OPERATIVE VS NONOPERATIVE

MGT OF DISPLACED MIDSHAFT

CLAVICLE FRACTURES
OBJECTIVES
To compare results of primary internal fixation
of acute displaced midshaft clavicle fractures
with those managed nonoperatively in terms
of fracture union and functional outcome.
Setting: Level II military trauma center.
Patients/Participants: Seventy-three patients
(civilian and military) between 20- 50 years of
age with displaced midshaft clavicle fractures.
operative (n = 45) or nonoperative (n = 28)
group.
 FIGURE 4
Operative versus Nonoperative
Management of Displaced Midshaft
Clavicle Fractures: A Prospective Cohort
Study.
Kulshrestha, Vikas; Roy, Tanmoy; Audige,
Laurent; DVM, PhD

Journal of Orthopaedic Trauma. 25(1):31-38,

January 2011.
DOI: 10.1097/BOT.0b013e3181d8290e

FIGURE 4 . Flow chart representation of

patient recruitment and the follow-up rates.

2011 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 6
INTERVENTION
nonoperative group- simple sling for 6 weeks &
immobilization, "out of sling" activities after
-3weeks and at the 6-week time point.
-3 months, patients were allowed pre-injury levels of
activity (excluding all contact sports). -6
months,patients were allowed unrestricted activities.
operative group-
fractures were reduced and fixed with a contoured
reconstruction plate.
-sling was used for 7 to 10 days and then
active range of motion exercises. After 6 weeks
shoulder strengthening exercises were allowed.
OPERATIVE TECHNIQUE
- general anesthesia
-single preoperative dose of
prophylactic antibiotics.
-beachchair semisitting
position -first 15 cases, a
curved incision along the clavicle centered
over the fracture site.
-changed to an anteroinferior approach (1 cm
anterior and inferior to the palpable bony
landmark) for the next 30 patients, prevented
scar irritation caused by the implant.
 - contoured reconstruction plate on the
superior surface of the bone using a minimum
of three screws in the main proximal and
distal fragments
-long oblique or wedge
comminuted fractures, lag screws were used.
- comminuted fractures,long plate with 9 or
10 holes was used to bridge the fracture and
obtain at least six cortex fixations on each
side of the fracture.
 FIGURE 3
Operative versus Nonoperative
Management of Displaced Midshaft
Clavicle Fractures: A Prospective Cohort
Study.
Kulshrestha, Vikas; Roy, Tanmoy; Audige,
Laurent; DVM, PhD

Journal of Orthopaedic Trauma. 25(1):31-38,

January 2011.
DOI: 10.1097/BOT.0b013e3181d8290e

FIGURE 3 . (A) Comminuted Robinson Type

2B2 fracture (Orthopaedic Trauma Association
[OTA] 15B3). (B) Fracture fixed with a long
reconstruction plate fixing eight cortices on
both sides along with one interfragmentary
screw. (C) The plate is bent with resultant
angulation at the fracture site observed at the
6-week follow-up.

2011 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 4
MAIN OUTCOME
18-month period-Primary outcome measures
were the rates ofnonunion,malunion,infection
& implant failure.
RESULTS
18-month follow-up rate was 90%.
All fractures in the operative group
united compared with eight nonunions (29%)
in the nonoperative group.
Ten symptomatic malunions (36%)
occurred in the nonoperative group.
Whereas only two (4%) patients
w/comminuted frxs. had malunions reported
for the operative group.
 TABLE 3
Operative versus Nonoperative
Management of Displaced Midshaft
Clavicle Fractures: A Prospective Cohort
Study.
Kulshrestha, Vikas; Roy, Tanmoy; Audige,
Laurent; DVM, PhD

Journal of Orthopaedic Trauma. 25(1):31-38,

January 2011.
DOI: 10.1097/BOT.0b013e3181d8290e

TABLE 3 . Complication Rates for the

Operative and Conservative Groups Including
Relative Risk and Significance

2011 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 9
Two patients with comminuted fractures had
implant deformation associated with a
delayed union.
This was managed with autogenous bone
marrow infiltration at the fracture site.
Eight patients with nonunion/malunion in the
nonoperative group underwent open reduction
and internal fixation of the fracture with
autogenous iliac crest grafting.
Conclusions: In this study a young,active patient
population, primary open reduction and internal
plate fixation of acute displaced midshaft clavicular
fractures resulted in improved outcomes and a
decreased rate of nonunion and symptomatic
malunion compared with nonoperative tx.
Limited complications
were implant-related and can be reduced with better
availability of modern implants.They use anatomic
clavicle plates with locking holes to fix these
fractures using an anteroinferior approach while
plating the anterosuperior surface.
THANK YOU