¹Associate Professor, Department of Orthopaedics, Government Medical College, Aurangabad, INDIA.

²Professor, Department of Anaesthesia, Pacific Institute of Medical Sciences, Udaipur Rajasthan, INDIA.

Email: gadehospital@gmail.com

RESULTS

In present study, total 31 patients underwent surgery. 19-29 years age group was most common (45%), followed by 30-39 years age group (26%). Male predominance (71%) was noted as compared to females (29%). Right side was commonly involved (61%). Road traffic Accident (55%) was most common mode of injury. Robinson’s fracture type 2B1 was most fracture noted (65%).

Table 1: Demographic data.

Perioperative characteristics are mentioned in table 2. We noted 100% union rate with 5.6 ± 2.3 months required for complete union.

Table 2: Perioperative measures and outcome

After complete healing, according Constant Murley scoring system, functional outcome was excellent in 81% patients while good and fair outcome was noted in 13% and 9% patients respectively.

Table 3: Outcome based on Constant Murley score

Complications such as delayed union (3 %) and superficial infection (3 %) were noted in present study. We did not noted any non-union, malunion, deep infection, plate loosening, plate breakage, plate prominence, hypertrophic scar, signs of nerve compression, pain after complete union or restriction of shoulder movement in study patients.

Table 4: Complications

DISCUSSION

Several prospective comparative studies and meta-analyses recommended surgery for displaced midshaft fracture, to reduce risk of non-union and malunion, which can cause discomfort due to shortening of the global shoulder skeleton. Also functional recovery is faster and pain is alleviated after surgery.^4,8 Displaced fractures of the middle third of the clavicle are common in young, athletic populations and following road traffic accidents. Clavicular fractures have a bimodal age distribution. The first peak occurs in young active adult men, and the second peak occurs in elderly women with osteoporosis.⁹ In present study majority of the patients were from age group of 19 to 29 years (45%). The average age was 33.9 ± 9.2 years. Similar findings were noted in the study by Ankur Mittal et al..,¹⁰ and Wali PC.¹¹ Many methods of conservative treatment, namely, triangular sling, cuff and collar sling, three sling method, figure of eight bandage, figure of eight plaster of Paris shoulder Spica, clavicular brace, arm shoulder pouch, and many others have been described from time-to-time.¹² Hill et al..,¹³ evaluated 242 fractures of clavicle which had been treated conservatively and found unsatisfactory results with initial shortening of 20mm or more. They recommended open reduction and internal fixation for severely displaced fracture of middle third of clavicle in adult patients. K. Ramkumar et al.., noted that majority of the cases are united by the end of 10 weeks (86.6 %) and between 10 – 12 weeks (13.4%). There were no delayed union or nonunion cases. The functional outcome according to Constant and Murley score is excellent in 19 patients (63.3%) and good in 11 patients (36.7%).¹⁴ Similar findings were noted in present study. In study by Ghosh A et al..,¹⁵ Constant score was excellent in 26 patients (<11) good in 2 patients (11-20) and fair in 2 patients (21-30). No patients had a poor result (>30) on constant scoring system. Functional outcome was excellent in 87% of cases. The mean time to union was 6.8 months. No patient developed non-union or mal union.¹⁵ In a multicenter prospective randomized study by the Canadian orthopaedic trauma society in 132 patients with displaced midshaft fracture, in which 65 patients were managed by plates and 67 by slings. Constant and DASH scores were significantly better, consolidation time was shorter, and non-union and symptomatic malunion rates were lower; at 1-year post-trauma, functional and esthetic satisfaction rates were significantly higher in the plate group.⁴ Similarly , Gilde¹⁶ found good functional results with isolated locking plate in 32 patients,13 of whom with more than 1 year’s follow-up; no revision of internal fixation or other surgery was required.

Nayak A.J. et al..,¹⁷ assessed functional outcome and noted that 85% had excellent outcome, 10% had good functional outcome and 5% had fair outcome. While in study by Panthi S et al..,¹⁸ noted that Constant and Murley score 45 (90%) of the study subjects showed excellent results, 4 (8%) showed good results, 1 (2%) showed good results. Mean Constant and Murley score was 96.0±5.20. Similar findings were noted in present study Proponent of early fixation of fresh clavicle fracture is to prevent complication, like non-union, malunion, shoulder stiffness, cosmesis; emphasize the value of accurate reduction and rigid fixation in offering quick pain relief. Disadvantages of plate fixation include the necessity for increased exposure and soft tissue stripping, potential injury to the supraclavicular nerves, higher infection rates and the re-fracture after plate removal these complications can be reduced by careful soft tissue handling, minimal periosteal stripping and meticulous plate fixation.⁸ Risks associated with operative management of the fractured clavicle include neuropathy of the supraclavicular nerve, infection, pneumothorax, implant failure and the need for hardware removal due to hardware-related complaints.¹⁹ Leroux et al. retrospectively evaluated rate and risk of reoperation of a cohort of 1350 patients who had undergone open reduction and internal fixation with at least two years of follow-up. They reported 24.6% reoperation rate. Isolated implant removal was the most common cause of reoperation accounting for 18.8% reoperations. They reported lower rates of other complications such as non-union (2.6%), deep infection (2.6%), pneumothorax (1.2%) and malunion (1.1%).²⁰ M. Ropars et al..,²¹ concluded that internal fixation should be considered on a case-by-case basis in clavicle fracture. Emergency surgery is mandatory in complicated fracture, skin opening of whatever grade, or primary neurovascular complications. In young patients with > 15 mm clavicle shortening in the frontal plane, and especially in case of communitive fracture, surgery should be considered. The current gold standard in operative treatment is Open Reduction Internal Fixation (ORIF) using plates and screws. An alternative to this technique is internal fixation using intramedullary fixation devices. These devices aim to reduce the displaced mid-shaft clavicle fractures (DMCF) in a minimally invasive manner and thereby improving cosmetic satisfaction and union rates while lowering infection rates. ²²

Biomechanically, plate fixation is superior to intramedullary fixation because it better resists the bending and torsional forces that occur during elevation of the upper extremity above shoulder level.²³ Short-term data show that ORIF using plates and screws results in a more rapid return to normal function compared with conservative treatment. Shoulder function after six weeks may therefore play a role in choosing operative management.^24,25 Conservative management need longer duration for producing union at fracture site, so longer duration of useful work days loss which put more economic and financial burden. In Non-union end results, operative treatment done to achieve union, further increases morbidity and more work days loss and more economic burden. Present study had small sample size, institution-based study with single method of fracture fixation. Larger studies comparing conservative treatment and various fixation methods for displaced midshaft clavicle fractures are needed.

CONCLUSION

Open reduction and internal fixation with plate for displaced midshaft fracture clavicle results in high rates of fracture union, increased patient satisfaction, early pain-free movement of shoulder and improves patient- oriented functional outcome. Use of anatomical contoured clavicle plate provides fixation of clavicle to its normal contour and provides better fixation and stability.

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