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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 9  |  Issue : 2  |  Page : 88-92

Radiographic examination alone is not a good indication for surgical intervention of displace midshaft clavicle fractures


1 Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands
2 Emergency Department, Meander Medical Centre, Amersfoort, The Netherlands

Date of Web Publication14-Dec-2017

Correspondence Address:
Dr. Denise J.C. Van Der Ven
Department of Surgery, Meander Medical Centre, PO Box 1502, 3800 BM, Amersfoort
The Netherlands
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_13_17

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  Abstract 


Background: Whether or not to operate midshaft clavicle fractures is mostly based on the amount of shortening and dislocation seen on the radiograph. Previous studies already suggested that radiographic shortening of midshaft clavicle fractures cannot be adequately determined with an anterior-posterior (AP) view alone. Therefore, before a therapeutic decision can be made based on radiographic examination; the observed fracture characteristics should be evaluated. Patients and Methods: Between January and July 2016, ninety patients were prospectively included in this study. When the classification of the fracture was confirmed with a standard AP radiographs, additional radiograph examinations were done; rhomboideus radiograph: a standard AP radiograph in military position. All patients were treated conservatively and followed for 24 weeks. Patients visited the outpatient clinic department after 1, 6, and 24 weeks. The study end-points were investigated (Disabilities of Arm, Shoulder, and Hand [DASH] and constant score) and radiographic combined with physical examinations were done. Results: On the standard AP radiographs in all occasions, radiographic shortening was seen. On the additional rhomboideus views, the degree of shortening was no longer observable. The mean constant and DASH score of 6 were 88.2 ± 11.8, respectively, 18.9 ± 14.4. After conservative treatment, nine patients developed a nonunion and were operated and excluded from this study. Conclusion: In conclusion, our results show that the degree of shortening and displacement cannot be adequately determined on standard 2-view radiographic series and that the correlation between permanent clavicle shortening and functional outcome can be questioned. Good functional outcomes were seen after conservative treatment. This indicates that the importance of shortening seen on a radiograph and the degree of permanent shortening in determining functional outcomes remains unclear.

Keywords: Clavicle fracture, displaced, midshaft, radiograph


How to cite this article:
Van Der Ven DJ, Timmers TK, Welsing RT, Van Olden GD. Radiographic examination alone is not a good indication for surgical intervention of displace midshaft clavicle fractures. J Orthop Traumatol Rehabil 2017;9:88-92

How to cite this URL:
Van Der Ven DJ, Timmers TK, Welsing RT, Van Olden GD. Radiographic examination alone is not a good indication for surgical intervention of displace midshaft clavicle fractures. J Orthop Traumatol Rehabil [serial online] 2017 [cited 2021 Feb 25];9:88-92. Available from: https://www.jotr.in/text.asp?2017/9/2/88/220755




  Introduction Top


The decision to treat closed midshaft clavicle fractures either operatively or nonoperatively remains a topic of debate. There are studies that raised concerns that certain midshaft clavicle fractures treated nonoperatively have a higher rate of nonunion or symptomatic malunion; therefore, a poorer functional outcome.[1],[2] However, recent research has not shown convincingly that operative treatment is better for these kinds of fractures.[3],[4],[5],[6] Plain radiography is the most common way in which clavicle fractures are radiologically assessed radiographic examination for clavicle fractures includes an anterior-posterior (AP) radiograph and a clavicle radiograph with some horizontal angle (15°–45°). The currently described indications for surgical treatment as seen on radiograph examination are complete displacement and clavicle shortening exceeding 20 mm. Since shortening caused by displacement has been associated with potential shoulder dysfunction.[3],[4],[5],[6] Different degrees of shortening leading to an unfortunate outcome are being reported; varying from 15 mm to 20 mm.[5],[6],[7],[8],[9],[10],[11] However, patients' posture due to pain; therefore, the radiographic angle may influence the displayed degree of shortening and as a consequence the difference in reported outcome. Nevertheless, an indication for surgical treatment is mostly based on radiologic examination. Previous studies already suggested that the degree of dislocation and shortening of these common clavicle fractures cannot be adequately determined with an AP view alone.[12],[13],[14] Ideally, before a therapeutic decision can be made the observed fracture characteristics should be evaluated. Our hypothesis is that the amount of shortening and displacement cannot be adequately determined with a standard radiograph alone. As we believe the change seen on the rhomboideus view is dynamic; clavicle shortening could be reduced in this position.


