Radiological and clinical comparison of surgical and conservative treatment of distal fractures of the clavicle (Neer type 2b)

doi:10.21203/rs.3.rs-3212744/v1

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Radiological and clinical comparison of surgical and conservative treatment of distal fractures of the clavicle (Neer type 2b)

https://doi.org/10.21203/rs.3.rs-3212744/v1

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Introduction:

In this study, we aimed to compare the patients we treated conservatively with those treated surgically in distal Neer type 2b fractures of the clavicle radiologically and clinically.

Patients and Methods:

Between May 2015 and June 2020, 67 patients who were treated and followed up with the diagnosis of Neer type 2b distal clavicle fracture were evaluated retrospectively. Thirty-six patients who were followed up conservatively were assigned to Group 1, and 31 patients who were treated surgically were assigned to Group 2. Age, gender, fracture side, fracture type and follow-up period of the patients included in the study were calculated. Preoperative fracture displacement amounts were measured radiologically. As a result of conservative or surgical treatment, the distance between the coracoid process and the clavicle (Coracoclavicular (CC) distance) in the final radiological image was measured. The clinical result at the last follow-up was made according to the Constant-Murley scoring. Those who developed nonunion were detected.

Results

Group 1 had a higher mean age compared to Group 2. (p = 0.24) Both groups had a similar distribution in terms of gender, fracture side and follow-up time. (p > 0.05) It was observed that the preoperative displacement amount of Group 2 was higher than Group 1. (p = 0.003) CC distance of Group 2 was higher than Group 1. (p = 0.018) Constant-Murley scores of both groups had similar distribution. (p = 0.086) While uneventful union developed in all patients in Group 2, nonunion was observed in 12 (33%) patients in Group 1.

Conclusion

Even though Neer type 2b distal clavicle fractures have a high nonunion rate, their effect on the clinical outcome is quite low. They do not need surgical treatment unless symptomatic nonunion develops.

Level of evidence:

Level 3, Retrospective comparative study

Clavicle distal fractures

Clavicle nonunion

Coracoclavicular ligament

Neer type 2b

All clavicle fractures heal easily with mostly conservative methods. However, clavicle distal fractures can result in radiological nonunion at a rate of 10–44%. The treatment choices of surgeons for these fractures, which are very difficult and controversial to manage, also vary. While the choice of treatment is provided according to the age, profession and expectation of the patient, at the same time, radiological measurements such as the configuration of the fracture and the amount of displacement may be the reason for preference in the treatment. In addition, two different treatments can be explained to the patient and left to the patient's preference. [1–3]

Although conservative treatment is favored in clavicle distal fractures, surgical treatment is recommended more frequently for the Neer type 2b group due to the high rate of nonunion in the literature. [4–5] It has been suggested in many publications in the literature that nonunion results of clavicle diaphyseal fractures do not cause clinical problems. [6–7] If patients who develop nonunion are symptomatic, surgery can be applied for some selected patients. [8] In addition, while the choice of implants in the treatment of these fractures is discussed in the literature, the comparison of conservative preferences is seen very rarely.

In this study, we wanted to compare radiologically and clinically the patients we treated conservatively with the patients we treated surgically for clavicle distal Neer type 2b fractures.

One hundred twenty five patients who were treated and followed up with the diagnosis of clavicle distal fracture between May 2015 and June 2020 were evaluated retrospectively. Ethics committee approval was obtained for the study (KAEK/2021.02.39).

Inclusion and exclusion criteria;

All patients with Neer type 2b clavicle distal fracture and over 18 years of age who were treated conservatively and surgically were included in the study. Patients with a history of previous fractures, patients with pathological fractures, patients with vascular-nerve damage, open fractures and patients with more than one fracture in the same extremity were excluded from the study.

The patients who were followed conservatively were named as Group 1, and those who were treated surgically were named as Group 2.

After the diagnosis is made at the first admission, the decision of conservative or surgical treatment is taken according to the choice of the orthopedic surgeon responsible for the emergency. Indications may vary depending on the surgeon's preference. (Table I)

Surgeon 1; He always follows conservatively and ends the follow-up if there is a union in his outpatient follow-ups. If there is nonunion and symptomatic, he recommends nonunion treatment. If there are no symptoms, the follow-up is terminated.

Surgeon 2; He attaches great importance to the expectation of the patient. He recommends routine surgery to patients who use shoulder functions actively and effectively as a professional or social lifestyle. He recommends conservative treatment to patients with low expectations and a sedentary life.

