Aims. Tobacco, in addition to being one of the greatest public health threats facing our world, is believed to have deleterious effects on bone metabolism and especially on bone healing. It has been described in the literature that patients who smoke are approximately twice as likely to develop a nonunion following a non-specific bone fracture. For clavicle fractures, this risk is unclear, as is the impact that such a complication might have on the initial management of these fractures. Methods. A systematic review and meta-analysis were performed for conservatively treated displaced midshaft clavicle fractures. Embase, PubMed, and Cochrane Central Register of Controlled Trials (via Cochrane Library) were searched from inception to 12 May 2022, with supplementary searches in Open Grey, ClinicalTrials.gov, ProQuest Dissertations & Theses, and Google Scholar. The searches were performed without limits for publication date or languages. Results. The meta-analysis included eight studies, 2,285 observations, and 304 events (nonunion). The random effects model predicted a pooled risk ratio (RR) of 3.68 (95% confidence interval 1.87 to 7.23), which can be considered significant (p = 0.003). It indicates that smoking more than triples the risk of nonunion when a fracture is treated conservatively. Conclusion. Smoking confers a RR of 3.68 for developing a nonunion in patients with a displaced middle third clavicle fracture treated conservatively. We know that most patients with pseudarthrosis will have pain and a poor functional outcome. Therefore, patients should be informed of the significantly higher risks of nonunion and offered smoking cessation efforts and counselling. Moreover, surgery should be considered for any patient who smokes with this type of fracture. Cite this article: Bone Joint J 2023;105-B(7):801–807

Aims. The primary aim of this study was to establish the cost-effectiveness of the early fixation of displaced midshaft clavicle fractures. Patients and Methods. A cost analysis was conducted within a randomized controlled trial comparing conservative management (n = 92) versus early plate fixation (n = 86) of displaced midshaft clavicular fractures. The incremental cost-effectiveness ratio (ICER) was used to express the cost per quality-adjusted life-year (QALY). The Six-Dimension Short-Form Health Survey (SF-6D) score was used as the preference-based health index to calculate the cost per QALY at 12 months after the injury. Results. The mean 12-month SF-6D was 0.9522 (95% confidence interval (CI) 0.9355 to 0.9689) following conservative management and 0.9607 (95% CI 0.9447 to 0.9767) following fixation, giving an advantage for fixation of 0.0085, which was not statistically significant (p = 0.46). The mean cost per patient was £1322.69 for conservative management and £5405.32 for early fixation. This gave an ICER of £480 309.41 per QALY. For a threshold of £20 000 per QALY, the benefit of fixation would need to be present for 24 years to be cost-effective compared with conservative treatment. Linear regression analysis identified nonunion as the only factor to adversely influence the SF-6D at 12 months (p < 0.001). Conclusion. Routine plate fixation of displaced midshaft clavicular fractures is not cost-effective. Nonunion following conservative management has an increased morbidity with comparable expense to early fixation. This may suggest that a targeted approach of fixation in patients who are at higher risk of nonunion would be more cost-effective than the routine fixation of all displaced fractures. Cite this article: Bone Joint J 2019;101-B:995–1001

Aims. Recent studies of nonoperatively treated displaced midshaft clavicular fractures have shown a high incidence of nonunion and unsatisfactory functional outcome. Some studies have shown superior functional results and higher rates of healing following operative treatment. The aim of this study was to compare the outcome in these patients after nonoperative management with those treated with fixation. Patients and Methods. In a multicentre, parallel randomized controlled trial, 146 adult patients with an acute displaced fracture of the midthird of the clavicle were randomized to either nonoperative treatment with a sling (71, 55 men and 16 women with a mean age of 39 years, 18 to 60) or fixation with a pre-contoured plate and locking screws (75, 64 men and 11 women with a mean age of 40 years, 18 to 60). Outcome was assessed using the Disabilities of the Arm, Shoulder and Hand (DASH) Score, the Constant Score, and radiographical evidence of union. Patients were followed for one year. Results. A total of 60 patients in the nonoperative group and 64 in the operative group completed one-year follow-up. At three months’ follow-up, both the median DASH (1.7 vs 8.3) and median Constant scores (97 vs 90) were significantly better in the operated group (both p = 0.02). After six months and one year, there was no difference in the median DASH or Constant scores. The rate of nonunion was lower in the operative group (2 vs 11 patients, p < 0.02). Nine patients in the nonoperative group underwent surgery for nonunion. The plate was subsequently removed in 16 patients (25%). One patient had a new fracture after removal of the plate and one underwent revision surgery for failure of fixation. Conclusion. Fixation of a displaced midshaft clavicular fracture using a pre-contoured plate and locking screws results in faster functional recovery and a higher rate of union compared with nonoperative management, but the function of the shoulder is equal after six months and at one year. Cite this article: Bone Joint J 2018;100-B:1385–91

