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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 9  |  Issue : 2  |  Page : 81-83

A retrospective study on surgical management of clavicle midshaft fractures by locking plate in tertiary care center


Department of Orthopedics, Chirayu Medical College and Hospital, Bhopal, Madhya Pradesh, India

Date of Web Publication14-Dec-2017

Correspondence Address:
Dr. Sachin Samaiya
B-201, B-Block, Chirayu Medical College Campus, Indore Bhopal highway, Bhopal - 462 030, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_16_17

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  Abstract 


Aim: The aim of this study was to analyze the outcome by surgical management of clavicle midshaft fractures by locking plate. Materials and Methods: This is a retrospective study of thirty patients who were operated for midshaft clavicular fractures and treated surgically with locking compression plate and screws between January 2012 and June 2016 in Chirayu Medical College and Hospital Bhopal. The case files of these patients were retrieved from the Medical Record Department and data were analyzed. Results: Thirty cases of clavicle midshaft fractures were treated with precontoured locking plate. Average hospital stay was 7 days. The average time for fracture union was 10 weeks (8–12 weeks). Patients were followed weekly up to 4 weeks and then, after 2 and 6 months. The functional outcome according to Constant and Murley score is excellent in 18 patients (60.0%) and good in 12 patients (40%). There was no major complication, two (6.66%) patients had superficial skin infection, and one (3.33%) had nonunion. Conclusion: This study shows stable fixation with locking compression plate and screws for displaced middle-third clavicle fracture gives immediate relief of pain, prevents the development of shoulder stiffness, and helps in early rehabilitation.

Keywords: Clavicle, fractures, locking plate


How to cite this article:
Samaiya S, Gupta R, Saran R. A retrospective study on surgical management of clavicle midshaft fractures by locking plate in tertiary care center. J Orthop Traumatol Rehabil 2017;9:81-3

How to cite this URL:
Samaiya S, Gupta R, Saran R. A retrospective study on surgical management of clavicle midshaft fractures by locking plate in tertiary care center. J Orthop Traumatol Rehabil [serial online] 2017 [cited 2018 Jan 22];9:81-3. Available from: http://www.jotr.in/text.asp?2017/9/2/81/220758




  Introduction Top


Displaced and shortened fractures of the middle third of the clavicle [Figure 1] are common in young, athletic populations, and road traffic accidents. Fractures of the clavicle account for 44% of injuries around the shoulder girdle, approximately 70%–80% of which occur in the middle third.[1] Several studies in the adult literature have shown a greater prevalence of symptomatic malunion, nonunion, and poor functional outcomes after nonsurgical management of displaced fractures. Several techniques of fixation have been described in literature, including the use of plates; Kirschner wires, Steinmann Pins, and external fixators.[2] In literature, surgical and nonoperative management have both been recommended. The use of a precontoured superiorly placed locking plate and screws, for the lateral end of the clavicle, is a recent development.[3],[4] With the advent of locked plating, several site-specific distal clavicle locking plates are available that may provide improved fixation.[5]
Figure 1: Radiograph showing fracture clavicle

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  Materials and Methods Top


It was a retrospective study of thirty patients who were operated for midshaft clavicular fractures and treated surgically with locking compression plate and screws between January 2012 and June 2016 in Chirayu Medical College and Hospital Bhopal. The case files of these patients were retrieved from the Medical Record Department and data were analyzed. During this period of 4 years, thirty patients of clavicle midshaft fractures were treated surgically. In our study, the inclusion criteria were adult male and female patients above 16 years who required surgical intervention for displaced and comminution middle-third fracture of clavicle. Exclusion criteria in this study were pediatric patients, patients with undisplaced fracture, pathological fractures, and any medical contraindication to surgery or general anesthesia. Detailed demographic details of the patients were noted.

Surgical technique

A 5–8 cm incision was given on the anterior aspect of clavicle centering over the fracture site. The skin, subcutaneous tissue, and platysma were divided. The overlying fascia and periosteum were divided. The osseous ends were then separated from surrounding tissue. Fracture fragments were reduced, and plate was then applied with locking screws over the superior aspect [Figure 2] of the clavicle. Patients were discharged after 3-4 days and suture removal done at 12th day, and further follow-up was done after 4 weeks. On each visit, X-ray examination was done to assess fracture healing. Physiotherapy was advised according to the suitable postoperative time and stage of fracture union. In all patients, the functional outcome was assessed by Constant and Murley score.[12]
Figure 2: Superiorly placed precontoured locking plate

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  Results Top


Among the thirty midshaft clavicle fracture patients, most were in the age group between 15 and 35 years (66%), in our study all patients were males, 15 cases were road traffic accident, 12 patients were due to fall on shoulder, and 3 cases were due to direct violence. There were no major complications in this study. Age incidence, mode of injury, and complications are shown in [Table 1], [Table 2], [Table 3].
Table 1: Age-wise distribution of patients according to the incidence of middle clavicle fractures (n=30)

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Table 2: Distribution of the patients according to the mode of injury

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Table 3: Distribution of the patients according to the complications

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The fracture was considered to be united when clinically there was no tenderness, radiologically the fracture line was not visible [Figure 3], and full unprotected function of the limb was possible. The majority of the cases were united by the end of 10 weeks (90%) and between 10 and 12 weeks (6.66%). The average time for fracture union is 10 weeks (8–12 weeks).
Figure 3: Radiograph showing union at 4 months

