Abstract
Introduction
Fractures ofthe clavicle are frequent injuries (between 4 and 10% of adult fractures) and mid-shaft diaphyseal fractures represent more than 80% of clavicle fractures. In a recent study from the USA in 2019, an incidence of 22.4 fractures per year per 100,000 people was reported. Multiple injury mechanisms are recognised, with sport accounting for 50 to 85% of these injuries. There is little or no consensus as to the optimal treatment but in recent years multiple studies have suggested operative management should be favoured in athletes and young active patients.
Objectives
These are (1) to present the anatomy and the anatomical-pathology of the fractures of the clavicle as well as the mechanisms of injury, (2), (3) to describe non-operative and operative treatment methods, (4) to review the literature around different treatment modalities and (5) to attempt to describe the best treatment for athletes.
Methods
To collect and analyse the most recent articles of the literature regarding the management of displaced mid-shaft fractures of the clavicle for athletes and young active people.
Results
Looking at studies of the general population, the results tend to favour surgical treatment with a smaller incidence of non-union and faster return to function. These results are mirrored in the athlete population where several studies have shown excellent anatomic restoration and functional recovery after plate fixation.
Conclusion
Based on this analysis, with the exception of patients who refuse operative management after an informed discussion, the treatment of choice in displaced clavicle fractures in athletes seems to be operative treatment with a plate and screws. However, prospective randomised studies comparing non-surgical treatment and plate osteosynthesis are missing and it is not possible to state that the latter is the best treatment.
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Data availability
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References
Robinson CM (1998) Fractures of the clavicle in the adult. Epidemiology and classification. J Bone Joint Surg Br 80(3):476–84. https://doi.org/10.1302/0301-620x.80b3.8079
Postacchini F, Gumina S, De Santis P, Albo F (2002) Epidemiology of clavicle fractures. J Shoulder Elbow Surg 11(5):452–456
DeFroda SF, Lemme N, Kleiner J, Gil J, Owens BD (2019) Incidence and mechanism of injury of clavicle fractures in the NEISS database: athletic and non-athletic injuries. J Clin Orthop Trauma 10(5):954–958. https://doi.org/10.1016/j.jcot.2019.01.019
Saragaglia D, Cavalié G, Rubens-Duval B, Pailhé R, Lateur G (2019) Screw-plate fixation for displaced middle-third clavicular fractures with three or more fragments : a report of 172 cases. Orthop Traumatol Surg Res 105(8):1571–1574. https://doi.org/10.1016/j.otsr.2019.05.013
McCarthy MM, Bihl JH, Frank RM, Salem HS, McCarty EC, Comstock RD (2019) Epidemiology of clavicle fractures among US high school athletes, 2008–2009 through 2016–2017. Orthop J Sports Med 7(7):2325967119861812. https://doi.org/10.1177/2325967119861812
Ropars M, Thomazeau H, Huten D (2017) Clavicle fractures. Orthop Traumatol Surg Res 103(1S):S53–S59. https://doi.org/10.1016/j.otsr.2016.11.007
Wiesel B, Nagda S, Mehta S, Churchill R (2018) Management of midshaft clavicle fractures in adults. J Am Acad Orthop Surg 26(22):e468–e476. https://doi.org/10.5435/JAAOS-D-17-00442
Havet E, Duparc F, Tobenas-Dujardin AC, Muller JM, Delas B, Fréger P (2008) Vascular anatomical basis of clavicular non-union. Surg Radiol Anat 30:23–28
Meinberg EG, Agel J, Roberts CS, Karam MD (2018) Kellam JF (2018) Fracture and dislocation classification compendium-2018. J Orthop Trauma 32(Suppl 1):S1–S170
Neer CS 2nd (1968) Fractures of the distal third of the clavicle. Clin Orthop Relat Res 58:43–50
Faraud A, Bonnevialle N, Allavena C, Nouaille Degorce H, Bonnevialle P, Mansat P (2014) Outcomes from surgical treatment of middle-third clavicle fractures nonunion in adults: a series of 21 cases. Orthop Traumatol Surg Res 100:171–176
McKnight B, Heckmann N, Hill JR, Pannell WC, Mostofi A, Omid R et al (2016) Surgical management of midshaft clavicle nonunions is associated with a higher rate of short-term complications compared with acute fractures. J Shoulder Elbow Surg 25(9):1412–1417. https://doi.org/10.1016/j.jse.2016.01.028
O’Connor D, Kutty S, McCabe JP (2004) Long-term functional outcome assessment of plate fixation and autogenous bone grafting for clavicular non-union. Injury 35(6):575–579. https://doi.org/10.1016/S0020-1383(03)00239-0