Aims. To evaluate if union of clavicle fractures can be predicted at six weeks post-injury by the presence of bridging callus on ultrasound. Methods. Adult patients managed nonoperatively with a displaced mid-shaft clavicle were recruited prospectively. Ultrasound evaluation of the fracture was undertaken to determine if sonographic bridging callus was present. Clinical risk factors at six weeks were used to stratify patients at high risk of nonunion with a combination of Quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) ≥ 40, fracture movement on examination, or absence of callus on radiograph. Results. A total of 112 patients completed follow-up at six months with a nonunion incidence of 16.7% (n = 18/112). Sonographic bridging callus was detected in 62.5% (n = 70/112) of the cohort at six weeks post-injury. If present, union occurred in 98.6% of the fractures (n = 69/70). If absent, nonunion developed in 40.5% of cases (n = 17/42). The sensitivity to predict union with sonographic bridging callus at six weeks was 73.4% and the specificity was 94.4%. Regression analysis found that failure to detect sonographic bridging callus at six weeks was associated with older age, female sex, simple fracture pattern, smoking, and greater fracture displacement (Nagelkerke R. 2. = 0.48). Of the cohort, 30.4% (n = 34/112) had absent sonographic bridging callus in addition to one or more of the clinical risk factors at six weeks that predispose to nonunion. If one was present the nonunion rate was 35%, 60% with two, and 100% when combined with all three. Conclusion. Ultrasound combined with clinical risk factors can accurately predict fracture healing at six weeks following a displaced midshaft clavicle fracture. Cite this article: Bone Joint Res 2021;10(2):113–121

Aims

The aims of this network meta-analysis (NMA) were to examine nonunion rates and functional outcomes following various operative and nonoperative treatments for displaced mid-shaft clavicle fractures.

Aims

It is unclear whether acute plate fixation facilitates earlier return of normal shoulder function following a displaced mid-shaft clavicular fracture compared with nonoperative management when union occurs. The primary aim of this study was to establish whether acute plate fixation was associated with a greater return of normal shoulder function when compared with nonoperative management in patients who unite their fractures. The secondary aim was to investigate whether there were identifiable predictors associated with return of normal shoulder function in patients who achieve union with nonoperative management.

Aims

To compare the functionality of adults with displaced mid-shaft clavicular fractures treated either operatively or nonoperatively and to compare the relative risk of nonunion and reoperation between the two groups.

The December 2022 Shoulder & Elbow Roundup. 360. looks at: Biceps tenotomy versus soft-tissue tenodesis in females aged 60 years and older with rotator cuff tears; Resistance training combined with corticosteroid injections or tendon needling in patients with lateral elbow tendinopathy; Two-year functional outcomes of completely displaced midshaft clavicle fractures in adolescents; Patients who undergo rotator cuff repair can safely return to driving at two weeks postoperatively; Are two plates better than one? A systematic review of dual plating for acute midshaft clavicle fractures; Treatment of acute distal biceps tendon ruptures; Rotator cuff tendinopathy: disability associated with depression rather than pathology severity; Coonrad-Morrey total elbow arthroplasty implications in young patients with post-traumatic sequelae

Introduction

Clavicle fractures accounting for 3–5% of all adult fractures are usually treated non-operatively. There is an increasing trend towards their surgical fixation.

