DOI: https://doi.org/10.21203/rs.3.rs-1784697/v1
Background: The tendency toward conservative treatment for clavicle fractures in polytrauma patients may be related to certain characteristics of polytrauma patients. The purpose of this study was to analyze the factors that could affect delayed displacement of fractures during conservative treatment for clavicle fracture in polytrauma patients.
Methods: From January 2013 to April 2017, 178 polytrauma patients with an ISS of 16 or more and a clavicle fracture were enrolled from a single trauma center. Of these patients, 79 who had an initial displacement of fractures of less than 100% of the clavicle diameter and initially underwent conservative treatment were included. We analyzed the risk factors that could affect delayed displacement of clavicle fracture by performing a regression analysis of the following factors: patients’ demographic characteristics, location of fracture, presence of comminuted fracture, duration of the intensive care unit stay, ventilator care, initial consciousness level, combined upper extremity injuries, rib fractures of the ipsilateral side, brain injury, and spinal cord injury.
Results: A total of 31 patients had delayed displacement of clavicle fracture. The univariable and multivariable logistic regression analyses showed that the statistically significant risk factors for delayed displacement of clavicle fractures were the presence of comminuted fracture and middle third shaft clavicle fracture. Other factors were not statistically related to delayed displacement.
Conclusion: Polytrauma patients with clavicle fractures are more likely to develop delayed displacement if there is a presence of comminuted fracture or middle third clavicle fracture. However, polytrauma-related factors did not reduce the risk of delayed displacement of clavicle fractures in polytrauma patients.
Level of Evidence: III, retrospective cohort study
Severe trauma or polytrauma refers to a fatal condition with an injury severity score (ISS) of 16 or greater [1]. Polytrauma is the leading cause of death in people aged < 40 years [2, 3]. It is also considered to be an important social problem because of the enormous socioeconomic costs of treatment of polytrauma patients and the resulting loss of workforce [4].
From a medical point of view, polytrauma patients may require a new therapeutic approach by specialists in their respective fields. Orthopedic surgery, which treats injuries to the musculoskeletal system that occurs in about 70% of patients with polytrauma, is no exception. This means that in special circumstances, such as polytrauma, orthopaedic treatment may differ from monotrauma patients. In fact, for clavicle fractures, which occurs in approximately 10% of patients in polytrauma, polytrauma patients with displaced midshaft clavicle fractures received operative intervention 5.9 times less often than monotrauma patients with displaced midshaft clavicle fractures. [5].
The tendency toward conservative treatment for clavicle fractures in polytrauma patients may be related to certain characteristics of polytrauma patients, such as prolonged bed-ridden status, sedation, and general inactivity due to concomitant organ damage. Indeed, Ferree et al. argued that conservative treatment is preferred because polytrauma-related factors result in a relatively lower risk of fracture displacement.[5] In this regard, the purpose of this study was to analyze the factors that could affect delayed displacement during conservative treatment for clavicle fractures in polytrauma patients. The null hypothesis was that polytrauma-related factors decreased the risk of delayed displacement of clavicle fractures in polytrauma patients.
From January 2014 to April 2017, polytrauma patients with clavicle fractures and an ISS of at least 16 points, who were admitted in a single institute, were selected using the 10th revision of the International Statistical Classification of Diseases and Related Health Problem code (S42.0) and their electronic medical records. A total of 178 patients were enrolled. Of them, 79 patients who 1) were aged ≥ 16 years, 2) had an initial displacement < 100% of their clavicle diameter, and 3) had initially undergone conservative treatment were finally included in the study. There is no evidence that conservative treatment with figure of eight bandages is better than conservative treatment with arm slings, but rather the figure of eight bandage is more painful and increases the risk of neurovascular injury and pressure sores.[6–8] Therefore, initial conservative treatment was performed only using arm slings. Immobilization was maintained for at least four weeks.
An anteroposterior radiograph of the clavicle, cephalic tilt radiograph, and acromioclavicular radiograph (clavicle series) were performed in clavicular fracture patients as baseline radiographic evaluation. Clavicle series were performed at 1-week interval for 4 weeks after the injury. Two observers (DHL, WSC) independently assessed displacement of clavicle fractures in the clavicle series. If there is a displacement exceeding 100% of the clavicle diameter in one or more images of the clavicle series at follow-up, and the two observers agree on the extent of the displacement, it is defined as “delayed displacement”. Initial displacement at this level was an indication for surgery. Thus, in the case of “delayed displacement,” conservative treatment was discontinued and surgery was considered. Since the clavicle series was performed at relatively long interval (1-week), the exact timing of delayed displacement was determined by reviewing the daily chest AP X-ray, which is generally performed for ICU patients.
The following factors were analyzed to determine their association with delayed displacement of clavicle fractures: demographic factors such as the sex and age, the location of the clavicle fracture, and presence of comminuted fractures. Other factors related to polytrauma patient, such as ventilator care or duration of intensive care unit (ICU) stay, associated fractures, central nervous system injury, and initial levels of consciousness (Glasgow Coma Scale) were also included. These are described in additional file 1.
Statistical analysis
A regression analysis was performed to determine the risk factors associated with delayed displacement. First, a univariable logistic regression analysis was carried out to analyze the individual factors, while a multivariable logistic regression analysis was conducted to analyze the factors that are related to delayed displacement with a p value of < 0.5. The odds ratio and 95% confidence interval of each factor were obtained. A p value of < 0.05 was considered significant.
