To Operate or not to Operate the Mid-Shaft Fractures of the Clavicle: A Comparative Study of Functional Outcomes of the Two Methods of Management

Abstract

Introduction: Fractures of the clavicle are some of the most common fractures which are seen in the adult population. Mid-shaft fractures of the clavicle are considered the most common form of clavicle fractures and about half of them are displaced fractures. They have been managed non-operatively over the years. However, severe displacement and comminution of these fractures have warranted the requirement of operative intervention, due to increased incidence of mal-union, worsening of shoulder functions etc., after conservative management. The introduction of locking compression plates, have increased the incidence of operative intervention in the management of these injuries.

Aim: To study and compare the functional outcome of the shoulder after open reduction and internal fixation versus non-operative management of mid-shaft clavicle fractures.

Materials and methods: A prospective study was conducted from June 2013-October 2015 in the Department of Orthopaedic Surgery, K.S. Hegde Medical Academy, Mangalore. A total of 30 skeletally mature patients between the age groups of 20-50 years with diagnosed fresh mid-shaft clavicle fractures, AO type A and B mild to moderate displacement, were enrolled into the study with. They were divided into two groups randomly. Group 1 consisted 16 patients who underwent open reduction and locking compression plate fixation and Group 2 consisted of 14 patients who were managed with application of a clavicle brace and arm pouch for three weeks. Reviews were done at three, six and 24 weeks postoperatively. The patients were assessed clinically and radiographs were taken during all the reviews. Scoring of shoulder function was done using the Disabilities of the Arm, Shoulder and Hand (DASH) score during all the reviews. The results were tabulated compared and analyzed statistically using the 'Independent t-test' and Chi-square test.

Results: The DASH scores at the end of 24 weeks were noted to be 8.57±6.073 points for the 14 patients in the conservative management group and 7.74±16.422 points for the 16 patients in the open reduction and internal fixation group. This indicated that there was no significant difference noted in terms of shoulder function between the two groups. Six of the 14 patients in the conservative management group were noted to have mal-union of the fracture. No non-unions were noted in the conservative or operative groups. No mal-union was noted in the open reduction and internal fixation group.

Conclusion: Though open reduction and internal fixation of mid-shaft clavicle fractures reduced the incidence of mal-union, no significant difference was noted in the functional outcome of shoulder function as compared to when the fracture was managed conservatively.

Keywords: Comminuted fractures; Conservative management; DASH score; Internal fixation; Locking compression plating; Open reduction.

[Table/Fig-1]:

Right midshaft clavicle fracture. AO type A3.

[Table/Fig-2]:

Intraoperative image showing locking compression plate fixation after open reduction of a midshaft clavicle fracture.

[Table/Fig-3]:

During the final review at 24 weeks after conservative management. A mild degree of mal-union is noted.

[Table/Fig-4]:

Right midshaft clavicle fracture during the final review at 24 weeks showing complete union of the fracture after locking compression plate fixation.

[Table/Fig-5]:

Bar graph showing the DASH score of the patient’s shoulder function in the conservative and operative group during the review at six weeks and 24 weeks.

[Table/Fig-6]:

Bar graphs representing the complication rate at 24 weeks post-op.