The primary aim of this study was to undertake a cost-effectiveness analysis (CEA) of acute fixation versus conservative management of displaced midshaft clavicle fractures. The secondary aim was to conduct a sensitivity analysis of patient characteristics that may influence a threshold of £20,000 per quality-adjusted life year gained (QALY). A CEA was conducted from a randomised control trial comparing conservative management (n=92) to acute plate fixation (n=86) of displaced midshaft clavicle fractures. The incremental cost effectiveness ratio (ICER) was used to express the cost per QALY. The short form 6-dimensional (SF-6D) score was the preference based index to calculate the cost per QALY. The 12-month SF-6D advantage of acute fixation over conservative management was 0.0085 (p=0.464) with a mean cost difference of £4,096.22 and resultant ICER of £481,908.24/QALY. For a threshold of £20,000/QALY the benefit of acute fixation would need to be present for 24.1 years. Linear regression analysis identified nonunion as the only independent factor to influence the SF-6D at 12-months (p<0.001). Conservatively managed fractures that resulted in a nonunion (n=16) had a significantly worse SF-6D compared to acute fixation (0.0723, p=0.001) with comparable healthcare cost at 12-months (£170.12 difference). Modelling the ICER of acute fixation against those complicated by a nonunion proved to be cost effective at £2,352.97/QALY at 12-months. Routine plate fixation of displaced midshaft clavicle fractures is not cost-effective. Patients with nonunion after conservative management have increased morbidity with comparable expense to those undergoing acute fixation which suggests targeting these patients is a more cost-effective strategy

Background:. Displaced midshaft clavicle fractures unite well in children less than 12 years old, owing to their inherent ability to remodel bone. In adolescents, remodeling occurs less and deformity or shortening can result. Recent literature in adults shows improved outcomes of these fractures with operative treatment. It has been suggested that these results may translate to adolescents. Study Objective:. To assess the effectiveness of titanium elastic TEN nails in the treatment of displaced midshaft clavicle fractures in adolescents. Methods:. Adolescent patients (age 12 to 18) with closed displaced midshaft clavicle fractures, sustained between 2008 and 2014, were treated operatively by a single surgeon, who inserted a TEN nail in an unreamed fashion from the sternal end of the clavicle. Post-operatively, patients were immobilised in a sling for 6 weeks. The nail was removed routinely at 12 weeks. All patients were assessed by the surgeon at 24 weeks with regards to the radiological outcome, Constant shoulder score, scar quality and complications. Results:. Thirteen patients, 9 males and 4 females (mean age 14,2 years) were assessed. Eleven patients had complete union by 6 weeks and the remaining two by 12 weeks. The Constant score was graded below 11 for all patients by 12 weeks follow up and all patients were satisfied with their scars after 24 weeks. Two patients developed complications: in one, the nail perforated the posterior cortex of the lateral fragment and the other developed a haematoma. Conclusion:. Operative treatment with a TEN nail is a safe, minimally invasive and reliable treatment method for displaced midshaft clavicle fractures in adolescents resulting in a satisfactory surgical outcome

Non-union has traditionally been considered a rare complication following the non-operative management of clavicle fractures. Recent studies demonstrate higher rates of non-union in adults with displaced fractures, yet the variables predicting non-union remain unclear. We evaluated the prevalence and risk factors for non-union following displaced midshaft clavicle fractures in a large consecutive series of patients managed non-operatively. 1097 consecutive adults (mean age 26.1yrs) with displaced midshaft clavicle fractures treated non-operatively in our Unit were included. All patients were interviewed, examined and underwent radiological assessment within a week of injury. All patients were managed in a sling for two weeks followed by early mobilization. All patients were followed-up until clinical and radiological confirmation of union. Non-union was defined clinically as pain or mobility of the fracture segments on stressing, and radiologically as failure of cortical bridging by 6 months. 198 (18%) of patients had evidence of non-union at 6 months. Patient factors associated with non-union included increasing age, smoking and the presence of medical comorbidities (p<0.05). Injury-related factors associated with non-union included increasing fragment translation and displacement, and injury pattern (Edinburgh 2B2: comminuted segmental fracture)(p<0.01). We present the largest series reporting prevalence and risk factors for non-union following conservatively treated, displaced midshaft clavicle fractures. These fractures can no longer be viewed as a single clinical entity, but as a spectrum of injuries each requiring individualized assessment and treatment. Increased understanding of the outcomes of these injuries will enable clinicians to better identify those patients that may be better served with primary operative reconstruction

