Outcome of Plating and Intramedullary Fixation of Displaced Midshaft Clavicle Fractures: A Search for the Optimal Surgical Management

Balachandar, S (2016) Outcome of Plating and Intramedullary Fixation of Displaced Midshaft Clavicle Fractures: A Search for the Optimal Surgical Management. Masters thesis, Stanley Medical College, Chennai.

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Abstract

Clavicle fractures account for 2-5% of all fractures in adults. Historically general consensus was that vast majority of clavicle fractures heal well without operative intervention. Other than traditional indications for surgical intervention such as neurovascular compromise and open fractures, operative management remained somewhat controversial and quite often it still forms an ongoing topic of debate. But recent studies point out that an exception should be made for the subgroup of patients with displaced fractures of middle third of the clavicle. Reported patient outcome improve following operative reduction and fixation and the risk of malunions and nonunions is significantly reduced. Main objective of this thesis is to directly compare open reduction and internal plate fixation with closed reduction and intramedullary fixation using a nail in favour of rate of recovery and scapulothoracic kinematics following clavicle fractures. INTRODUCTION : Approximately 2-5% of all fractures in adults and 10-15% in involve the clavicle. The incidence of this type of fracture in the adolescent and adult population is reportedly 29-64 per 100,000 annually. Fractures of the clavicle also demonstrate a bimodal age distribution. Young males who are less than 30 years old and elderly patients over the age of 70 appear to be two distinct age groups at higher risk for clavicle fractures. In adults more than two thirds of these injuries occur at the diaphysis of the clavicle and are more likely to be displaced as compared to medial and lateral third fractures. Lateral third fractures are less common, accounting for approximately 25% of all clavicle fractures and are less likely to be displaced than those occurring in the midshaft. Medial third fractures comprise the remaining 2-3% of these injuries. Traditionally nonsurgical management has been favoured as the initial treatment modality for most clavicle fractures because of the high non-union rates reported following treatment. Although nonsurgical management may be optimal for many clavicle fractures, good outcomes of nonsurgically treated fractures are not universal. Recent evidence suggests that specific subsets of patients may be at high risk for non-union, shoulder dysfunction or residual pain after nonsurgical management. In this subset of patients acute surgical intervention may minimize suboptimal outcomes. Therefore specific treatment of clavicle fractures should not be broadly applied, but rather individualized based on fracture characteristics and patient expectations. The purpose of this thesis is to compare the outcome after plate and intramedullary fixation of displaced midshaft clavicle fractures. Our institution being a referral unit we are receiving many closed displaced middle third fracture clavicle. Hence it is necessary to compare surgical techniques using open reduction and internal plate fixation with closed reduction and intramedullary fixation using a nail in terms of rate of malunions, nonunions, rate of recovery, shoulder dysfunction and residual pain. AIMS : 1. To study the objective and subjective results of comparing plate fixation and intramedullary fixation of DMCF and to study the Surgical Therapeutic Index as an indicator of benefits and risks of surgical trauma care 2. To study the scapulothoracic kinematics of patients after surgical fixation of DMCF. METHODS AND MATERIALS : Sample Size: 30 Cases (15 cases for ORIF with plating, 15 cases for Closed Reduction & Intramedullary Nailing). Period of Study: 6 Months (Aug 2014 to May 2015) Follow-up Period: 3-6 Months (12-24 Weeks) Indication for Internal Fixation: 1. Unstable fractures, 2. Open fractures, 3. Neurovascular injury, 4. Floating shoulder, 5. Symptomatic non-union, 6. Displaced Group I > 2cm shortening. Advantages of Plating: 1) Comminuted fractures – Lagging possible, 2) No need for implant removal, 3) Symptomatic non-union – Bone grafting possible. Disadvantages of Plating: 1) Cosmetically inferior, 2) Chance of infection, 3) Disturbing fracture hematoma. Advantages of IM Nailing: 1) Minimally invasive, 2) Cosmetically superior, 3) Intramedullary fixation (Endosteal Callus). Disadvantages of IM Nailing: 1) Not suitable for comminuted fractures, 2) Skin irritation and pain, 3) Need for implant removal. Inclusion Criteria : Patients aged more than 17 years irrespective of sex with closed displaced midshaft clavicle fractures (DMCF). Exclusion Criteria: - Patients aged less than 17 years, - Patients on drugs that affect bone metabolism, - Patients who have pre-existing malignancies, - Patients who have metabolic disorders. Funding: No external or internal funding is provided for this study. CONCLUSION : Even though increased popularity of surgical methods most of the clavicle fractures managed by conservative methods till now. Nonsurgical methods are nowadays used in elderly patients with less physiological demand. But increasing evidence of good functional outcome of surgical methods favors fixation for young individuals and elderly patients with physiological demand. Good anatomical reduction for comminuted fractures and no need for implant exit are merits of plating. But surgical scar and chances of infection are more in plating. Intramedullary fixation, minimally invasive and early mobilization are the merits of elastic nailing. But need for implant exit and inadequate fixation for comminuted fractures are demerits of nailing. In conclusion titanium elastic nail size of 2–2.5mm diameter is recommended for displaced midshaft clavicle fractures. When compared to plating, nailing has excellent functional outcome and minimal complications.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Plating and Intramedullary Fixation, Displaced Midshaft Clavicle Fractures, Optimal Surgical Management.
Subjects: MEDICAL > Orthopaedics
Depositing User: Subramani R
Date Deposited: 11 Jan 2018 02:32
Last Modified: 04 Dec 2018 11:35
URI: http://repository-tnmgrmu.ac.in/id/eprint/5447

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