Please rate topic.
Average 4.5 of 122 Ratings
Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC.
A 22-year-old left hand dominant laborer sustains the injury shown in Figures A and B as the result of a fall from a ladder. Which of the following has been shown to be true regarding operative versus nonoperative treatment of this injury?
Decreased chance of nonunion with nonoperative treatment
Improved Constant and DASH scores with operative treatment at all time points
Increased symptomatic malunion rate with operative treatment
No change in shoulder abduction strength
Increased time to union with operative treatment
Select Answer to see Preferred Response
Surgical management of displaced, shortened clavicle fractures is associated with a decreased rate of nonunion and malunion. General recommendations for surgical treatment include shortening of greater than 2 centimeters.
Kim et al. review clavicle fracture treatment history and current indications. They report that although previous thought was that nearly all clavicle fractures should be treated nonoperatively, outcomes can be improved with fixation of certain clavicle fracture patterns.
COTS et al. performed a multicenter, randomized controlled trial of 132 patients with a displaced midshaft fracture of the clavicle. They found that Constant and DASH scores were improved in the operative fixation group at all points in time, with union time being 28 weeks in the nonoperative group and 16 weeks in the operative group. Malunion was higher in the nonoperative group as well.
McKee et al. reviewed 30 patients who underwent closed treatment of a displaced midshaft clavicle fracture. They found that range of motion of the shoulder was maintained but the strength of the shoulder was decreased to 81% for flexion, 82% for maximum abduction, 81% for maximum external rotation, and 85% for maximum internal rotation. Endurance for these movements was also significantly decreased as compared to the contralateral side.
Figure A shows a clinical photo of a patient with a clavicle fracture. Figure B shows a displaced, comminuted clavicle fracture.
Answer 1: Operative treatment increases the union rate.
Answer 3: Operative treatment decreases the rate of symptomatic malunion.
Answer 4: Operative treatment increases shoulder abduction strength.
Answer 5: Time to union is decreased with operative treatment.
Kim W, McKee MD.
Orthop Clin North Am. 2008 Oct;39(4):491-505, vii. PMID: 18803979 (Link to Abstract)
Canadian Orthopaedic Trauma Society.
J Bone Joint Surg Am. 2007 Jan;89(1):1-10. PMID: 17200303 (Link to Abstract)
Canadian, JBJS 2007
McKee MD, Pedersen EM, Jones C, Stephen DJ, Kreder HJ, Schemitsch EH, Wild LM, Potter J
J Bone Joint Surg Am. 2006 Jan;88(1):35-40. PMID: 16391247 (Link to Abstract)
McKee, JBJS 2006
Please rate question.
Average 3.0 of 17 Ratings
A 25-year-old patient is involved in a motor vehicle accident. An isolated orthopaedic injury is sustained to the upper extremity with no compromise of skin integrity or neurovascular function. A radiograph of the injury is shown in Figure A. The patient is interested in pursuing surgical intervention. What is a reported outcome of surgery when compared to nonoperative management at 1 year postoperatively?
Increased rates of symptomatic nonunion
Similar rates of symptomatic nonunion
No differences in cosmetic results
Increased functional outcome scores
Improved range of motion of the shoulder
Surgical fixation of this significantly displaced clavicle fracture (greater than 100%) has been associated with greater functional outcomes up to 1 year after injury compared to non-operative measures
Clavicle fractures are often seen in young active patients as the result of falls or direct compressive trauma. Non-operative management of midshaft clavicle fractures is associated with decreased shoulder strength and increased nonunion rates. Risk factors for non-union in non-operative management of midshaft clavicle fractures include advanced age, female gender, displacement and comminution. Open reduction and internal fixation of clavicle fractures is associated with improved results when there is > 2 cm of shortening and 100% displacement.
Zlowodzki et al. retrospectively to compared nonoperative versus operative management of 2144 clavicle fractures. They found that non-operative treatment of displaced midshaft clavicle fractures had a nonunion rate of 15%. Risk of nonunion was reduced by 86% when plating was compared to non-operative measures.
The Canadian Orthopaedic Trauma Society conducted a multicenter prospective study comparing non-operative management versus plate fixation of midshaft clavicle fractures. They found that Constant/DASH scores were significantly improved in the operatively treated group at all time points up to one year of followup. Additionally, a lower rate of nonunion/malunion was identified in the operative group.