Background. Non-union has traditionally been considered a rare complication following the non-operative management of clavicle fractures. A growing body of evidence has demonstrated higher rates of non-union in adults with displaced fractures. However, the variables that predict non-union in these patients remain unclear. We evaluated the prevalence and risk factors for non-union following displaced midshaft clavicle fractures in a large consecutive series of patients managed non-operatively in our Unit. Materials and Methods. 1097 consecutive adults (mean age 26.1yrs) with displaced midshaft clavicle fractures treated non-operatively in our Unit were included. All patients were interviewed and examined by an orthopaedic trauma surgeon and underwent radiological assessment within a week of injury. All patients were managed in a simple sling for two weeks followed by early mobilization. All patients were followed-up until clinical and radiological confirmation of union. Non-union was defined clinically as the presence of pain or mobility of the fracture segments on stressing, and radiologically as failure of cortical bridging by 6 months. Results. 198 (18%) of patients had evidence of non-union at 6 months. Patient factors significantly associated with non-union included increasing age, smoking and the presence of medical comorbidities (p<0.05). Injury-related factors associated with non-union included Increasing fragment translation and displacement, and a severe pattern of injury (Edinburgh 2B2: comminuted segmental fracture)(p<0.01). Conclusions. We present the largest series reporting the prevalence and risk factors for non-union following conservatively treated, displaced midshaft clavicle fractures. These fractures can no longer be viewed as a single clinical entity, but as a spectrum of injuries each requiring individualized assessment and treatment. Increased understanding of the outcomes of these injuries will enable clinicians to better identify those patients that may be better served with primary operative reconstruction

This study aimed to evaluate the effect of clavicular shortening, measured by three-dimensional computerized tomography (3DCT), on functional outcomes and satisfaction in patients with healed, displaced, midshaft clavicle fractures up to one year following injury. The data used in this study were collected as part of a multicenter, prospective randomized control trial comparing open reduction and plate fixation with nonoperative treatment for displaced midshaft clavicle factures. Patients who were randomized to nonoperative treatment and who had healed by one year were included. Clavicle shortening relative to the uninjured contralateral clavicle was measured on 3DCT. Outcome analysis was conducted at six weeks, three months, six months and one year following injury and included the Disabilities of the Arm, Shoulder and Hand (DASH), Constant and Short Form-12 (SF-12) scores, and patient satisfaction. 48 patients were included. The mean shortening of injured clavicles, relative to the contralateral side, was 11mm (+/− 7.6mm) with a mean proportional shortening of 8percnt;. Proportional shortening did not significantly correlate with the DASH (p>0.42), Constant (p>0.32) or SF-12 (p>0.08) scores at any time point. There was no significant difference in the mean DASH or Constant scores at any followup time point both when the cut off for shortening was defined as one centimeter (p>0.11) or two centimeters (p>0.35). There was no significant difference in clavicle shortening between satisfied and unsatisfied patients (p>0.49). This study demonstrated no association between shortening and functional outcome or satisfaction in patients with healed, displaced, midshaft clavicle fractures up to one year following injury

Purpose. Displaced midshaft clavicular fractures are a common injury with a high occurrence rate in young, active individuals. Non-operative care has traditionally been the standard of care for such fractures, but more recent studies have suggested benefits following primary operative fixation. The purpose of this study was to review the literature on displaced midshaft clavicle fractures, identify randomized controlled trials of operative versus non-operative treatment, and pool the functional outcome and complication rates (including nonunion and symptomatic malunion), to arrive at summary estimates of these outcomes. Method. A systematic review of the literature was performed to identify studies of randomized controlled trials comparing operative versus non-operative care for displaced midshaft clavicle fractures. Meeting abstracts were also searched and included in this study. Results. Six randomized controlled trials (n=421 patients, mean Detsky score= 15.2) were identified and included. The nonunion rate was higher in the non-operative group (28/207) then it was in patients treated operatively (3/214) (p<0.001). The rate of symptomatic malunion was higher in the non-operative group (15/207) than the operative group (0/214) (p<0.001). The total complication rate was 71 complications in 214 operative cases (33%), and 93 complications in 207 non-operative cases (45%)(p=0.016). The Constant Shoulder scores (CS) and Disability of the Arm, Shoulder and Hand (DASH) scores showed marginally improved (mean 4.1 point increase in CS at one year, mean 5.8 point decrease in DASH at one year) functional values in the operative group: this difference was especially marked in the early post operative period. Conclusion. Operative treatment provided lower complication rates (especially nonunion and symptomatic malunion) and an earlier functional return compared to non-operative treatment. However, there is little evidence at present to show that the long term effects of operative intervention are significantly superior to non-operative care