Ghislandi X, Lecomte L, Zappaterra T, Garbuio P, Lepage D, Obert L (2012) Incidence of early venous thrombosis in functional treatment of middle-third clavicle fracture [in French]. Rev Chir Orthop Reparatrice Appar Mot 98S:S 111-S 117
Andersen K, Jensen PO, Lauritzen J (1987) Treatment of clavicular fractures. Figure-of-eight bandage versus a simple sling. Acta Orthop Scand 58:71–4
Ersen A, Atalar AC, Birisik F, Saglam Y, Demirhan M (2015) Comparison of simple arm sling and figure of eight clavicular bandage for midshaft clavicular fractures: a randomised controlled study. Bone Joint J 97-B(11):1562–1565. https://doi.org/10.1302/0301-620X.97B11.35588
Collinge C, Devinney S, Herscovici D, DiPasquale T, Sanders R (2006) Anterior-inferior plate fixation of middle-third fractures and nonunions of the clavicle. J Orthop Trauma 20:680–686
Iannotti MR, Crosby LA, Stafford P, Grayson G, Goulet R (2002) Effects of plate location and selection on the stability of midshaft clavicle osteotomies: a biomechanical study. J Shoulder Elbow Surg 11:457–462
Chen W, Tang K, Tao X, Yuan C, Zhou B (2018) Clavicular non-union treated with fixation using locking compression plate without bone graft. J Orthop Surg Res 13(1):317. https://doi.org/10.1186/s13018-018-1015-7
Peroni l (1950) Medullary osteosynthesis in the treatment of clavicle fractures [L’osteosintesi midollare nel trattamento delle fratture della clavicola]. Arch ortop 63:398–405
Lengua F, Nuss JM, Lechner R, Baruthio J, Veillon F (1987) Traitement des fractures de la clavicule par embrochage à foyer fermé de dedans en dehors sans va-et-vient. Rev Chir Orthop Reparatrice Appar Mot 73:377–380
Beguin JM, Poilvache G (1984) Les fractures de la clavicule. Étude de 17 cas opérés par enclouage centro-médullaire. Intérêt de la broche de Knowles. Acta Orthop Belg 50:758–68
Shukla A, Sinha S, Yadav G, Beniwal S (2014) Comparison of treatment of fracture midshaft clavicle in adults by external fixator with conservative treatment. J Clin Orthop Trauma 5:123–128. https://doi.org/10.1016/j.jcot.2014.07.012
Canadian Orthopaedic Trauma Society (2007) Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am 89:1–10
McKee MD (2010) Clavicle fractures in 2010: sling/swathe or open reduction and internal fixation. Orthop Clin North Am 41:225–231. https://doi.org/10.1016/j.ocl.2009.12.005
Kulshrestha V, Roy T, Audige L (2011) Operative versus nonoperative management of displaced midshaft clavicle fractures: a prospective cohort study. J Orthop Trauma 25:31–38
Virtanen KJ, Malmivaara AO, Remes VM, Paavola MP (2012) Operative and nonoperative treatment of clavicle fractures in adults. Acta Orthop 83:65–73. https://doi.org/10.3109/17453674.2011.652884
Daniilidis K, Raschke MJ, Vogt B, Herbort M, Schliemann B, Günther N et al (2013) Comparison between conservative and surgical treatment of midshaft clavicle fractures: outcome of 151 cases. Technol Health Care 21(2):143–147. https://doi.org/10.3233/THC-130714
Robinson CM, Goudie EB, Murray IR, Jenkins PJ, Ahktar MA, Read EO et al (2013) Open reduction and plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures: a multicenter, randomized, controlled trial. J Bone Joint Surg Am 95(17):1576–1584. https://doi.org/10.2106/JBJS.L.00307
van der Ven Denise JC, Timmers TK, Flikweert PE, Van Ijseldijk AL, van Olden GD (2015) Plate fixation versus conservative treatment of displaced midshaft clavicle fractures: functional outcome and patients’ satisfaction during a mean follow-up of 5 years. Injury 46(11):2223–2229. https://doi.org/10.1016/j.injury.2015.08.004
Woltz S, Stegeman SA, Krijnen P, van Dijkman BA, van Thiel TP, Schep NW et al (2017) Plate fixation compared with nonoperative treatment for displaced midshaft clavicular fractures: a multicenter randomized controlled trial. J Bone Joint Surg Am 99(2):106–112. https://doi.org/10.2106/JBJS.15.01394
Ahrens PM, Garlick NI, Barber J, Tims EM, Clavicle Trial Collaborative Group (2017) The clavicle trial: a multicenter randomized controlled trial comparing operative with nonoperative treatment of displaced midshaft clavicle fractures. J Bone Joint Surg Am 99(1345):1354. https://doi.org/10.2106/JBJS.16.01112
Tamaoki MJS, Matsunaga FT, Costa ARFD, Netto NA, Matsumoto MH, Belloti JC (2017) Treatment of displaced midshaft clfvicle Fractures: figure-of-eight harness versus anterior plate osteosynthesis: a randomized controlled trial. J Bone Joint Surg Am 99:1159–1165. https://doi.org/10.2106/JBJS.16.01184
Lenza M, Buchbinder R, Johnston RV, Ferrari BA, Faloppa F (2019) Surgical versus conservative interventions for treating fractures of the middle third of the clavicle. Cochrane Database Syst Rev 1(1):CD009363. https://doi.org/10.1002/14651858.CD009363.pub2