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Only two (6.66%) patients have superficial skin infection and one (3.33%) had nonunion. The functional outcome according to Constant and Murley score is excellent in 18 out of total 30 patients and good in 12 patients. Functional outcome according to Constant and Murley score is shown in [Table 4].
Table 4: Distribution of the patients according to the functional outcome

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  Discussion Top


About 80% of fracture of clavicle occurs in middle third. In our series, road traffic accident followed by fall on outstretched hand is the most common cause of this fracture. Maximum patients were of middle-age group. Hill et al. reported a 15% nonunion rate and 31% patient dissatisfaction rate in conservatively treated displaced middle-third fractures of the clavicle.[6] Recent study has shown that rate of malunion and nonunion is much higher in nonoperative group. Open reduction and internal fixation with plates are the standard methods for surgical management of clavicular fracture. The surgical treatment of displaced midclavicular fracture with locking compression plate, which is shaped to match the shape of clavicle, is very effective. Fractures of the midshaft clavicle with 100% displacement and more than 2 cm shortening require surgical fixation. In our study, precontoured locking plates were used in treatment of clavicle midshaft fractures instead of recon plate. The advantages with these plates include strong fixation due to locking between the screw and plate and blood supply preservation due to minimal contact between plate and cortical bone.[7] Neer's original report recommended operative fixation based on a 67% rate of delayed union and a 33% incidence of nonunion with nonoperative management compared with 100% union within 6 weeks after operative treatment.[8] Adults do not possess same remodeling potential as younger children and most midshaft clavicle fractures heal with some degree of malunion.

Böstman et al. studied 103 patients treated with open reduction and internal fixation using plates the wound infection rate in their study was 4.8% (3/62), and they were managed with antibiotics and local wound care and subsequently underwent removal of metalwork once the fracture had healed.[9] Edwards et al. reported 43 patients with Type II fractures in which 23 were treated operatively. Union occurred in all operatively treated patients,[10] in Canadian study no patient in the operative group presented with symptomatic malunion,[11] the results of the current series compare favorably with previous reports, with fracture union achieved in 94.7% of cases. The functional outcome [Figure 4] according to Constant and Murley was found to be significantly higher in operative group. In this study, average Constant score in the operative group was found to be 93.7 and 85.9 in nonoperative group. Canadian Orthopaedics Trauma Society[6] found an average Constant score of 96.1 in operative group and 90.8 in the nonoperative group 12 sample size being small; low prevalence complications could not be encountered in this study. Larger sample size will be a prerequisite for knowing the prevalence of nonunion and symptomatic malunion in operative group.
Figure 4: Functional recovery after clavicle plating

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  Conclusion Top


Clavicle fractures are usually treated conservatively, but there are specific indications for which operative treatment is needed such as comminuted and displaced middle-third clavicle fractures. It was observed that primary fixation with plate and screws of fresh middle-third clavicle fractures provides a more rigid fixation and yielded better functional outcome and resulted in high union rates.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rowe CR. An atlas of anatomy and treatment of midclavicular fractures. Clin Orthop Relat Res 1968;58:29-42.  Back to cited text no. 1
    
2.
Putnam MD, Walsh TM 4th. External fixation for open fractures of the upper extremity. Hand Clin 1993;9:613-23.  Back to cited text no. 2
    
3.
Oh JH, Kim SH, Lee JH, Shin SH, Gong HS. Treatment of distal clavicle fracture: A systematic review of treatment modalities in 425 fractures. Arch Orthop Trauma Surg 2011;131:525-33.  Back to cited text no. 3
    
4.
Andersen JR, Willis MP, Nelson R, Mighell MA. Precontoured superior locked plating of distal clavicle fractures: A new strategy. Clin Orthop Relat Res 2011;469:3344-50.  Back to cited text no. 4
    
5.
Muramatsu K, Shigetomi M, Matsunaga T, Murata Y, Taguchi T. Use of the AO hook-plate for treatment of unstable fractures of the distal clavicle. Arch Orthop Trauma Surg 2007;127:191-4.  Back to cited text no. 5
    
6.
Hill JM, McGuire MH, Crosby LA. Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg Br 1997;79:537-9.  Back to cited text no. 6
    
7.
Craig EV. Fractures of the clavicle. In: Rockwood CA, Matsen FA, editors. The Shoulder. Philadelphia: WB Saunders; 1998. p. 428-82.  Back to cited text no. 7
    
8.
Neer CS 2nd. Fracture of the distal clavicle with detachment of the coracoclavicular ligaments in adults. J Trauma 1963;3:99-110.  Back to cited text no. 8
    
9.
Böstman O, Manninen M, Pihlajamäki H. Complications of plate fixation in fresh displaced midclavicular fractures. J Trauma 1997;43:778-83.  Back to cited text no. 9
    
10.
Edwards DJ, Kavanagh TG, Flannery MC. Fractures of the distal clavicle: A case for fixation. Injury 1992;23:44-6.  Back to cited text no. 10
    
11.
Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am 2007;89:1-10.  Back to cited text no. 11
    
12.
Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res 1987;214:160-4.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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Abstract
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