Deficits Following Nonoperative Treatment of Displaced Midshaft Clavicular Fractures

Author(s): McKee MD, Pedersen EM, Jones C, Stephen DJG, Kreder HJ, Schemitsch EH, Wild LM, Potter J

Source: Journal of Bone and Joint Surg 88A:1, 35-40, 2006.

Summary:

This retrospective review identified and evaluated 30 patients with a midshaft displaced clavicle fracture treated non-operatively.  The initial group included 107 patients between 1994 and 2000 treated with a sling.  Thirty-three patients were lost to follow-up, others were excluded due to open or associated injuries or unwillingness to participate, resulting in only 30 patients for study.  There were 22 men and 8 women with a mean age of 37 years (range, 19-67 years) and a mean follow- up of 55 months (range, 12-72 months).  Patients were examined for range of motion using a handheld goniometer, isometric muscle testing with a BTE Work Simulator, and the Dash and Constant Shoulder Scores.  Fifteen patients were completely satisfied with their shoulder, seven were only partially satisfied, and eight were dissatisfied.  Of the 15 patients who were not completely satisfied, six were unhappy with the cosmetic appearance of their shoulder despite no limitations with their normal activities.  Eighteen patients had returned to their pre-injury levels of work and recreational activity.  Eight patients returned to a less strenuous occupation and four patients did not work or had not returned to work due to associated injuries.  Range of motion was well maintained and not significantly different between groups.  The mean DASH score and Constant scores were significantly inferior to the values for the normal population, indicating substantial residual impairment.  Compared with the strength of the uninjured shoulder, the strength of the injured shoulder was reduced to 67-85% for maximum flexion, endurance of flexion, maximum abduction, endurance of abduction, maximum external rotation, endurance of external rotation, maximum internal rotation and endurance of internal rotation.  There was a strong inverse correlation between the DASH and Constant scores indicating that the patients’ report of less disability on the DASH corresponded to a higher objective Constant score.  An inverse correlation between abduction, endurance and shortening, (i.e., and association between increased shortening and less abduction endurance) approached significance.  A trend was identified for patients with greater than 2 cm of shortening to have a poorer DASH score.

This paper adds to the growing evidence in the literature questioning the classic teaching that midshaft clavicle fractures heal well without any residual deficits.  Although this study indicated a 0 % nonunion rate, the literature supports up to a 15-20% nonunion rate with significantly displaced midshaft clavicle fractures, especially those with comminution.  In addition, this study indicates that only 50% of the patients were completely satisfied with the outcome of their shoulder and many had significant deficits with respect to strength and endurance in addition to appearance.  The major weakness of the study is that there was no comparison group treated surgically.  The results, however, may be used to counsel patients regarding the long-term potential deficits with non-operative treatment of midshaft clavicle fractures.  Future studies will hopefully elucidate the subsets of patients that will be best treated operatively.

 

Related Links
Journal of Bone and Joint Surgery