This study was reviewed and approved by Ajou University Hospital review board and determined that written consent was not required for this study.
Of 79 patients, 58 were men and 21 were women. The average age of the patients was 49.5 (16–80) years old. The average ISS was 24.9 (16–50) points. A total of 31 (39.2%) patients had delayed displacement. Delayed displacement occurred 10.1 (2–34) days after injury. Eighteen (58%) patients with delayed displacement underwent surgery (Fig. 1) (Table 1). Twelve patients did not undergo surgery because their general condition worsened, while one patient refused to undergo surgery.
| Delayed displacement (N = 31) | Total (N = 79) | |
|---|---|---|
| Sex | ||
| Male | 24 | 58 |
| Female | 7 | 21 |
| Surgery | 18 | 18 |
| Comminution of fracture | 16 | 23 |
| Use of ventilator | 13 | 40 |
| Ipsilateral scapular fracture | 6 | 19 |
| Accompanying upper extremity fracture | 7 | 17 |
| Traumatic CNSa injury | 17 | 43 |
| Location of clavicle fracture | ||
| Proximal 1/3 | 2 | 8 |
| Middle 1/3 | 23 | 43 |
| Distal 1/3 | 6 | 28 |
| Ipsilateral rib fractures | 27 | 61 |
| Timing of delayed displacement | 10.1 (2–34) days | |
| Age | 47.3 (18–77) years old | 49.5 (16–80) years old |
| Injury severity score | 24.5 (17–45) points | 24.9 (17–50) points |
| Duration of ICUb care | 13 (0–56) days | 15.1 (0–73) days |
| Duration of intubation | 9.2 (0–45) days | 10 (0–64) days |
| Glasgow coma scale | 11.4 (3–15) points | 11.4 (3–15) points |
| a: central nervous system, b: intensive unit care | ||
In the univariable logistic regression analysis, the location and comminution of clavicle fractures were statistically significant risk factors for delayed displacement (Table 2). In other words, the comminuted fracture or fracture in the middle third was more likely displaced late. A multivariable logistic regression analysis was performed to analyze the factors with a p value of < 0.5 in the univariable analysis, such as ventilator care, ipsilateral scapula fracture, ipsilateral rib fracture, age, duration of ICU stay, location of fracture, and presence of comminuted fractures (Table 3). Finally, only comminuted fractures and middle third fractures were considered as statistically significant risk factors for delayed displacement. All factors related to the occurrence of polytrauma, such as combined fractures, damage to the central nervous system, use of ventilators, and duration of ICU stay, were not statistically associated with delayed displacement.
| p value | Odds ratio | 95% Confidence interval | |
|---|---|---|---|
| Sex (male compared to female) | 0.519 | 1.412 | 0.496–4.022 |
| Comminution of fracture | 0.001 | 6.248 | 2.149–18.161 |
| Use of ventilator | 0.216 | 0.562 | 0.225-1.400 |
| Ipsilateral scapular fracture | 0.434 | 0.646 | 0.216–1.932 |
| Accompanying upper extremity fracture | 0.854 | 1.108 | 0.372–3.306 |
| Traumatic CNSa injury | 0.953 | 1.027 | 0.415–2.545 |
| Location of clavicle fracture | 0.022 | ||
| Proximal 1/3 compared to distal 1/3 | 0.830 | 1.222 | 0.195–7.675 |
| Middle 1/3 compared to distal 1/3 | 0.009 | 4.217 | 1.427–12.460 |
| Ipsilateral rib fractures | 0.101 | 2.779 | 0.820–9.421 |
| Age | 0.362 | 0.988 | 0.962–1.014 |
| Injury severity score | 0.621 | 1.015 | 0.958–1.075 |
| Duration of ICUb care | 0.429 | 0.990 | 0.965–1.015 |
| Duration of intubation | 0.709 | 0.994 | 0.964–1.026 |
| Glasgow coma scale | 0.925 | 0.995 | 0.894–1.107 |
| a: central nervous system, b: intensive unit care | |||
| p value | Odds ratio | 95% Confidence interval | |
|---|---|---|---|
| Comminution of fracture | 0.002 | 6.225 | 1.987–19.503 |
| Use of ventilator | 0.132 | 0.225-1.400 | |
| Ipsilateral scapular fracture | 0.217 | 0.216–1.932 | |
| Location of clavicle fracture | 0.001 | ||
| Proximal 1/3 compared to distal 1/3 | 0.827 | 0.799 | 0.107–5.948 |
| Middle 1/3 compared to distal 1/3 | 0.027 | 3.720 | 1.163–11.896 |
| Ipsilateral rib fractures | 0.145 | 0.820–9.421 | |
| Age | 0.157 | 0.962–1.014 | |
| Duration of ICUa care | 0.321 | 0.965–1.015 | |
| a: intensive unit care | |||
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.
Ethics approval and consent to participate
Local institutional review board approval from Ajou University Hospital was obtained for the study. (AJIRB-MED-MDB-19-566)
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent
This study was reviewed and approved by Ajou University Hospital review board and determined that written consent was not required for this study.
Availability of data and materials
The dataset supporting the conclusions of this article is included withing the article and its additional file.
Competing interests
The authors declare that they have no competing interests.
Funding
Not appicable
Author’s contribution
DHL developed the idea of the study, WSC participated in its design and helped to draft the manuscript. KJH, JHC, THK and HSY contributed to the acquisition and interpretation of data. DHL, WSC revised the manuscript. All authors read and approved the final manuscript.
Acknowledgements
Not applicable