Current Treatment Concepts for Mid-Shaft Fractures of the Clavicle - Results of a Prospective Multicentre Study

Background: Mid-shaft clavicular fractures are mainly treated conservatively with an average incidence of non-union in 4.5%. Gender, age, grade of fragment dislocation and comminution are risk factors to develop a pseudarthrosis. In contrast to patients who where operated on, conservative treatment was also associated with a higher complication rate and pain level as well as a poor shoulder function and cosmetic result. Therefore more patients are treated operatively, especially modern minimally invasive techniques have been developed and remain as equals to the standard plate fixation. Patients/Material: Within a period of 24 months patients with a mid-shaft clavicular fracture were included into a prospective, non-randomised multicentre study. A modified AO classification was used. Patients were treated either conservatively, by plating or intramedullary nailing. Pain level, cosmetic result, shoulder function and complication rate were documented as well as the influence of the profession on the therapeutic strategy and duration of unfitness for work. Results: 120 patients (95 male, 25 female) were included in the study. Fractures were caused in 35 (29%) by a direct, in 85 (71%) by an indirect trauma mechanism. Because of their lower grade fractures with overlapping fragments 47 (39%) patients were treated conservatively with a figure-of-eight-bandage. Patients with higher graded fractures and fragment displacement were stabilised either by intramedullary nailing (n = 20, 27%) or plate fixation (n = 53, 73%). 96 (80%) patients were examined at a follow-up of eight weeks and eight months after injury. Early freedom from pain (p = 0.014), a better cosmetic result (p = 0.1) and an improved subjective (p = 0.004) and objective (p = 0.01) shoulder function were statistically significant in operated patients. Clavicle shortening was often found to be significant in conservatively treated patients (p = 0.006). Duration of unfitness for work depended on the physical activity in the job. The complication rate was 15% for each therapy, non-union was detected in one (0.8%) patient. Conclusion: Mid-shaft clavicular fractures have to be classified by the criteria contact and number of fragments. Advantages of operative procedures are early freedom from pain and shoulder function recovery. Non-displaced low grade shaft fractures without shortening should be treated conservatively, whereas displaced low-grade shaft fractures have a better result after intramedullary nailing. Plate fixation should be predominantly used in dislocated and comminuted fractures as well as in patients with a high level of physical activity in their jobs.