Figure A shows an AP radiograph of the clavicle that is significantly shortened and displaced. Illustration A shows a postoperative AP radiograph of the clavicle after open reduction/internal fixation was completed.
Answers 1,2: ORIF is associated with decreased rates of nonunion
Answer 3: ORIF is associated with improved cosmetic results compared to non operative measures
Answer 5: Range of motion after ORIF is comparable to that of non operative treatment
Zlowodzki M, Zelle BA, Cole PA, Jeray K, McKee MD.
J Orthop Trauma. 2005 Aug;19(7):504-7. PMID: 16056089 (Link to Abstract)
Zlowodzki, JOT 2005
Average 4.0 of 12 Ratings
A 35-year-old right hand dominant man falls from a ladder and sustains the injury seen in Figure A. When discussing the risks and benefits of operative versus nonoperative treatment for his fracture, which of the following is true?
No difference in shoulder function
Higher risk of nonunion with operative management
Higher risk of symptomatic malunion or nonunion with nonoperative management
Earlier return to sport with nonoperative management
No difference in union rates
Historically, displaced midshaft clavicle fractures, as seen in Figure A, were managed nonoperatively. Recent literature has demonsrated improved outcomes with operative management of these fractures.
Khan et al review current concepts in the management of clavicle fractures. For displaced midshaft clavice fractures, operative treatment seems to result in improved patient and surgeon-based outcomes, decreased rates of malunion and nonunion, and shorter time to union.
Kim and McKee review recent evidence regarding the management of clavicle fractures. For midshaft clavicle fractures, the incidence of nonunion and symptomatic malunion with nonoperative management is higher than previously believed. They state that risk factors include 100% displacement, comminution, increasing age and female gender.
Answer 1. Recent randomized prospective trials have shown improved short term shoulder function with operative management of displaced midshaft clavicle fractures.
Answer 2. Nonunion rates of 7-15% have been shown with nonoperative management versus 2% with operative fixation
Answer 4. Earlier return to activities has been reported with operative management
Answer 5. As with answer 2, there is a significantly higher rate of nonunion with nonoperative management
Khan LA, Bradnock TJ, Scott C, Robinson CM
J Bone Joint Surg Am. 2009 Feb;91(2):447-60. PMID: 19181992 (Link to Abstract)
Khan, JBJS 2009
HPI - 60-year-old male crashed his Mountain Bike at ~20 mph descending a dirt fire road, impacting left elbow and shoulder.
How would you treat this fracture?
Average 3.0 of 33 Ratings
A 32-year-old female sustains an isolated midshaft clavicle fracture, as shown in Figure A. Her clinical exam does not reveal skin tenting or neurovascular injury, but shortening is measured at 2.6 cm. Which of the following treatment methods has been shown to have the lowest rate of nonunion and symptomatic malunion?
Open reduction and internal fixation with plating
Open reduction and percutaneous pinning
Closed reduction and percutaneous pinning
Closed reduction and external fixation
Nonoperative treatment with a sling and early range of motion
Figure A shows a left clavicle fracture with significant shortening. Open reduction and internal fixation with plate and screw constructs of displaced, shortened clavicle fractures has been shown to lead to the best patient reported functional outcomes as well as have the least incidence of nonunion and symptomatic malunion. Factors associated with poor functional outcome as well as nonunion in these injuries include fracture shortening >2cm, fracture comminution, fracture displacement > 100%, female gender, and advancing age.
The referenced article by Khan et al is an excellent review of the indications, treatment methods and outcomes of clavicle fractures.
Average 3.0 of 27 Ratings
Which of the following factors increase the risk of nonunion in midshaft clavicle fractures when treated nonoperatively?
Displacement and comminution
Age less than 40 years old
Immediate motion exercises
Robinson et al have shown that lack of cortical apposition, comminution, female gender, and advancing age are the 4 factors that contribute to nonunion.
The Canadian Orthopaedic Trauma Society in a randomized, prospective study showed that for midshaft fracture in adults with 100% displacement, ORIF results in improved DASH and Constant scores (p = 0.001 and p < 0.01, respectively), lower nonunion (2 vs. 7, p=0.042) & lower malunion (0 vs. 9, p=0.001). Surgery resulted in quicker radiographic union (16.4 weeks vs. 28.4 weeks, p=0.001). However, 15% had hardware and wound complications. At one year, the operative group was more likely to be satisfied with the shoulder in general (p=0.002) and the appearance of the shoulder in particular (p=0.001) in comparison to the nonoperative group.