Surgeon 3; He takes into account the age of the patient. While it recommends routine surgical treatment under the age of 40, he recommends conservative treatment over the age of 40. If symptomatic nonunion develops during outpatient follow-ups, surgical treatment may be recommended.

Surgeon 4; The treatment decision is made according to the radiological appearance. If the preoperative displacement is less than 10 mm, conservative treatment is taken, and if it is higher than 10 mm, surgical treatment is decided.

Other surgeons; Based on the experience of the above surgeons, they decide on the type of treatment they are convinced of.

Data collection

Age, gender, fracture side, fracture type and follow-up period of the patients included in the study were calculated.

Preoperative fracture displacement amounts were measured radiologically. (Fig. 1) As a result of conservative or surgical treatment, the distance between the coracoid process and the clavicle (Coracoclavicular (CC) distance) in the final radiological image was measured. (Figs. 2 and 3) Normal side CC distance measurements of both groups were made. The clinical outcome at the final follow-up was made according to the Constant-Murley score [9]. Those who developed nonunion were detected.

All parameters and measurements performed by the same surgeon.

Statistical analysis;

IBM SPSS Statistics 26 (IBM, Chicago, IL, USA) program was used for statistical analysis. Explanatory statistics (mean, standard deviation, median, frequency, ratio, range) and data distribution were evaluated with the Shapiro-Wilk test. Student's t test was used to compare the data distributed between the two groups. p < 0.05 was taken for statistical significance level in all analyzes.

The total number of patients with Neer type 2b distal clavicle fracture meeting the inclusion criteria was 67. Thirty-six patients who were followed up conservatively were assigned to Group 1, and 31 patients who were treated surgically were assigned to Group 2. It was observed that hook plate fixation was preferred in 3 of 31 patients who were surgically treated, open fixation with kirshner-wire in 2 patients, and plate-screw fixation was preferred in 26 patients.

Group 1 mean age was 40.47 years, while Group 2 mean age was 34.25. The mean age of Group 1 was higher than Group 2. (p = 0.024) It was seen that the decision for conservative treatment was taken more frequently in patients with advanced age. (Table II)

While the female/male ratio was 0.33 in Group 1, it was 0.14 in Group 2. The fracture side right/left ratio was 1.76 in Group 1, while it was 1.38 in Group 2. While the mean follow-up period was 70.88 weeks in Group 1, it was 64.45 weeks in Group 2. Both groups had a similar distribution in terms of gender, fracture site and follow-up time. (p > 0.05)

While the mean preoperative fracture displacement was 10 mm in Group 1, it was 15.29 mm in Group 2. It was observed that the preoperative displacement amount of Group 2 was higher than Group 1. (p = 0.003)

While the CC distance in the last radiological evaluation was 11.02 in Group 1, it was 13 mm in Group 2. The CC distance of Group 2 was higher compared to Group 1. (p = 0.018)

According to the CC distance of the non-fractured sides of the patients, in the final radiological evaluation, Group 1 patients had a higher CC distance from the fractured side compared to the normal side CC distance compared to the normal side. (p = 0.002) Likewise, Group 2 patients had a higher CC distance on the fractured side compared to the normal side. (p = 0.0005)

As a result of the clinical Constant-Murley scoring, the mean was 95.94 in Group 1, while it was 93.48 in Group 2. Constant-Murley scores of both groups had similar distribution. (p = 0.086)(Table II)

While uneventful union developed in all patients in Group 2, nonunion was observed in 12 (33%) patients in Group 1. Patients who developed nonunion were re-evaluated on their own. While 8 patients were under 40 years old, 4 patients were over 40 years old. The female/male ratio was 0.71. Fracture side right/left ratio was 1. The mean follow-up period was 79.75 months. The mean amount of preoperative fracture displacement was 11.08. While 6 patients had a displacement of more than 10 mm, 6 patients had a displacement of less than 10 mm. The CC distance at the last follow-up was 12.66 mm. It had a higher distance compared to the normal side. (p = 0.008) The mean Constant-Murley score of patients with nonunion was 93.5. Since no patient developed symptomatic nonunion, surgical treatment was not decided. (Table III) (Fig. 4)

Fifteen of the surgically treated patients mentioned cold intolerance as a nonspecific finding. No patient developed infection. It was observed that all patients who had hook plates were removed due to long-term irritation.

