Midshaft clavicula fractures non-operative or operative treatment? Sune Larsson Department of Orthopedics Uppsala University Hospital Uppsala Sweden
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1 Midshaft clavicula fractures non-operative or operative treatment? Sune Larsson Department of Orthopedics Uppsala University Hospital Uppsala Sweden
2 Historical classical papers nonunion rate of midshaft fractures Neer (1960) 3/2235 (0.1%) of those treated conservatively 2/45 (4.4%) of those treated surgically Rowe (1968) 5/566 (0.8%) of those treated conservatively 2/54 (3.7%) of those treated surgically
3 Prospective study started in 1989 Aims 1. Describe the natural history 2. Identify risk factors, if any, for fractures treated non-operatively
4 Prospective study started in consecutive patients ( ) 15 years or older Radiographically verified clavicular fracture 208/245 followed for 10 years A true consecutive series
5 Methods specific protocol Baseline variables Objective 46 Demographic 11 Radiographic 22 Patient s status 13 Subjective 25
6 Methods radiographs at specific time points g two views g time points acute 1week 6 months 12 months 9-10 years
7 Methods two views 0 45
8 Methods radiographs at specific time points g time points acute 1week 6 months 12 months 9-10 years Less displacement at 7 days compared with directly after trauma Fracture position at 7 days will be the same as after healing 7 70 rule
9 Treatment Pain killer Sling for a week (optional) Free movement as tolerated
10 Clavicula fractures annual total incidence in adults 4% Total 50 / Men 71 / Women 30 / Men:Women 2.4:1 Nowak and Larsson Injury 2000
11 Clavicula fractures age specific incidence Nowak and Larsson Injury 2000
12 Clavicula fractures location 2% 71% 27% Nowak and Larsson Injury 2000
13 Results 167/175 midshaft fractures at 6 months 10/167 (6%) non-union rate
14 Results 167/175 midshaft fractures at 6 months 75/167 (45%) had sequelae at 6 months
15 Results 16 weeks median time to complete recovery for patients without sequeale
16
17 Results baseline data vs sequelae at 6 months (45%) Sequelae 6 months Risk factor Age < High age Gender NS Fracture type Comminute Displacement 0 view > 1 bone width 45 view < > 1 bone width
18 Results baseline data vs nonunion (6%) Nonunion Risk factor Age NS Gender Female Fracture type NS Displacement 0 view >1 bone width 45 view NS Smoking NS
19 Risk factors for non-union 6.2%
20 Risk factors for non-union
21 Results 154/175 midshaft fractures at 10 years Sequelae 48% Pain at rest 8% Pain during activity 28% Cosmetic defects 30%
22 Results 10 years after injury Risk factors for sequelae Age (older means higher risk) Displacement with no bony contact Shortening Transversally placed fragments
23 Transversally placed fragments (Z fracture ) 0 AP view 45 tilted view Z fracture
24 Transversally placed fragments (Z fracture ) 0 AP view 45 tilted view Z fracture
25 Transversally placed fragments (Z fracture ) 0 AP view 45 tilted view Z fracture
26 Midshaft clavicular fractures Will surgical treatment provide better results?
27 Midshaft clavicular fractures surgery vs conservative treatment Canadian Orthopedic Trauma Society JBJS 89-A 2007
28 Midshaft clavicular fractures surgery vs conservative treatment Canadian Orthopedic Trauma Society JBJS 89-A 2007
29 Midshaft clavicular fractures surgery vs conservative treatment Canadian Orthopedic Trauma Society JBJS 89-A 2007
30 Midshaft clavicular fractures surgery vs conservative treatment Canadian Orthopedic Trauma Society JBJS 89-A 2007
31 Midshaft clavicular fractures surgery vs conservative treatment Canadian Orthopedic Trauma Society JBJS 89-A 2007
32 Midshaft clavicular fractures surgery vs conservative treatment Canadian Orthopedic Trauma Society JBJS 89-A 2007
33 Midshaft clavicular fractures surgery vs conservative treatment Canadian Orthopedic Trauma Society JBJS 89-A 2007
34 Summary midshaft clavicular fractures radiographs with two views 0 0 och 45 very useful consider surgery if no bony contact at one week severe shortening (overlap( or angulation) transversally placed fragments on 45 (Z-fracture)
35 Summary midshaft clavicular fractures radiographs with two views 0 0 och 45 very useful consider surgery if no bony contact at one week severe shortening transversally placed fragments on 45 (Z-fracture) 15-18% of adult midshaft fractures considered for surgery
36 Thank You!
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