Prior studies have shown that greater than 2cm of shortening treated non-operatively results in increased fatigueability and poor outcome, but not necessarily nonunion. The Lazarides article concluded that “Final clavicular shortening of more than 18 mm in male patients and of more than 14 mm in female patients was significantly associated with an unsatisfactory result.”
Studies have shown no difference in outcome when treated with a Figure-of-8 harness compared to a simple sling.
Lazarides S, Zafiropoulos G.
J Shoulder Elbow Surg. 2006 Mar-Apr;15(2):191-4. PMID: 16517363 (Link to Abstract)
Lazarides, JSES 2006
Robinson CM, Court-Brown CM, McQueen MM, Wakefield AE.
J Bone Joint Surg Am. 2004 Jul;86-A(7):1359-65. PMID: 15252081 (Link to Abstract)
Robinson, JBJS 2004
Average 4.0 of 19 Ratings
A 20-year-old woman is involved in a high-speed motor vehicle collision and sustains bilateral tibial plateau fractures as well as the clavicle fracture shown in Figure A. What is the most appropriate management of the clavicular injury?
Closed reduction and figure of 8 splinting
Open reduction and plate fixation
Simple sling to involved side
Sling with abduction pillow to involved side
The radiograph shows a comminuted clavicle fracture with significant displacement. Indications for surgical fixation of clavicle fractures include: open fractures, underlying neurovascular injury, or impending open fracture from internal bony pressure causing skin compromise. Relative indications for fixation include: greater than 15 mm of shortening, greater than 100% displacement (no bony contact), highly comminuted fractures, and polytrauma patients.
Jeray et al review the evaluation and treatment of midshaft clavicle fractures. They state "when midshaft clavicular fractures are completely displaced or comminuted, and when they occur in elderly patients or females, the risk of nonunion, cosmetic deformity, and poor outcome may be markedly higher. Thus, some surgeons propose surgical stabilization of a complex midshaft clavicular fracture with either plate-and-screw fixation or intramedullary devices. Further randomized, prospective trials are needed to provide better data on which to base treatment decisions."
J Am Acad Orthop Surg. 2007 Apr;15(4):239-48. PMID: 17426295 (Link to Abstract)
Jeray, JAAOS 2007
Average 4.0 of 21 Ratings
A 22-year-old male sustains a right shoulder injury after being thrown from his motorcycle. After nine months of conservative treatment, he continues to complain of pain. A current radiograph is shown in Figure A. What is the most appropriate treatment?
Addition of a bone stimulator
Figure of eight brace
Open reduction and intramedullary nailing
Open reduction and compression plating
Figure A shows a clavicular nonunion. Observation is the wrong answer because the patient is symptomatic (if the patient is asymptomatic an atrophic nonunion of the clavicle can be observed unless neurovascular symptoms are present). Intramedullary fixation is difficult because the pin has to pass through thin atrophic ends of bone close to neurovascular structures. Percutaneous pinning may cause distraction and migration of K-wires is common.
In the referenced study by Boyer et al, the authors note success in treating atrophic nonunions of the clavicle with compression and lag-screw fixation (absolute stability), in conjunction with cancellous autograft.
The referenced study by Bradbury et al reports on 32 clavicle nonunion procedures. They note 31 of 32 went on to union with use of a 3.5mm recon plate or small fragment DCP plate, also in conjunction with cancellous autograft.
Boyer MI, Axelrod TS.
J Bone Joint Surg Br. 1997 Mar;79(2):301-3. PMID: 9119861 (Link to Abstract)
Boyer, BJJ 1997
Bradbury N, Hutchinson J, Hahn D, Colton CL.
Acta Orthop Scand. 1996 Aug;67(4):367-70. PMID: 8792741 (Link to Abstract)
Bradbury, ACTA 1996
A 45-year-old male falls onto his left shoulder while biking and an injury radiograph is shown in Figure A. He elects for nonoperative treatment. What is the most likely clinical outcome at one year after injury?
Symmetric cosmesis of shoulders
Decreased shoulder motion
Decreased shoulder strength and endurance
Patients who have nonoperative treatment of displaced midshaft clavicle fractures have significant decreases in both strength and endurance to approximately 80% of the contralateral side as described by the McKee article. There was a trend correlating shortening >2cm with poor outcome (p=0.06). Motion was found to be preserved.