As a result of this study, we revealed that when Neer type 2b distal clavicle fractures are followed conservatively, even if nonunion develops, its effect on clinical outcome is quite low and it has high clinical success. It was observed that those who were treated surgically did not have a clinical advantage over those who were treated conservatively. In general, surgeons were found to be more prone to surgical indications at higher fracture displacement and higher CC distances. Advanced age has pushed surgeons to conservative treatment more. In addition, when the relative indications of 4 different surgeons are evaluated, the approach of Surgeon 1 seems more acceptable.

Advanced age, low functional expectation and comorbid diseases push surgeons to conservative treatment. In addition, no demographic evaluations for distal clavicle fractures were found in the literature. We are of the opinion that absolute conservative treatment should be preferred in patients with low expectations due to asymptomatic nonunion.

Neer type 2b fractures often lead to advanced displacement due to rupture of the coracoclavicular ligament. There is no clear surgical displacement limit in the literature. It is seen that the surgeons in our clinic tend to conservative treatment around 10 mm and below.

Neer type 2b fractures result in isolated or total rupture of the CC ligament. [10] Because the acromioclavicular ligament is intact, the CC ligament is often not repaired and fibrous healing is expected. In the last radiological evaluation, it was observed that the operated group and the conservative group had higher CC ligament distances than the normal sides. Although surgical treatment techniques in which the CC ligament is fixed simultaneously with fracture fixation have been presented in the literature, there are also publications reporting that those that are not repaired do not cause functional defects. [11, 12]

Since the main function of the clavicle is to provide attachment to the muscles [13], it probably provides the continuation of the muscle biomechanics despite all kinds of nonunion, and the Constant-Murley scoring is persistently high.

Surgeon 1's approach is considered more acceptable among surgeons for whom we present 4 different indication approaches. Surgeon 1 heals all fractures conservatively and treats with bone grafting if symptomatic nonunion develops. It provides both cost savings and prevents unnecessary surgical interventions. In addition, we believe that the results of nonunion surgery should not be worried about the development of nonunion because of the high success rates in the literatüre. [14]

Due to its relatively relative indication, we see different surgical approaches in literature reviews. There are still various uncertainties regarding both indication selection and implant selection. Considering current publications, we see that more focus is placed on radiological results and various implant designs, various ligament reconstructions or ligament fixations are investigated. [15–17] It is also seen that a few clinics have again brought the clinical success of conservative treatment to the agenda by conducting retrospective and prospective studies for conservative treatment. [18–20] Therefore, we are of the opinion that clinical evaluations should be re-evaluated in distal clavicle fractures and awareness of unnecessary correction efforts of radiology should be created.

Limitations; It is very difficult for a single center to keep the number of Neer type 2b group cases of distal clavicle fractures high. The need for multicenter and prospective studies continues.

Funding:

There were no financial conflicts of interest. There was no external funding.

Ethical approval:

Approval has been granted by Local Ethics Committee (KAEK/2021.02.39).

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article.