  Patients and Methods Top


Between January 2013 and October 2016, all consecutive patients presenting at the Emergency Department (ED) of the Meander Medical centre, Amersfoort (The Netherlands), with a new, dislocated midshaft clavicle fracture were prospectively recorded and included in this study. Our hospital serves as a regional level 2 trauma center. Our hospital treats an increasing number of ED patients of around 40,000 patients. Standard 2-view trauma series of the clavicle at our institution include AP radiograph examination and a clavicle radiographs with some horizontal angle (15°–45°). This study was approved by the local medical ethics committee; reference number W15.052.

Patient selection

Inclusion criteria were (1) complete dislocated midshaft clavicle fracture after trauma (no fracture side contact of lateral and medial fragments) according to Robinson classification 2B; (2) age ≥18 years. Exclusion criteria were (1) fracture in the proximal or distal third of the clavicle; (2) fracture with side contact of lateral and medial fragments; (3) pathologic fracture (bony abnormalities at the side of the fracture); (4) open fracture; (5) a significant ipsilateral upper extremity fracture; (6) neurovascular injury of the shoulder region with objective neurological findings on physical examination; (7) a midshaft clavicle fracture more than 14 days old at first hospital visit. When classification of the fracture was confirmed with a standard AP radiograph, additional radiograph examinations were done. These consist of a rhomboideus radiograph: a standard AP radiograph in military position. The military position involves rolling your shoulders back and down. To achieve this position, while in pain, all patients received adequate analgesics and wore a special figure-of-eight clavicle brace [Figure 1]. The figure-of-eight clavicle brace holds the clavicle in the correct alignment by forcing the shoulders into a retracted position.
Figure 1: Left: a standard anterior-posterior radiograph. Right: a rhomboideus radiograph: a standard anterior-posterior radiograph only in military position wearing a figure-of-eight brace and receiving adequate analgesia

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End-points

The primary radiographic outcome parameters were (1) the degree of clavicle shortening; (2) to compare these with an rhomboideus view; the primary clinically outcome parameters were (1) consolidation of the fracture and the development of nonunion; (2) functional outcome measured with the DASH score and constant score; and 3) adverse events.

Union

Union of the clavicle fracture was defined as complete cortical bridging between lateral and medial fragments. If no callus/bridging between two cortices was present during radiological examination and/or clinical evidence of pain and/or motion at the fracture site at 6 months this was considered a nonunion. Delayed union was diagnosed if no callus/bridging between two cortices was present during radiological examination or clinical evidence of and motion at the fracture site at 3 months.

Functional outcome score

The DASH outcome measure is a validated 30-item, self-report questionnaire. The DASH outcome measure consists of two components: the disability/symptom section (30-items) and the optional high performance sport/music module (4-items).[15] The Constant-Murley score is a validated 14-item questionnaire with a total score of 0–100 and consist of a subjective and objective component. The questionnaire records individual parameters and provides an overall clinical functional assessment.[16]

Adverse events

Other complications were considered to exist if refracture (i.e., a recurrent fracture of the same clavicle after new trauma) or patients underwent resurgery for an exostosis.

Follow-up

After inclusion, all patients were conservatively treated and followed for 24 weeks in total. The figure-of-eight brace was worn for 1 week and it served merely as a reminder for the patients to keep an adequate military position. Hereafter, the patient was seen in the clinic department and physical therapy (rhomboideus training) was prescribed. Rhomboideus training consist of physiotherapy focusing meanly on retraction and mediorotation of the angulus inferior of both scapulae within individual arthrogenic limits. Herewith, the musculus rhomboideii and the musculus serratus posterior are trained. As a result, by retaining an anatomical position of the fracture parts, the amount of shortening due to an imbalance of muscle forces is reduced. Patients visited the clinic department, herein, after with 6 and 24 weeks. On all occasions, the study end-points were investigated and radiographic examinations were done. Patient who developed a nonunion underwent operative fixation using a VA-LCP anterior clavicle plate [17] and were excluded from further follow-up analysis of this study.