In the Canadian Orthopaedic Trauma Society's landmark randomized control trial of operative versus nonoperative treatment for displaced clavicle fractures, patients treated non-operatively had lower subjective outcomes scores, slower rates to union, more nonunions, more symptomatic malunions, and were less satisfied with the appearance of their shoulder. There were more hardware related complications in the operatively treated group.
The second McKee article describes improvements in subjective outcome scores after midshaft clavicle malunion corrective osteotomy.
Figure A shows a comminuted, displaced midshaft clavicle fracture.
McKee MD, Wild LM, Schemitsch EH.
J Bone Joint Surg Am. 2003 May;85-A(5):790-7. PMID: 12728026 (Link to Abstract)
McKee, JBJS 2003
Average 3.0 of 30 Ratings
A 31-year-old male sustains the injury shown in Figure A. As compared to treatment with a simple sling, what is the primary advantage of treatment with a figure-of-eight brace?
Decreased sleep disturbance
Decreased personal care and hygiene impairment
Decreased rates of malunion
Improved long-term clinical outcomes
No advantage, equivalent result between a simple sling and figure-of-eight brace
Figure of eight braces have been shown to have no differences as compared to simple slings in regard to healing times, healing rates, and alignment at final follow-up.
The referenced study by Andersen et al is a Level 1 randomized controlled study showing equivalent cosmetic and clinical outcomes with sling versus figure of eight bracing despite increased sleep disturbances and increased rate of personal care impairment in those treated with a figure of eight brace.
The second referenced study by Nordqvist et al is a Level 4 case series designed to analyze the long-term outcome of mid-clavicle fractures in adults and to evaluate the clinical importance of displacement and fracture comminution. They found a 39/225 rate of moderate shoulder pain with figure of eight bracing. Overall they concluded that few patients with fractures of the mid-part of the clavicle require operative treatment.
Andersen K, Jensen PO, Lauritzen J.
Acta Orthop Scand. 1987 Feb;58(1):71-4. PMID: 3554886 (Link to Abstract)
Andersen, ACTA 1987
Nordqvist A, Petersson CJ, Redlund-Johnell I.
J Orthop Trauma. 1998 Nov-Dec;12(8):572-6. PMID: 9840792 (Link to Abstract)
Nordqvist, JOT 1998
Average 3.0 of 32 Ratings
Which of the following factors is associated with the highest rate of nonunion of a midshaft clavicle fracture?
simple fracture pattern
The risk of nonunion in patients sustaining middle 1/3 clavicle fractures is increased in female patients.
Clavicle fractures are often secondary to direct blows to the lateral aspect of the shoulder. Physical examination is important to ascertain the status of the skin and neurovascular structures to help guide treatment management. Although most non-displaced middle 1/3 clavicle fractures may be treated successfully with conservative measures, the risk for non-union (1-5%) increases with increasing comminution, female gender, shortening greater than 2 cm and an advanced age of the patient.
Robinson et al. reviewed 581 patients treated non-operatively for midshaft clavicle fractures. A nonunion rate of 4.5 % was identified at 24 weeks after the injury. They identified four factors that contributed to non-union, including: female gender, lack of cortical apposition, comminution of the fracture fragments and advancing age.
Zlowdzki et al. reviewed 2144 clavicle fracture cases in a comprehensive meta-analysis. They report displacement as the highest risk factor for nonunion (15.1%) in nonoperatively treated clavicle fractures, and simple slings were favored over figure of 8 braces. They also report an 86% reduction in the nonunion rate when operative fixation is chosen over nonoperative treatment for displaced clavicle fractures.
Illustration A shows the presence of a non-union of a midshaft clavicle fracture. A video is provided that reviews management of clavicle injuries.
Answers 1, 3: Older patients and comminution of the fracture were found to be risk factors for non-union in midshaft clavicle injuries
Answers 4, 5: Neither of these are associated with an increased risk of non-union in midshaft clavicular fractures.
Average 2.0 of 45 Ratings
Titanium elastic nailing vs anatomical plate - what are you thoughts?
16 year-old female basketball player requesting surgery for her clavicle fr...
Title: Case Presentation: Midshaft Clavicle Fracture (CSOT #16, 2016) Faculty: D...
