Comparison of the effectiveness of oblique and transverse incisions in the treatment of fractures of the middle and outer third of the clavicle

Abstract

Background: Iatrogenic supraclavicular nerve injury is frequent during surgical repair of clavicle fractures through a transverse incision. The use of an oblique incision may be a potential approach to avoiding this complication. This study compared the clinical effectiveness of oblique and transverse incisions in the treatment of fractures in the middle and outer thirds of the clavicle. Methods: This prospective observational study included patients with fracture of the mid-to-outer third of the clavicle between August 2011 and August 2016. We allocated the patients into 2 groups based on their choice of treatment: oblique incision (n ¼ 62) and transverse incision (n ¼ 64). We compared the following parameters between the 2 groups: operative time, intraoperative blood loss, postoperative fracture healing time, incision size, clinical complications, postoperative subjective satisfaction, and shoulder function. Results: Operative time, postoperative fracture healing time, postoperative shoulder function (Constant-Murley and disabilities of the arm, shoulder and hand [DASH] scores), and clinical complications did not differ significantly between groups (all P > .05). The oblique incision group had less intraoperative blood loss (41.4 AE 16.4 vs. 65.3 AE 10.4 mL, P < .001) and smaller surgical incisions (3.6 AE 1.6 vs. 10.3 AE 2.6 cm, P < .001). The oblique incision group showed better outcomes for postoperative satisfaction (85.5% vs. 64.1%, P ¼ .015), absence of shoulder numbness at the last follow-up (89.3% vs. 70.3%, P ¼ .010), and satisfaction with the scar (90.3% vs. 3.1%, P < .001). Conclusion: Oblique incisions have several advantages over transverse incisions: less bleeding, smaller incisions, less iatrogenic injury to supraclavicular nerves, and higher patient satisfaction. These 2 approaches have equivalent effects on recovery of shoulder joint function. This study was approved by the ethics committee of the Second Fuzhou Hospital Affiliated to Xiamen University (Approval No. FZSE2011-06-09). Written informed consent was obtained from all participants.

Minimally invasive plating of midshaft clavicle fractures with distal clavicle anatomic locking plate

“…There were no clavicle region paresthesia or numbness was observed in this group. In open group there were 8 patients reported paresthesia or numbness because of supraclavicular nerve injury which was accordance with previous reports [22,23].…”

“…In minimally invasive group the mean Constant-Murley score was 93.8±3.8 at sixth month after the operation, and there was a signi cant difference when comparing with the open group with a mean Constant-Murley score of 90.6±4.0. (P 0.05) Because of supraclavicular nerve injury the rate of incisional and proximal chest wall numbness was reported 10% to 29% after operative fixation of the clavicle [22,23]. Nathe T et al [24] dissected 37 cadavers, found there were two or three branches of the supraclavicular nerve crossing the clavicle 97% of the time and no branch was found within 1.9cm of the acromioclavicular joint.…”

Incisional paresthesia following clavicle plate fixation: does it matter to patients?

“…Fifteen studies, including 836 patients, reported on average, when weighted, a 27% incidence of numbness at approximately 28 months following longitudinal approach to plate fixation of acute clavicle diaphyseal fractures. (Appendix I) [11,19,[23][24][25][26][27][28][29][30][31][32][33][34][35][36]. However, this rate increases to 52% when the affected area is measured as part of the study protocol suggesting a possibility of under reporting [29,34,36].…”

“…Given the impact of sensory disturbance on patient outcomes, recent studies have explored alternative incision placements as well as minimally invasive plate osteosynthesis (MIPO) approach. Vertical incision, oblique incision following the nerve course longitudinally, or "necklace" incision following Langer's lines have not consistently shown improved outcomes [26,27,33,35]. MIPO technique, which utilizes the peripheral "safe zones" of the supraclavicular nerve path, has been shown to decrease the area size affected by paresthesia [29,30,36] without improvement in functional scores, operative time, union rate compared to traditional techniques, though there is some evidence of reduction in post-operative pain and improvement in patient satisfaction.…”

“…Incidence varies widely from 6 to 90% (Appendix I). There is a consistent trend of improvement over time, though without full resolution for all patients [11,19,[23][24][25][26][27][28][29][30][31][32][33][34][35][36]. Previous groups have demonstrated good outcomes despite high prevalence of numbness leading them to refute correlation between numbness and patient satisfaction [19,23,31]; whereas You et al [29] concluded that conventional approaches led to discomfort in 74.3% of their patients.…”