The last time OrthoBuzz reported on a JBJS randomized trial looking at treatment of midshaft clavicle fractures, the authors concluded that “neither treatment option [nonoperative or surgical] is clearly superior for all patients” and that “the clavicular fracture is preeminently suitable for shared treatment decision-making.”
Now, a multicenter randomized trial by Ahrens et al. published in the August 16, 2017 JBJS adds more data for that shared decision-making discussion. In this trial, 300 patients with a displaced midshaft clavicle fracture were randomized to receive either open reduction and internal fixation (ORIF) with a plate or nonoperative management. Patients were recruited from a range of UK hospitals, and a single implant and standardized technique were used in the operative group. The rehabilitation protocol was the same for both groups.
The union rate in both groups at 3 months was low, approximately 70%. But at 9 months after the injury, the nonunion rate was <1% in the surgically treated patients, compared to 11% in the nonsurgically treated patients. The patient-reported scores (DASH and Constant-Murley) were significantly better in the operative group at 6 weeks and 3 months, but were equivalent to those in the nonoperative group at 9 months.
“Overall,” the authors conclude, “we think that surgical treatment for a displaced midshaft clavicle fracture should be offered to patients, and [these findings] can provide clear, robust data to help patients make their choices.”
Really, ORIF for a fracture that heals well with a simple and cheap figure of 8 strap? What would you recommend for your son or daughter?
I started plating these displaced overriding fractures in 2003 only after one of my relative suffered from painful disabling nonunion with compromised shoulder function at one year and had to undergo plating and bone grafting.
Since then last fifteen years have plated all these displaced ones/ anteroinferior plating with contoured LCP. Have published a cohort study in JOT
I enjoy doing surgery, when necessary, but In my 35 years of practice, I only recall two nonunions of mid-shaft clavicle fractures that I treated initially with a figure of 8 strap. Both were alcoholics, and non compliant individuals.
Nonoperative treatment was recommended to us as Orthopaedic residents in 1977, and I never saw a need for ORIF for these fractures as a matter of routine.
I also treated a close family relative with a significantly widely displaced mid-shaft fracture using a figure of 8 strap. She tolerated the sling, and she healed and remodeled solidly.
The strap is simple and a minor inconvenience for about four to six weeks. A second strap and Right Guard help. Many patients have come to my office from the ED in recent years with a cradle arm sling. Some were quite uncomfortable with this cradle arm sling. I placed them in a figure of 8 strap, and they have left comfortable and happy. They all healed.
I have reviewed many articles on this subject, and it seems that almost all of the “failures/nonunions” were treated with a simple cradle arm sling.