What Are the Functional Outcomes and Pain Scores after Medial Clavicle Fracture Treatment?

Abstract

Background Medial clavicle fractures are uncommon, occurring in older and multiply injured patients. The management of these fractures and the factors that predispose toward poor outcomes are controversial. Furthermore, the functional outcomes of treatment are not well characterized or correlated with fracture patterns. Questions/purposes (1) To determine minimum 1-year functional outcomes using QuickDASH scores and pain scores after medial clavicle fractures and (2) to identify factors associated with these outcome variables. Methods In an institutional review board–approved, retrospective study, we identified adult patients with medial clavicle fractures at two tertiary care referral centers in a single metropolitan area in the United States from January 2010 to March 2019. Our initial query identified 1950 patients with clavicle fractures, from which 74 adult patients with medial clavicle fractures and at least 1 year of follow-up were identified. We attempted to contact these eligible patients by telephone for functional outcomes and pain scores. Twenty-six patients were deceased according to the most recent Social Security Death Index data and public obituaries, three declined participation, and 14 could not be reached, leaving 42% of the total (31 of 74) and 65% (31 of 48) of living patients included in the analysis. Demographic characteristics, fracture characteristics, and clinical and radiographic union as assessed by plain radiography and CT were collected through record review. Twenty-nine patients were treated nonoperatively and two patients underwent open reduction internal fixation. Sixty-eight percent (21 of 31) of the included patients also had radiographic follow-up at least 6 weeks postoperatively; two patients had persistent nonunion at a mean of 5 ± 3 years after injury. Our primary response variable was the QuickDASH score at a minimum of 1 year (median [range] 5 years [2 to 10]). Our secondary response variable was the pain score on a 10-point Likert scale. A bivariate analysis was performed to identify factors associated with these response variables. The following explanatory variables were studied: age, gender, race, dominant hand injury, employment status, manual labor occupation, primary health insurance, social deprivation, BMI, diabetes mellitus, smoking status, American Society of Anesthesiologists physical status classification, Charlson Comorbidity Index, nonisolated injury, high-energy mechanism of injury, nondisplaced fracture, fracture comminution, superior-inferior fracture displacement, medial-lateral fracture shortening, and surgical treatment of the medial clavicle fracture. Results The mean QuickDASH score was 12 ± 15, and the mean pain score was 1 ± 1 at a mean of 5 ± 3 years after injury. The mortality rate of the cohort was 15% (11 of 74) at 1 year, 22% (16 of 74) at 3 years, and 34% (25 of 74) at 5 years after injury. With the numbers available, no factors were associated with the QuickDASH score or pain score, but it is likely we were underpowered to detect potentially important differences. Conclusion Medial clavicle fractures have favorable functional outcomes and pain relief at minimum 1-year follow-up among those patients who survive the trauma, but a high proportion will die within 3 years of the injury. This likely reflects both the frailty of a predominantly older patient population and the fact that these often are high-energy injuries. The outcome measures in our cohort were not associated with fracture displacement, shortening, or comminution; however, our sample size was underpowered on these points, and so these findings should be considered preliminary. Further studies are needed to determine the subset of patients with this injury who would benefit from surgical intervention. Level of Evidence Level IV, therapeutic study.

Displaced medial clavicle fractures: a systematic review of outcomes after nonoperative and operative management

“…Traditional radiographic-based studies have reported medial end clavicle fractures to be uncommon, accounting for only 2%-3% of all clavicle fractures. 2 , 11 , 13 , 18 , 19 , 21 , 22 Displacement of medial end clavicle fractures is most commonly defined in the literature using either the Robinson (>100% translation of major fracture fragments) 22 or Throckmorton (>10 mm displacement) 33 classification systems. By this definition, up to a third of all medial end clavicle fractures are considered displaced.…”

“…Fractures of the medial end of the clavicle are uncommon, accounting for only 2%-3% of all clavicle fractures. 2 , 11 , 13 , 18 , 19 , 21 , 22 They are associated with high energy trauma, multisystem injury, and death. 1 , 2 , 13 , 19 , 24 , 33 Traditionally, medial end clavicle fractures have been treated nonoperatively, even when significantly displaced.…”

“… 2 , 11 , 13 , 18 , 19 , 21 , 22 They are associated with high energy trauma, multisystem injury, and death. 1 , 2 , 13 , 19 , 24 , 33 Traditionally, medial end clavicle fractures have been treated nonoperatively, even when significantly displaced. 22 , 24 , 33 However, nonoperative treatment of displaced fractures is often unsatisfactory, with reports up to half of all patients are still symptomatic more than a year after injury, 17 , 33 and a nonunion rate approaching 15%.…”

The German version of the Nottingham Clavicle Score is a reliable and valid patient-reported outcome measure to evaluate patients with clavicle and acromioclavicular pathologies

“…Clavicle fractures and acromioclavicular joint (ACJ) dislocations are frequent injuries affecting mostly young, active patients [ 18 , 25 , 33 – 35 , 39 ]. Together with the rarer injuries of the sternoclavicular joint (SCJ) and with degenerative conditions of both ACJ and SCJ affecting elderly patients, these pathologies may impair everyday- and professional- and recreational-life as well as the function of the whole upper limb, chest external appearance, and cosmesis [ 15 , 19 , 24 , 27 , 28 , 38 , 42 ]. The Nottingham Clavicle Score (NCS) is a patient-reported outcome measure (PROM), specifically designed to assess clinical outcome after injuries and degenerative pathologies of the clavicle, ACJ and SCJ [ 9 ].…”

Editorial Comment: Selected Proceedings from the Society of Military Orthopaedic Surgeons 2020 Annual Meeting

“…Additionally, they found favorable functional outcomes and pain relief a minimum 1-year post-follow-up for those patients who survived the trauma. Still, there was a high proportion that will die within 3 years of the injury, demonstrating that these are often high-energy injuries [2].…”