Review Question - QID 211111

In a patient with a displaced and shortened middle third clavicle fracture, nonunion would be expected to occur more often than any of the other complications listed.

The risk of nonunion following mid-shaft clavicle fractures is increased with advanced age, female gender, displacement, and comminution ("Z-deformity"). Nonoperative management of mid-shaft clavicle fractures has also been associated with decreased shoulder strength and endurance. Furthermore, range of motion and shoulder strength have not been shown to be sufficiently different between operative and nonoperative management.

Hoogervorst et al. reviewed the treatment of mid-shaft clavicle fractures. They cite that the rate of nonunion for fractures treated nonoperatively is about 15%. The authors note that those with >2cm of shortening and displacement >100% of the shaft width are at a greater risk for nonunion and that nearly 66% of those who go on to nonunion eventually undergo surgical repair.

Robinson et al. performed a prospective observational cohort study to evaluate the prevalence of and risk factors for nonunion of clavicle fractures treated nonoperatively. They found that the risk of nonunion was significantly increased by advancing age, female gender, displacement of the fracture, and the presence of comminution.

Figure A shows a radiograph demonstrating a middle third clavicle shaft fracture with >100% displacement and >2cm shortening.

Incorrect Answers:
Answer 1: The rate of skin necrosis following nonoperative treatment has not been shown to be higher than nonunion.
Answer 3: The rate of complex regional pain syndrome (CRPS) was shown to be around 2% in nonoperatively treated patients.
Answer 4 ad 5: Sternoclavicular arthritis and acromioclavicular arthritis or abnormalities have been shown to be somewhere between 4-6%