Title: Acute Clavicle Fractures: Why are we fixing them and how?Duration: 15m: 1...
Session III Author: L. Pearce McCarty, III, MD Duration: 11:57
Dr. Peter Millett is a Vail, Colorado orthopedic shoulder surgeon in private pra...
HPI - RTA victim
How would you choose to manage this fracture?
HPI - A 30 year old male patient presents with right shoulder pain following an MVA. At the behest of his mother, patient wants surgery. He specifically requests an IM nail. After reviewing his radiographs, I recommended non-operative treatment.
The patient traveled to another surgeon for a second opinion, which resulted in IM fixation of his clavicle fracture. 4 weeks s/p IM nail, patient presents to the ER with complaints of pain, fever, and chills.
Physical exam yields erythematous incision, purulent drainage and wound dehiscence. Skin is warm and tender to palpation near clavicle.
How would you address the infection in this patient?
HPI - A 30 year old male patient presents with 6 months of right clavicle pain following ORIF for a clavicle nonunion after fracturing his clavicle in a motor vehicle accident.
He was initially treated non-operatively, but went on to develop a nonunion at the fracture site. He then underwent ORIF with graft and did well at first, but is now extremely painful.
XRays and CT are shown.
After ruling out infection, would you offer revision surgery?
HPI - o 72 year old right hand dominant presents to clinic with a 1 week history of right shoulder pain
o Her symptoms began after a mechanical fall onto her right shoulder
o Moderate pain and difficulty with activities of daily living
o Very active lifestyle involving gardening and apple picking on her farm
HPI - Simple fall 18 months ago which was treated non-operatively.
Able to perform normal daily activities.
What is your recommended treatment?
HPI - This gentleman had a FOOSH from 5 feet onto right side in December 2014. Presented in clinic after returning back to his home area in Feb 2015 with painful right clavicle despite cuff and collar treatment.
Came back in March with no improvement in symptoms and no progression of callous formation.
How do you treat the majority of displaced midshaft clavicle fractures in your practice?
HPI - slip down injury
He was diagnosed distal clavicle fracture and treated CRIF c k-wire 6 weeks ago
At POD 6 weeks, X-ray reveals k-wire loosening & gap maintenance
According to the Neer classification of distal clavicle fractures, what Type is this?
HPI - Sports bicycle accident with direct blow to his left shoulder. No other injuries
Operative vs. Conservative treatment?
HPI - fall from horse on right shoulder today, pain and limitation of movement of dominant right shoulder, no other injury
HPI - Fall while running. Direct injury to right shoulder
How would you treat this injury?
HPI - falling on the rt shoulder
what is the best method of treatment of fracutre clavicle in children
HPI - Right shoulder injury during robbery
How would you treat this distal clavicle injury?
HPI - pain rt clavicle inability to raise rt shoulder after fall
If performing surgical fixation, what would you do for this injury?
HPI - Patient had sustained a fall 2 months prior was seen at another center treated conservatively. Now presents 2 months later with pain with shoulder movements.
How would you have treated this fracture initially?
HPI - falling from height since 2 mounth....comatosed for 3 w .....partial loss of memory
How would you manage this fracture?
HPI - Patient had fracture of clavicle 3 months back, now presenting with deformity and pain around shoulder.
How would you treat?
HPI - h/o fall from height injury to right shoulder
How would you treat this patient?
HPI - Physician, motorcycle accident , right clavicule ( Dominant Side) fracture. No skin compromise.
do u operate this patient ?
HPI - fall at work site. injury to the rt arm. inabilty to move arm. skin condition good. profession labourer
operative plate fixation or fixation with k wire and cc ligament reconstruction
HPI - h/o fall at basket ball.pain and inbilty to move the rt arm. no neurovascular compromise.
operative or conservative.
HPI - pain since 2 and half yrs
deformity of clavicle with covexity anteriorly
is this the best modality for treatment or not?
HPI - 25-year-old downhill ski coach and extreme skier, right hand dominant, has this middle-third clavicle fracture following a fall skiing. It is the beginning of the ski season and he walks to return to the slopes as soon as possible.
How would you treat this clavicle fracture
HPI - c/o fall
What would you do in this case?
HPI - road traffic accident. no other associated injuries. no neurovascular deficit
How would you treat this clavicle fracture?