Statistical analysis

Statistical analysis was performed using SPSS 15.0, Chicago, USA for Microsoft Windows. Differences in the DASH and the constant score between the treatment groups were compared with use of the independent t-test. The Chi-square test was used for categorical data. Continuous variables were reported as mean ± standard deviation or median (25th and 75th inter quartile ranges) and categorical variables as number and percentages, unless otherwise stated. All tests were two-sided, and the level of significance was set at P < 0.05.


  Results Top


Within the study timeframe, a total of 87 patients were included in the study. Nine patients developed a nonunion. These patients underwent surgery and were excluded from the study. A total of 78 patients were included for further analysis.

Baseline characteristics

Of the included patients 67 patients were male. The mean age was 42.2 ± 15.7 years, in 31 patients the fracture occurred in the clavicle of the dominant arm, and 19 patients were smokers. When inquiring about physical exercise, twenty patients declared that they used to do heavy physical work [Table 1].
Table 1: Baseline characteristics of the study population (n=87)

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Radiographic evaluation

On the standard AP radiographs in all occasions a degree of shortening and displacement was seen [Figure 2]. On the additional rhomboideus views, the degree of shortening and displacement was no longer observed [Figure 3]. The difference in the position of the patient due to the military position (the figure-of-eight brace and adequate analgesia) changed the amount of shortening seen on the radiographs.
Figure 2: Standard anterior-posterior radiographs

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Figure 3: Rhomboideus radiograph

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Clinical outcomes

Fracture union

Within these 87 patients fracture union was seen in 78 patients (89.7%), after 24 weeks without surgery. Nine (10.3%) patients developed a nonunion. Those patients were operated and excluded from this study. Three patients (3.8%) developed a delayed union. These patients were not operated and union still occurred after 6 months [Table 2].
Table 2: Clinical outcomes (n=87)

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Functional outcome

The DASH and constant questionnaire was completed in 78 patients (100%) after 6 weeks. An average DASH score of 18.9 ± 14.4 was seen and a constant score of 88.2 ± 11.8 after 6 weeks [Table 2].

Adverse events

One patient had a refracture after new trauma. Two patients underwent surgery for an exostosis [Table 2].


  Discussion Top


Shortening caused by dislocation has been associated with potential shoulder dysfunction when treated conservatively.[5],[6] Interestingly, different degrees of shortening leading to an unfortunate outcome are being reported; varying from 15 mm to 20 mm.[5],[6],[7],[8],[9],[10],[11] The decision to treat midshaft clavicle fractures conservatively or operatively; however, still heavily dependents on radiographic examination and outcome.[5],[6] The accuracy of these standard radiographs as a diagnostic instrument can, nonetheless, be questioned. Previous studies showed that shortening could not reliably be assessed on AP and 30° caudocephalad radiographs. There was only a moderate to weak interobserver agreement and minimal intraobserver agreement on the amount of shortening seen on a radiograph.[18],[19] Jones et al.[18] found that these values were particularly low in the range of shortening around 1–2 cm, which is the most important range when determining the outcome of nonoperatively treated fractures. Furthermore, Stegeman et al.[19] showed that radiologists classified these fractures more reliably than surgeons. Although when deciding on treatment, 60% of the evaluators ranked the amount of shortening as the most important criterion.[18] Furthermore, other studies showed that the extent of shortening and dislocation might be misjudged if displayed on standard radiographs.[12],[13] A study of Sharr and Mohammed [13] demonstrated the inaccuracy of the commonly used AP 15 cephalic clavicle radiographs. They found a 15% magnification on the AP 15 cephalic radiographs, with up to 19 mm of variation on oblique views. An earlier study of Austin et al.[12] found that the standard 2-view clavicle radiographic X-ray underestimates the degree of displacement and shortening. They used of a novel 4-view radiographic series (standard 2-views plus orthogonal views) and concluded that surgeons, with these additional views, were more likely to treat fractures of the clavicle operatively. To evaluate the adequacy of the radiographic techniques, we compared the standard 2-view radiographs with a rhomboideus radiograph and found that the amount of shortening seen on a standard radiograph was no longer observable on a rhomboideus radiograph. The intention of the rhomboideus radiograph is not to propose a new diagnostic manner, but to evaluate the accuracy of the standard trauma series. Herewith, address that therapeutic decisions should not solely be based on a radiographical assessment. The combination of the unusual sigmoid shape of the clavicle with the translation of a three-dimensional bone into a two-dimensional radiograph makes it difficult to adequately evaluate the classification of the fracture. An amount of shortening occurs in up to 50% of cases, but the relationship of shortening with an impaired functional outcome remains unclear in the literature.[5],[7] Nordqvist et al.[20] found permanent shortening to be common after clavicle fractures but that this had no clinical significance. A study of Nowak et al.[21] showed that fracture shortening did not predict outcome except for cosmetic defects. Moreover, utilizing chest radiographs to compare both clavicles, Rasmussen et al.[22] found that shortening of >2 cm was not associated with poorer outcomes. Therefore, although static anatomic changes in the shoulder girdle due to a shortened clavicle were observed. None of the studies found a direct correlation between the extent of clavicle shortening and the degree of objective reduction in shoulder function.[20],[21],[22] Therefore, the critical amount of acceptable shortening has not been determined and the value of the standard trauma series can be questioned. A significant amount of research has been done to establish a general consensus on how to treat displaced midshaft clavicle fractures. As these fractures commonly afflict a young, working population were rapid return to function and early union has a high priority.