Sonographic callus may enable assessment of fracture healing. The aim of this study was to establish a reliable method for three-dimensional reconstruction of sonographic callus. Patients that underwent non-operative management of displaced midshaft clavicle fractures and intramedullary nailing of tibia fractures were prospectively recruited and followed to union. Ultrasound scanning was performed at periodical time points following injury. Infra-red tracking technology was used to map each image to a three-dimensional lattice. Criteria was fist established for two-dimensional bridging callus detection in a pilot study. Using echo intensity of the ultrasound image, semi-automated mapping was used to create an anatomic three-dimensional representation of fracture healing. Agreement on the presence of sonographic bridging callus was assessed using the kappa coefficient and intra-class-correlation (ICC) between observers. 112 clavicle fractures and 10 tibia fractures completed follow-up at six months. Sonographic bridging callus was detected in 62.5% (n=70/112) of the clavicles at six weeks post-injury. If present, union occurred in 98.6% of the fractures (n=69/70). If absent, nonunion developed in 40.5% of cases (n=17/42)(73.4%-sensitive and 100%-specific to predict union). Out of 10 tibia fractures, 7 had bridging callus of at least one cortex at 6 weeks and when present all united. Of the three patients lacking sonographic bridging callus, one went onto a nonunion (77.8%-sensitive and 100%-specific to predict union). The ICC for sonographic callus between four reviewers was 0.82 (95% CI 0.68–0.91). Three-dimensional ultrasound reconstruction of bridging callus has the potential to identify impaired fracture healing at an early stage in fracture management

Abstract. Objectives. We aimed to evaluate if union of clavicle fractures can be predicted at six weeks post-injury by the presence of bridging callus detected by ultrasound. Methods. Adult patients who sustained a displaced midshaft clavicle were recruited prospectively. We assessed patient demographics, functional scores and radiographic predictors with a standardized protocol at six weeks. Ultrasound evaluation of the fracture site was undertaken to determine if sonographic bridging callus was present. Nonunion was determined by CT scanning at six months post-injury. Clinical features at six weeks were used to stratify patients at high risk of nonunion and a QuickDASH ≥40, fracture movement on examination or absence of callus on radiograph. Results. 112 patients completed follow-up at six months with a nonunion incidence of 17% (n=18/112). Sonographic bridging callus was detected in 62.5% (n=70/112) of the cohort at six weeks post-injury. If present, union occurred in 98.6% of the fractures (n=69/70). If absent, nonunion developed in 40.5% of cases (n=17/42). The sensitivity to predict union with sonographic bridging callus at six weeks was 73.4% and the specificity was 94.4%. Regression analysis found failure to detect sonographic bridging callus at six weeks was associated with nonunion, older age, female sex, and greater overall fracture displacement (Nagelkerke R2=0.60). Of the cohort, 30.4% (n=34/112) had absent sonographic bridging callus at six weeks in combination with one or more of the ‘high risk’ clinical features. If one was present the nonunion rate was 47.1%, increasing to 60% with two risk factors and 100% when combined with all three. Conclusions. Ultrasound can accurately predict fracture healing at six weeks following a displaced midshaft clavicle fracture. When combined with poor clinical recovery this could be used to target patients for early operative intervention. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

