Is intramedullary nailing more effective than non-operative treatment in adults with displaced middle-third clavicle fractures?

Journal of Orthopaedics and Traumatology, Sep 2014

Background Clavicle fractures are common, accounting for 5–12 % of all fractures. Traditionally, displaced middle-third clavicle fractures have been managed non-operatively but the associated displacement often leads to mal-union with shortening, cosmetic deformity and occasionally non-union, with clinicians looking towards alternative operative methods such as intramedullary nailing (IMN). However, such methods have their own complications. In order to ascertain the effectiveness of IMN in the management of middle-third clavicle fractures compared with non-operative treatment, analysis of recent evidence is required and this review aims to achieve that, focusing on relevant, contemporary randomised-control trials. Materials and methods Essential search-terms identified from the research question were used to formulate a search strategy. A systematic search of multiple databases was then performed from 1966 until present and appropriate papers for appraisal identified. Results Thirteen papers were identified, with 10 excluded using appropriate eligibility criteria. The remaining papers were then critically appraised. With regards shoulder function, all papers demonstrated an association between IMN and a significantly (P < 0.05) superior shoulder function score, but no consensus with regards to complication rates. However, all have identified limitations; therefore, their overall findings must be considered conservatively. Conclusions Further, high-quality research, ideally in the form of well-designed, multi-centre RCTs is required to allow acceptable implementation of IMN of middle-third clavicle fractures into widespread practice. However, early results demonstrate that in young patients with displaced middle-third clavicle fractures, who are motivated to return to work, IMN provides superior functional results and should be considered. However, the importance of considering each patient individually as to their suitability for each management option, before coming to an informed decision with the patient rather than having a blanket approach to MTCF is essential. Level of Evidence Level 1.

A PDF file should load here. If you do not see its contents the file may be temporarily unavailable at the journal website or you do not have a PDF plug-in installed and enabled in your browser.

Alternatively, you can download the file locally and open with any standalone PDF reader:

https://link.springer.com/content/pdf/10.1007%2Fs10195-014-0299-6.pdf

Is intramedullary nailing more effective than non-operative treatment in adults with displaced middle-third clavicle fractures?

0 C. E. Hill University Hospital of Coventry and Warwickshire , Clifford Bridge Road, Coventry CV22 5PX, UK 1 C. E. Hill (&) 46, Hermitage Road, Kenilworth, Warwickshire CV8 2DW, UK Background Clavicle fractures are common, accounting for 5-12 % of all fractures. Traditionally, displaced middle-third clavicle fractures have been managed non-operatively but the associated displacement often leads to malunion with shortening, cosmetic deformity and occasionally non-union, with clinicians looking towards alternative operative methods such as intramedullary nailing (IMN). However, such methods have their own complications. In order to ascertain the effectiveness of IMN in the management of middle-third clavicle fractures compared with non-operative treatment, analysis of recent evidence is required and this review aims to achieve that, focusing on relevant, contemporary randomised-control trials. Materials and methods Essential search-terms identified from the research question were used to formulate a search strategy. A systematic search of multiple databases was then performed from 1966 until present and appropriate papers for appraisal identified. Results Thirteen papers were identified, with 10 excluded using appropriate eligibility criteria. The remaining papers were then critically appraised. With regards shoulder function, all papers demonstrated an association between IMN and a significantly (P 0.05) superior shoulder function score, but no consensus with regards to complication rates. However, all have identified limitations; therefore, their overall findings must be considered conservatively. Conclusions Further, high-quality research, ideally in the form of well-designed, multi-centre RCTs is required to allow acceptable implementation of IMN of middle-third clavicle fractures into widespread practice. However, early results demonstrate that in young patients with displaced middle-third clavicle fractures, who are motivated to return to work, IMN provides superior functional results and should be considered. However, the importance of considering each patient individually as to their suitability for each management option, before coming to an informed decision with the patient rather than having a blanket approach to MTCF is essential. Level of Evidence Level 1. - This review aims to use clinically based, contemporary literature to ascertain whether intramedullary nailing (IMN) is a more beneficial management technique than non-operative management in adult middle-third clavicle fractures (MTCF) with regards to shoulder function. Clavicle fractures account for 512 % of all fractures, with an estimated incidence of 2964/100,000 adult population/year [14]. Eighty per cent occur in the middlethird zone of the clavicle, identified as Grade 1 using the anatomical Allman classification [5] (Table 1). Most MTCF are displaced by the deforming pull of associated muscle attachments [68]. Traditionally, MTCF have been managed non-operatively [911], however, the Table 1 The Allman classification of clavicle fractures Fractures of the middle-third of the clavicle Fractures of the clavicle distal to the coracoclavicular ligament (lateral) Fractures of the proximal end of the clavicle (medial) Table 2 Internal plate fixation complications [16, 54] associated displacement often leads to mal-union with shortening, cosmetic deformity and occasionally non-union [1, 12, 13]. In connecting the upper limb with the thoracic cage, the clavicle is salient to shoulder mechanics and stabilising the shoulder girdle, hence fracture patients with loss of length and curvature have been reported to suffer with residual deficits in shoulder strength and endurance [1, 3, 12, 13]. These potential drawbacks demonstrate why MTCF management has become increasingly controversial, with clinicians looking towards alternative operative methods [1, 14]. Two main operative methods exist: internal plate fixation and IMN [15]. Internal plate fixation has been shown to have a number of complications, (Table 2), leading many to explore IMN [16]: Clavicle IMN was initially described over 50 years ago [17, 18]. Biomechanically, the technique provides optimal fracture stabilisation and aims to preserve clavicular length, avoiding mal-union and maintaining good cosmetic and functional results, allowing faster return to daily activities and employment [19]. However, concerns regarding complication rates have raised doubts as to the best treatment method [17, 20]. Cochrane reviews have separately studied non-operative and operative treatment methods but not compared the two; therefore, given the fractures common incidence and management choice controversy, this review is fully justified [15, 21]. Evidence-based medicine is defined as the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients [22]. In order to ascertain the effectiveness of IMN in the management of adult MT (...truncated)


This is a preview of a remote PDF: https://link.springer.com/content/pdf/10.1007%2Fs10195-014-0299-6.pdf

Christopher Edward Hill. Is intramedullary nailing more effective than non-operative treatment in adults with displaced middle-third clavicle fractures?, Journal of Orthopaedics and Traumatology, 2014, pp. 155-164, Volume 15, Issue 3, DOI: 10.1007/s10195-014-0299-6