiographic and clinical evaluation was 8 weeks (range, 6-10 weeks). There were no cases of non-union. Four plates were removed for prominence and local cutaneous irritation. The average SF-36 score was 103. Functional assessment by the ASES Shoulder score demonstrated a mean of 89. The mean Constant score was 93. A delayed deep infection developed in 1 patient 7 weeks postoperatively. This patient was treated with removal of the implant, intravenous antibiotics, and subsequently had an excellent result at final follow-up.

Discussion & Conclusion: The purpose of this investigation was to report the results of internal fixation of high-energy, severely displaced mid-shaft clavicle fractures treated at a level I trauma institution. The frequent association of chest and shoulder girdle injuries in these patients makes early fixation a beneficial factor in their recovery. We believe that early fixation should be considered in the treatment algorithm of these patients because it may result in a better long-term functional result. The recent literature suggests that primary fixation of high-energy clavicle fractures results in a 5-17% nonunion rate. We found a union rate of 100% with no instances of delayed union. It is interesting to note that in our study population, patients with ipsilateral clavicle and scapular neck fractures that underwent clavicular fixation achieved good functional results without fixation of their scapular neck fractures. Operative fixation allowed for earlier rehabilitation with a high level of patient satisfaction with respect to shoulder function. Stable operative fixation performed in high-energy clavicle fractures can be a safe and effective method of treatment which restores shoulder function with minimal complications.