To evaluate if clinical recovery following midshaft clavicle fracture is associated with nonunion and determine if this has superior predictive value compared to estimation at time of injury. A prospective study of all patients (≥16 years) who sustained a displaced midshaft clavicle fracture was performed. We assessed patient demographics, injury factors, functional scores and radiographic predictors with a standardized protocol at six-weeks. Conditional-stepwise regression was used to assess which factors independently predicted nonunion at six-months post-injury determined by CT. The nonunion predictor six-week model (NUP6) was compared against a previously validated model based on factors available at time of injury (NUP0-smoking, comminution and fracture displacement). 200 patients completed follow-up at six months. The nonunion rate was 14% (27/200). Of the functional scores, the QuickDASH had the highest accuracy on receiver-operator-characteristic (ROC) curve analysis with a 39.8 threshold, above which was associated with nonunion (Area Under Curve (AUC) 76.8%, p<0.001). On regression modelling QuickDASH ≥40 (p=0.001), no callus on radiograph (p=0.004) and fracture movement on examination (p=0.001) were significant predictors of nonunion. If none were present the predicted nonunion risk was 3%, found in 40% of the cohort (n=80/200). Conversely if two or more were present, found in 23.5% of the cohort, the predicted nonunion risk was 60%. The NUP6 model appeared to have superior accuracy when compared to the NUP0 model on ROC curve analysis (AUC 87.3% vs 64.8% respectively). Delayed assessment at six-weeks following displaced clavicle fracture enables a more accurate prediction of fracture healing

Background. Clavicle development occurs before the age of 9 in females and 12 in males. Children below the age of 10 with displaced midshaft clavicle fractures recover well with conservative management. However adolescents are more demanding of function and satisfaction following clavicle fractures and may benefit from operative management. Study aims: 1) Perform a systematic review of the current evidence supporting intramedullary fixation of adolescent clavicle fractures. 2) Review current management in a major trauma center (MTC) with a view to assess feasibility for a randomised controlled trial (RCT). Methods. The MEDLINE, EMBASE and AMED databases were searched in October 2014 to identify all English language studies evaluating intramedullary fixation in children aged 10–18 years using MeSH terms. Data was extracted using a standardised data collection sheet and studies were critically appraised by aid of the PRISMA checklist. All patients aged 9–15 attending an MTC receiving clavicle radiographs in 2014 were retrospectively reviewed for type of fracture, management and outcome. Results. Literature search identified 54 articles. After application of exclusion criteria 3 studies were selected for final review. 47 adolescent patients received intramedullary clavicle fixation from a prospective and two retrospective case series. 61 adolescents presented to our unit with a clavicle fracture in 2014, 2 were lost to follow-up, 54 were managed non-operatively, 3 received titanium-elastic nailing, 1 plate osteosynthesis and 1 bone suture. 0 and 19 patients reported a palpable lump, mean time to pain resolution was 4 and 6 weeks and time to full range of motion was 4 and 5 weeks following operative and conservative management respectively. All patients reached radiographic union. Conclusion. Current evidence supporting intramedullary fixation of clavicle fractures in adolescents is poor. There remains clinical equipoise on the best management of these patients, however they are predominantly treated conservatively. A future multi-center RCT may be feasible. Level of Evidence. 1

Introduction. Plate fixations have been recommended for dislocated clavicle fractures. However, existing plates are inadequate for morphological compatibility with the clavicle. The aim of this study is to measure the anatomical shape of the clavicle and to compare the radiographical and clinical outcomes of our tree-dimensional (3D) reconstruction plate with conventional straight plate. Methods. Chest CT image of 15 patients with normal clavicle were analyzed. Their clavicles were reconstructed and measured their anatomical variables. A hospital-based case-control study was conducted, including a consecutive series of 52 patients with displaced midshaft clavicle fractures. 3D reconstruction plate was used for 26 patients and another 26 patients were treated with conventional straight plate. Outcome measures included the period of bone union, revision surgery, operating times and clinical symptoms using DASH score. Results. The result indicated that plates applying to any shape of the clavicle require a strong curve on the distal part and a twist on the proximal part. A case-control study demonstrated that the conventional straight plate group had higher rate of delayed union and had more symptomatic than the 3D group. Conclusion. The plates with a strong curve on the distal end and a twist on the proximal end exhibit better compatibility with the clavicle. Our 3D reconstruction plate showed superiority in both radiographical and clinical outcome than conventional straight ones