However, we believe operating patients based on radiographic examination alone leads to overtreatment and preventable complications as it remains unclear which characteristics can reliably predict patient - important functional outcomes and union. Treatment should, therefore, be individualized, with consideration of each patient's age, activity level, job description, and expectations of treatment. We recognize that there are some limitations to this study. First, one of the primary end-points was the amount of shortening as seen on the standard radiographs and compares it with the rhomboideus radiograph. Despite clearly difference in radiographic views, we were not able to accurately measure the difference in shortening between both radiographs. The fracture at presentation was diagnosed by a nonstandardized radiographic method; therefore, we were not able to measure the amount of shortening. The unusual sigmoid shape of the clavicle, difficult patient positioning, variable film distance, and resultant magnification discrepancies all combine reduce an accurate reproduction of the clavicle; therefore, any clavicle length measurements are prone to be incorrect.[14] As a result, we were not able to establish a reliable association between the initial clavicle shortening and the final shortening after union. Nevertheless, this strengthens our hypothesis that the amount of shortening cannot be adequately determined with a standard radiograph alone and cannot be taken into consideration as an important factor in treatment decisions and functional outcome.


  Conclusion Top


In conclusion, our results show that the degree of shortening and displacement cannot be adequately determined on standard 2-view radiographic series and that the correlation between permanent clavicle shortening and functional outcome can be questioned. Good functional outcomes were seen after conservative treatment. This indicates that the importance of shortening seen on a radiograph and the degree of permanent shortening in determining functional outcomes remains unclear. Therefore, the amount of shortening cannot be taken into consideration as an important factor in treatment decisions and functional outcome. Making that the surgical indications need to be evaluated before therapeutic decisions can be made.

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.
Robinson CM, Court-Brown CM, McQueen MM, Wakefield AE. Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. J Bone Joint Surg Am 2004;86-A:1359-65.  Back to cited text no. 1
    
2.
Stegeman SA, de Jong M, Sier CF, Krijnen P, Duijff JW, van Thiel TP, et al. Displaced midshaft fractures of the clavicle: Non-operative treatment versus plate fixation (Sleutel-TRIAL). A multicentre randomised controlled trial. BMC Musculoskelet Disord 2011;12:196.  Back to cited text no. 2
    
3.
McKee RC, Whelan DB, Schemitsch EH, McKee MD. Operative versus nonoperative care of displaced midshaft clavicular fractures: A meta-analysis of randomized clinical trials. J Bone Joint Surg Am 2012;94:675-84.  Back to cited text no. 3
    
