The treatment of middle-third clavicle fractures: A paradigm shift

Since the time of Hippocrates, clavicle fractures have been considered a relatively benign entity that requires little more than neglect [1]. Recently, there has been a paradigm shift; lending serious consideration for operative care in the setting of middle third clavicle fractures and leading to a noticeable increase in the incidence of surgically treated middle-third clavicle fractures. The number of patients presenting with mid-shaft clavicle fractures has remained relatively constant but the incidence of operative fixation of clavicle fractures has increased by as much as 368% [2].


Introduction
Since the time of Hippocrates, clavicle fractures have been considered a relatively benign entity that requires little more than neglect [1]. Recently, there has been a paradigm shift; lending serious consideration for operative care in the setting of middle third clavicle fractures and leading to a noticeable increase in the incidence of surgically treated middle-third clavicle fractures. The number of patients presenting with mid-shaft clavicle fractures has remained relatively constant but the incidence of operative fixation of clavicle fractures has increased by as much as 368% [2].
Any shift of this magnitude in the time-proven principles of fracture care is certain to attract attention and beg the question; are we operating unnecessarily? To truly establish an evidence-based approach to the management of middle-third clavicle fractures and understand the rising incidence of operatively treated clavicle fractures, the evolution of the recommended operative indications must be understood.

A historical perspective
Neer initially published a cohort of 2235 patients in 1960 that encouraged a conservative, non-operative approach to the treatment of middle third clavicle fractures; because non-operative management was associated with a non-union rate of 0.13% versus 4.6% in the 45 patients that were treated operatively [3]. This study stressed the importance of simple, conservative care in the setting of these injuries. Over time, additional literature regarding this area of interest hinted that non-operative management might not be 'best' for all mid-shaft clavicle fractures. For example, Robinson, et al. noted a non-union rate of 4.5% in their cohort of non-operatively treated middle third clavicle fractures; more importantly they established several significant risk factors associated with these non-unions including advancing age, female gender, displacement of the fracture, and the presence of comminution [4]. In 2005, a systematic review further stressed the importance of these risk factors by publishing a non-union rate of 15.1% in displaced, mid-clavicle fractures that were treated nonoperatively [5].
Over time, clinical and performance based outcomes were published on these patients following non-operative care. McKee, et al. reported residual disability in patients who underwent non-operative treatment of displaced mid-shaft clavicle fractures with Constant scores of 71 points and DASH scores of 24.6 points at 55 months after injury [6]. Objective shoulder strength testing in this same cohort noted significantly decreased strength and endurance in flexion, abduction, external rotation, and internal rotation of the shoulder [6]. In addition, several studies found that shortening of 14-20mm at the sight of the fracture is associated with unsatisfactory results [7,8].
In 2007, a multicenter, prospective, randomized clinical trial conducted by the Canadian Orthopedic Trauma Society (COTS) compared operative (ORIF) and non-operative (Sling) treatment in 132 patients with displaced mid-shaft clavicle fractures [9]. They found that in addition to overall satisfaction, Constant and DASH scores significantly increased with surgical treatment, while mean time to radiographic union, non-unions, and symptomatic malunions all decreased with surgery [9].

Operative fixation modalities
Various surgical treatment options are available, but middle-third clavicle fractures are typically treated with open reduction and internal plate fixation or intramedullary nail fixation. Open reduction with plate fixation allows for rigid fixation that enables early mobilization of the involved shoulder [7,[10][11][12]. Intramedullary nailing offers a cosmetically appealing fixation technique at the cost of rotational and length stability [13][14][15][16]. Both fixation techniques have been reported to lead to faster mobilization of the involved extremity with faster return to sport [17][18][19][20]. A randomized control trial involving 68 athletes demonstrated better short-term mobility, improved strength, and quicker return-to sport if treated with an intramedullary fixation versus non-operative treatment [21].

Rehabilitation
There is not a consensus on the duration of immobilization or rehabilitation protocol following a clavicle fracture [7,[22][23][24][25][26]. However, 12 athletes reportedly returned to training at 5.9 days and competition at 16.8 days following intramedullary nailing of displaced, middle third clavicle fractures [17]. In addition, an accelerated rehab protocol has been published that allowed a collegiate football player to pursue immediate active shoulder mobilization after surgery, obtain full strength and range of motion at 5 weeks post-op, and return to competition at post-op week 6 following open reduction with plate fixation of a comminuted, midshaft clavicle fracture [19].

Conclusion
In summary, cumulative evidence has led to relative operative indications for middle-third clavicle fractures that likely explain the increasing incidence in surgical treatment for mid-shaft clavicle fractures and the paradigm shift noted in the literature. These relative indications include significant shortening (>1.4-2 cm), comminution, displacement (>100%), cosmetic deformity, and poly-trauma situations [26]. The intended outcome is to maximize patient clinical (Constant, DASH) and performance-based outcomes (strength, endurance); minimize time-to-union, non-unions, and malunions. The ultimate goal is to provide optimal outcomes with early return to activity for patients or at least allow patients to make a well-educated decision regarding operative versus non-operative management.