Surgery for Diaphyseal Fracture of the Clavicle Presents Low Risk of Nonunion
Key findings
- In a retrospective cohort of 249 patients who underwent surgical repair of a displaced diaphyseal fracture of the clavicle, the rate of unplanned reoperation or adverse events was 13%
- Female gender was the only factor associated with unplanned reoperations or adverse events
- Five patients (2%) developed symptoms related to brachial plexus dysfunction
- Four patients (1.6%) had early implant loosening or breakage
- The incidence of nonunion was 2%, substantially lower than in recent prospective studies of nonoperative treatment
Displaced diaphyseal fractures of the clavicle are now often treated surgically, but the outcomes have not been well studied. In research conducted in the Department of Orthopaedic Surgery at Massachusetts General Hospital, Femke M.A.P. Claessen, MD, research fellow, and David Ring, MD, orthopaedic surgeon, both formerly with the department, and colleagues recently investigated the prevalence of unplanned reoperations and adverse events, along with factors that affect those outcomes. Their report appears in the Archives of Bone and Joint Surgery.
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Study Design
The research team reviewed 249 patients in a billing database for three Boston hospitals (two level 1 trauma centers and a community hospital) who had surgery for a displaced diaphyseal clavicle fracture between January 2002 and March 2015. Each patient had at least 10 weeks of follow-up, which was considered sufficient time for healing.
Adverse Events
The average follow-up period was eight months (range, 10 weeks to 60 months). During that time there were 34 adverse events:
- Infection (n=10, 4%)
- Numbness surrounding incision (n=5, 2%)
- Brachial plexus dysfunction (n=5, 2%)
- Nonunion (n=4, 1.6%)
- Early implant loosening or breakage (n=4, 1.6%)
- Scarring (n=3, 1.2%)
- Refracture after plate removal (n=1, 0.4%)
- Hematoma (n=1, 0.4%)
- Shoulder stiffness (n=1, 0.4%)
Local implant irritation and sensory symptoms thought to be due to nerve irritation were not considered adverse events.
Adverse Events Requiring Reoperation
All told, 32 of 249 patients (13%) had at least one adverse event or unplanned reoperation.
- Brachial plexus dysfunction: All five patients underwent reoperation, including two of 157 patients (1.2%) who had plate fixation and three of 92 (3.3%) who had a fixation with an intramedullary pin (P = NS). All cases resolved completely within six months
- Infection: Four of the 10 patients underwent reoperation, including one patient who had two subsequent surgeries (irrigation and debridement, then vacuum dressing) and one patient who had four subsequent surgeries for an infected nonunion
- Implant loosening or breakage: All four patients underwent reoperation. In two patients the plate broke within three months of the initial surgery and in two patients the intramedullary rod loosened in the medial fragment
- Other complications: Other subsequent surgeries were performed for two of the three patients with scarring, for the hematoma and for the patient with refracture after implant removal. Nerve injury exploration and nerve transfer were also performed in one patient
Poor Outcomes Factors
The researchers tested multiple patient-related, injury-related and technical factors for their association with adverse events and unplanned reoperations: age, sex, Charlson comorbidity index, smoking, alcohol dependence, obesity, whether the patient was an athlete, side of injury, whether the fracture was open, whether the fracture was comminuted, fixation type, number of incisions and years of surgeon experience.
The only significant factor was that women were nearly three times more likely than men to have an adverse event or unplanned reoperation, perhaps because plates are more prominent in women or women are more likely to prefer implant removal.
Implications for Practice
Several recent prospective studies detected nonunion rates of 15% to 20% when displaced diaphyseal fractures of the clavicle are treated nonoperatively, compared with 2% in this study. Thus, patients considering surgery can expect to trade improved alignment and a decreased risk of nonunion for an approximately 13% risk of an adverse event or unplanned reoperation.
The cases of brachial plexus dysfunction observed in this study were probably related in part to traction. Regarding the four cases of implant breakage or loosening, the two plate problems were due to inadequately sized plates, and the two intramedullary rod issues were due to propagation or underappreciated fracture lines in the medial fragment, which led to inadequate or lost fixation.
Careful attention to technical factors is necessary to avoid these adverse outcomes.
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