Micheloni GM, Tarallo L, Porcellini G, Catani F (2019) Comparison between conservative treatment and plate fixation for displaced middle third clavicle fracture: clinical outcomes and complications. Acta Biomed 90(12-S):48–53. https://doi.org/10.23750/abm.v90i12-S.8995
Axelrod DE, Ekhtiari S, Bozzo A, Bhandari M, Johal H (2020) What is the best evidence for management of displaced midshaft clavicle fractures? A systematic review and network meta-analysis of 22 randomized controlled trials. Clin Orthop Relat Res 478(2):392–402. https://doi.org/10.1097/CORR.0000000000000986
Smeeing DPJ, van der Ven DJC, Hietbrink F, Timmers TK, van Heijl M, Kruyt MC et al (2017) Surgical versus nonsurgical treatment for midshaft clavicle fractures in patients aged 16 years and older: a systematic review, meta-analysis, and comparison of randomized controlled trials and observational studies. Am J Sports Med 45(8):1937–1945. https://doi.org/10.1177/0363546516673615
Guerra E, Previtali D, Tamborini S, Filardo G, Zaffagnini S, Candrian C (2019) Midshaft clavicle fractures: surgery provides better results as compared with nonoperative treatment: a meta-analysis. Am J Sports Med 47(14):3541–3551. https://doi.org/10.1177/0363546519826961
Hillen RJ, Burger BJ, Pöll RG, de Gast A, Robinson CM (2010) Malunion after midshaft clavicle fractures in adults. Acta Orthop 81:273–279. https://doi.org/10.3109/17453674.2010.480939
Nowak J, Holgersson M, Larsson S (2005) Sequelae from clavicular fractures are common: a prospective study of 222 patients. Acta Orthop 76:496–502
Jack RA 2nd, Sochacki KR, Navarro SM, McCulloch PC, Lintner DM, Harris JD (2017) Performance and return to sport after nonoperative treatment of clavicle fractures in National Football League players. Orthopedics 40(5):e836–e843. https://doi.org/10.3928/01477447-20170719-03
Meisterling SW, Cain EL, Fleisig GS, Hartzell JL, Dugas JR (2013) Return to athletic activity after plate fixation of displaced midshaft clavicle fractures. Am J Sports Med 41:2632–2636
Ranalletta M, Rossi LA, Piuzzi NS, Bertona A, Bongiovanni SL, Maignon G (2015) Return to sports after plate fixation of displaced midshaft clavicular fractures in athletes. Am J Sports Med 43(3):565–569. https://doi.org/10.1177/0363546514559913
Jack RA 2nd, Sochacki KR, Navarro SM, McCulloch PC, Lintner DM, Harris JD (2017) Performance and return to sport after clavicle open reduction and internal fixation in National Football League players. Orthop J Sports Med 5(8):2325967117720677. https://doi.org/10.1177/2325967117720677 (eCollection 2017 Aug)
van der Ven DJC, Timmers TK, Broeders IAMJ, van Olden GDJ (2019) Displaced clavicle fractures in cyclists: return to athletic activity after anteroinferior plate fixation. Clin J Sport Med 29(6):465–469. https://doi.org/10.1097/JSM.0000000000000552
Kamaci S, Bess L, Glogovac G, Colosimo AJ (2020) Plate osteosynthesis of midshaft clavicle fractures in adolescent contact sports athletes ‘adolescent clavicle fracture.’ J Pediatr Orthop B. https://doi.org/10.1097/BPB.0000000000000810
Tutuhatunewa ED, Stevens M, Dams OC, van Son J, Louhanepessy RD, Krabbe PFM et al (2020) Exploring patient satisfaction after operative and nonoperative treatment for midshaft clavicle fractures: a focus group analysis. BMC Musculoskelet Disord 21(1):560. https://doi.org/10.1186/s12891-020-03557-y
Barlow T, Beazley J, Barlow D (2013) A systematic review of plate versus intramedullary fixation in the treatment of midshaft clavicle fractures. Scott Med J 58:163–167. https://doi.org/10.1177/0036933013496960
Strauss EJ, Egol KA, France MA, Koval KJ, Zuckerman JD (2007) Complications of intramedullary Hagie pin fixation for acute midshaft clavicle fractures. J Shoulder Elbow Surg 16:280–284. https://doi.org/10.1016/j.jse.2006.08.012
Grassi FA, Tajana MS, D’Angelo F (2001) Management of midclavicular fractures: comparison between nonoperative treatment and open intramedullary fixation in 80 patients. J Trauma 50:1096–1100
Millett PJ, Hurst JM, Horan MP, Hawkins RJ (2011) Complications of clavicle fractures treated with intramedullary fixation. J Shoulder Elbow Surg 20:86–91. https://doi.org/10.1016/j.jse.2010.07.009
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Saragaglia, D., Refaie, R. Displaced mid-shaft clavicular fractures: state of the art for athletes and young active people. International Orthopaedics (SICOT) 45, 2679–2686 (2021). https://doi.org/10.1007/s00264-021-05113-2
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DOI: https://doi.org/10.1007/s00264-021-05113-2