Several recent studies have reported better outcomes of patients with clavicle fractures who underwent surgical treatment, i.e., high bone union rates and fast functional recovery [9–15]. Therefore, in clavicle fracture patients with displacement, surgical treatment is initially considered. However, most of these studies only evaluated those patients with isolated clavicle fractures, and it remains controversial whether the results of these studies can be applied to polytrauma patients with clavicle fractures. Indeed, Ferree et al. argued that for polytrauma patients with displaced midshaft clavicle fracture (DMCF), a wait-and-see approach could be advocated without the risk of decreased upper extremity function after delayed fixation [16]. As a basis of this argument, Ferree et al. noted that the union rates of DMCF is similar to those of polytrauma patients with an isolated DMCF, and the functional outcomes of conservative treatment and delayed fixation are also comparable [16]. However, we believe that these reasons are insufficient to justify the provision of conservative treatment in polytrauma patients with clavicle fractures, because conservative treatment is not effective in patients with nonunion or delayed union [9, 10, 12, 13], and delayed surgery is more likely to cause complications such as neurovascular injury [17, 18]. We initially performed conservative treatment in patients with clavicle fractures with slight displacement and then considered surgery if delayed displacement occurred. As a result, delayed displacement occurred in about 40% of patients, whose treatment was changed. Meanwhile, many of the patients failed to respond to the conservative treatment, and the risk factors for delayed displacement had to be analyzed to prevent treatment failure. Regression analysis revealed that the existence of comminution and fracture in the middle third of the shaft were significant risk factors for delayed displacement.
Ferree et al. argued that polytrauma patients often undergo intubation and sedation and remain on bed rest, resulting in a relatively lower risk of fracture displacement [5]. However, in this study, ventilator care, duration of ICU stay, and duration of intubation were not significantly associated with delayed displacement. In other words, the polytrauma-related factors did not reduce the risk of delayed displacement; only impact of comminution and location of the fractures on delayed displacement were significant. In the case of polytrauma patients with fractures, conservative treatment is usually performed because the general condition of these patients is poor and these fractures are often diagnosed at a later stage [5, 19–21]. However, stabilization of fractures can help restore the general systemic condition of polytrauma patients [22], prevent the contracture of joints, and preserve their function when the fracture site is fixed and early passive rehabilitation begins. Therefore, if the overall condition of the patient can be tolerated, it is necessary to carry out aggressive treatment, including surgery, for the musculoskeletal injury of polytrauma patients. Moreover, delayed surgery is more likely to cause complications than early surgery [17, 18, 23]. Callus formation and soft tissue contractures around the fracture site can make it difficult to correct the displaced fractures, and neurovascular injury might occur when the callus is removed and the scar tissue is dissected. If the surgery is further delayed and nonunion occurs, additional bone grafts may be needed [24–26]. Therefore, surgery should be performed as soon as possible in patients with fractures in whom conservative treatment may not be effective.
Recently, the importance of a multidisciplinary approach for polytrauma patients has been emphasized [27]. In the multidisciplinary approach, the assessment of the systemic status of polytrauma patients with extremity injury was decided by team members, including orthopedic surgeons and trauma-trained general surgeons [22, 27]. In this process, whether the general condition of polytrauma patients can withstand surgery can be more objectively and reasonably assessed. In addition, the burden of “loneliness” and risk from the individual departmental approach can be reduced so that safe but aggressive treatment can be carried out.
There were some limitations to this study. First, this study is a retrospective cohort study. Compared with prospective studies, it was difficult to control the factors that can lead to delayed displacement. However, since a single trauma team treated patients with the same protocol, it was possible to manage the factors more uniformly. Second, we were unable to assess the patients’ compliance to the conservative treatment. It was also difficult to evaluate whether the arm sling is properly maintained during conservative treatment. In particular, it was difficult to apply the arm sling in ICU patients who were attached to various monitoring devices. Third, long-term outcomes such as bone union rate or functional outcomes were not evaluated because the study only performed a short-term follow-up of delayed displacement. Further research is needed to determine the impact of delayed displacement on bone union and clinical outcomes.
In conclusion, we found that the null hypothesis was rejected. This means that polytrauma-related factors did not reduce the risk of delayed displacement. However, polytrauma patients with clavicle fractures are more likely to develop delayed displacement if there is a presence of comminuted fracture or middle third fracture. Therefore, if such risk factors exist, a short interval follow-up is necessary and the possibility of surgical treatment should be taken into account.