Clavicle fractures: a comparison of five classification systems and their relationship to treatment outcomes

Abstract

We compared five classification systems for clavicle fractures. The aim of this study was to evaluate the prognostic value of each system. Over a two-year period we reviewed all new radiographs of the shoulder region and identified 487 clavicle fractures. Each radiograph was classified using five classification systems. We reviewed all subsequent X-rays and clinical records until the patient was discharged. We assessed each classification system's prognostic value in predicting delayed/non-union. Our data show that 79.3% of clavicle fractures occur in the middle third, 19.3% in the lateral third and 1.4% in the medial third. The overall prevalence of delayed/non-union was 7.3%, with 3.2% requiring operative management and 4.1% developing asymptomatic non-union. The incidence of non-union in the lateral third was 9.6%, but only 0.4% required operative management. Craig's classification had the greatest prognostic value for lateral third fractures, and Robinson's classification had the greatest prognostic value for middle third fractures. Fractures of the clavicle are common injuries but non-union is an uncommon occurrence. Non-union is more common in the lateral third, but we found these to be mostly asymptomatic. Middle third fractures are more likely to require operative fixation. Middle third fractures should be classified according to Robinson's classification system and lateral third fractures according to Craig's classification. We did not assess sufficient medial third fractures for the data to be significant.

Reliability of the Robinson classification for displaced comminuted midshaft clavicular fractures

“…The Robinson classification has been stated to provide the most reliable prognostic information compared to the other classification methods for midshaft clavicular fractures [12,5]. We found no other studies on the reliability of classification systems for clavicular fractures to compare our data with.…”

“…The current study shows that the extent of comminution, as displayed in simple or wedge comminuted (2B1) and isolated or segmental comminuted fractures (2B2), is difficult to classify on both AP and 30-degree caudocephalad radiographs. The prognostic value of the Robinson classification as described by O'Neill et al [5] may therefore be overrated because there is a possibility that the clavicular fracture is wrongly classified. In contrast to our study, Jones et al [9] found a moderate to strong inter-and intra-observer agreement for displacement and comminution on similar radiographs.…”

“…This may be explained by the fact that the current study only focused on the distinction between type 2B1 and 2B2 fractures, whereas Robinson included all types of clavicular fractures. In our study, we deliberately did not include undisplaced or angulated midshaft clavicular fractures (types 2A1 and 2A2) because these types of fractures are uncommon in adults [5,4,8] and have good union results without surgical intervention.…”

“…Classification systems for clavicular fractures have been developed by Allman [1] for the anatomical site, by Neer [2] for the lateral third fractures, and by Craig [3] for the lateral and medial third fractures. The Robinson classification [4] has been established as the most appropriate classification method for the midshaft clavicular fractures [5] with the highest prognostic value for treatment outcome in terms of union and non-union. The Robinson classification differentiates between two main types of midshaft clavicular fractures, i.e., undisplaced (type A) fractures and displaced (type B) fractures (Fig.…”

Comparison between Accurate Anatomical Reduction and Unsuccessful Reduction with a Remaining Gap after Open Reduction and Plate Fixation of Midshaft Clavicle Fracture

“…1) Most clavicle fractures involve the midshaft, which is the thinnest part with the least soft tissue, and more than half of midshaft fractures are displaced. 2,3) Due to the reported unsatisfactory results after nonoperative treatment, operative fixation has been the recent treatment trend for the displaced midshaft clavicle fracture.…”