4.
Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicentre randomized clinical trial. J Bone Joint Surg Am 2007;89:1-10.  Back to cited text no. 4
    
5.
Eskola A, Vainionpää S, Myllynen P, Pätiälä H, Rokkanen P. Outcome of clavicular fracture in 89 patients. Arch Orthop Trauma Surg 1986;105:337-8.  Back to cited text no. 5
    
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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
    
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De Giorgi S, Notarnicola A, Tafuri S, Solarino G, Moretti L, Moretti B. Conservative treatment of fractures of the clavicle. BMC Res Notes 2011;4:333.  Back to cited text no. 7
    
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Lazarides S, Zafiropoulos G. Conservative treatment of fractures at the middle third of the clavicle: The relevance of shortening and clinical outcome. J Shoulder Elbow Surg 2006;15:191-4.  Back to cited text no. 8
    
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Ledger M, Leeks N, Ackland T, Wang A. Short malunions of the clavicle: An anatomic and functional study. J Shoulder Elbow Surg 2005;14:349-54.  Back to cited text no. 9
    
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Postacchini R, Gumina S, Farsetti P, Postacchini F. Long-term results of conservative management of midshaft clavicle fracture. Int Orthop 2010;34:731-6.  Back to cited text no. 10
    
11.
Thormodsgard TM, Stone K, Ciraulo DL, Camuso MR, Desjardins S. An assessment of patient satisfaction with nonoperative management of clavicular fractures using the disabilities of the arm, shoulder and hand outcome measure. J Trauma 2011;71:1126-9.  Back to cited text no. 11
    
12.
Austin LS, O'Brien MJ, Zmistowski B, Ricchetti ET, Kraeutler MJ, Joshi A, et al. Additional x-ray views increase decision to treat clavicular fractures surgically. J Shoulder Elbow Surg 2012;21:1263-8.  Back to cited text no. 12
    
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Sharr JR, Mohammed KD. Optimizing the radiographic technique in clavicular fractures. J Shoulder Elbow Surg 2003;12:170-2.  Back to cited text no. 13
    
14.
Smekal V, Deml C, Irenberger A, Niederwanger C, Lutz M, Blauth M, et al. Length determination in midshaft clavicle fractures: Validation of measurement. J Orthop Trauma 2008;22:458-62.  Back to cited text no. 14
    
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Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: The DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG) Am J Ind Med 1996;29:602-8.  Back to cited text no. 15
    
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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. 16
    
17.
van Olden GD. VA-LCP anterior clavicle plate: The anatomically precontoured fixation system with angular stability for clavicle shaft. Musculoskelet Surg 2014;98:217-23.  Back to cited text no. 17
    
18.
Jones GL, Bishop JY, Lewis B, Pedroza AD; MOON Shoulder Group. Intraobserver and interobserver agreement in the classification and treatment of midshaft clavicle fractures. Am J Sports Med 2014;42:1176-81.  Back to cited text no. 18
    
19.
Stegeman SA, Fernandes NC, Krijnen P, Schipper IB. Online radiographic survey of midshaft clavicular fractures: No consensus on treatment for displaced fractures. Acta Orthop Belg 2014;80:161-5.  Back to cited text no. 19
    
20.
Nordqvist A, Redlund-Johnell I, von Scheele A, Petersson CJ. Shortening of clavicle after fracture. Incidence and clinical significance, a 5-year follow-up of 85 patients. Acta Orthop Scand 1997;68:349-51.  Back to cited text no. 20
    
21.
Nowak J, Holgersson M, Larsson S. Can we predict long-term sequelae after fractures of the clavicle based on initial findings? A prospective study with nine to ten years of follow-up. J Shoulder Elbow Surg 2004;13:479-86.  Back to cited text no. 21
    
22.
Rasmussen JV, Jensen SL, Petersen JB, Falstie-Jensen T, Lausten G, Olsen BS. A retrospective study of the association between shortening of the clavicle after fracture and the clinical outcome in 136 patients. Injury 2011;42:414-7.  Back to cited text no. 22
    


    Figures

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

  [Table 1], [Table 2]



 

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