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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