Banerjee R, Waterman B, Padalecki J, Robertson W. Management of distal clavicle fractures. J Am Acad Orthop Surg. 2011 Jul;19(7):392-401. doi: 10.5435/00124635-201107000-00002. PMID: 21724918.
Kim DW, Kim DH, Kim BS, Cho CH. Current Concepts for Classification and Treatment of Distal Clavicle Fractures. Clin Orthop Surg. 2020 Jun;12(2):135-144. doi: 10.4055/cios20010. Epub 2020 May 14. PMID: 32489533; PMCID: PMC7237254.
Oh JH, Kim SH, Lee JH, Shin SH, Gong HS. Treatment of distal clavicle fracture: a systematic review of treatment modalities in 425 fractures. Arch Orthop Trauma Surg. 2011 Apr;131(4):525-33. doi: 10.1007/s00402-010-1196-y. Epub 2010 Oct 22. PMID: 20967548.
Panagopoulos A, Solou K, Tatani I, Triantafyllopoulos IK, Lakoumentas J, Kouzelis A, Athanasiou V, Kokkalis ZT. What is the optimal surgical treatment for Neer type IIB (IIC) distal clavicle fractures? A systematic review and meta-analysis. J Orthop Surg Res. 2022 Apr 7;17(1):215. doi: 10.1186/s13018-022-03108-2. PMID: 35392941; PMCID: PMC8991691.
Xu Y, Guo X, Peng H, Dai H, Huang Z, Zhao J. Different internal fixation methods for unstable distal clavicle fractures in adults: a systematic review and network meta-analysis. J Orthop Surg Res. 2022 Jan 24;17(1):43. doi: 10.1186/s13018-021-02904-6. PMID: 35073954; PMCID: PMC8785604.
Deafenbaugh MK, Dugdale TW, Staeheli JW, Nielsen R. Nonoperative treatment of Neer type II distal clavicle fractures: a prospective study. Contemp Orthop. 1990 Apr;20(4):405-13. PMID: 10148035.
Chen NC. In Patients with Displaced Type-II Distal Clavicle Fractures, Operative and Nonoperative Therapies Did Not Differ for Functional Outcomes at 1 Year. J Bone Joint Surg Am. 2022 Aug 17;104(16):1503. doi: 10.2106/JBJS.22.00484. Epub 2022 Jun 2. PMID: 35700086.
Kang HJ, Kim HS, Kim SJ, Yoo JH. Osteosynthesis of symptomatic nonunions of type II fractures of the distal clavicle using modified locking T-plate and bone grafting. J Trauma Acute Care Surg. 2012 Feb;72(2):E14-9. doi: 10.1097/TA.0b013e31822fb987. PMID: 22327996.
Constant, C. R., & Murley, A. H. (1987). A clinical method of functional assessment of the shoulder. Clinical Orthopaedics & Related Research, 214, 160–164.
Sarda P. Lateral Clavicle Fractures with Coracoclavicular Ligament Disruption (Neer's Type IIB): Review of Literature and a New Technique for All-Suture Fixation. Indian J Orthop. 2019 May-Jun;53(3):465-471. doi: 10.4103/ortho.IJOrtho_485_18. PMID: 31080289; PMCID: PMC6501619.
Salazar BP, Chen MJ, Bishop JA, Gardner MJ. Outcomes after locking plate fixation of distal clavicle fractures with and without coracoclavicular ligament augmentation. Eur J Orthop Surg Traumatol. 2021 Apr;31(3):473-479. doi: 10.1007/s00590-020-02797-x. Epub 2020 Sep 19. PMID: 32949271.
Furuhata R, Matsumura N, Udagawa K, Oki S, Morioka H. Residual coracoclavicular separation after plate fixation for distal clavicle fractures: comparison between fracture patterns. JSES Int. 2021 May 26;5(5):840-845. doi: 10.1016/j.jseint.2021.04.017. PMID: 34505093; PMCID: PMC8411066.
Johson D. Pectoral girdle and upper limb: overview and surface anatomy. In: Standring S, editor. Gray’s anatomy. 40th ed. Edinburgh: Longmans Green and Co.; 2008. pp. 777–822.
Jones GL, McCluskey GM 3rd, Curd DT. Nonunion of the fractured clavicle: evaluation, etiology, and treatment. J South Orthop Assoc. 2000 Spring;9(1):43-54. PMID: 12132810.
Gutman MJ, Joyce CD, Patel MS, Lazarus MD, Horneff JG. Outcomes Following Different Fixation Strategies of Neer Type IIB Distal Clavicle Fractures. Arch Bone Jt Surg. 2022 Feb;10(2):160-165. doi: 10.22038/ABJS.2021.54472.2718. PMID: 35655745; PMCID: PMC9117897.
Bandebuche AR, Rai AK, Bansal D, Gupta D, Naidu A. Comparative Analysis of Clavicular Hook Plate Versus Distal Radius Volar Plate With Coracoclavicular Augmentation for Neer's Type 2b Lateral Clavicle Fractures: A Prospective Study. Cureus. 2022 Mar 8;14(3):e22969. doi: 10.7759/cureus.22969. PMID: 35415023; PMCID: PMC8990979.
Xiong J, Chen JH, Dang Y, Zhang DY, Fu ZG, Zhang PX. Treatment of unstable distal clavicle fractures (Neer type II): A comparison of three internal fixation methods. J Int Med Res. 2018 Nov;46(11):4678-4683. doi: 10.1177/0300060518788245. Epub 2018 Aug 1. PMID: 30066599; PMCID: PMC6259385.
Hall JA, Schemitsch CE, Vicente MR, Dehghan N, Nauth A, Nowak LL, Schemitsch EH, McKee MD; Canadian Orthopaedic Trauma Society (COTS). Operative Versus Nonoperative Treatment of Acute Displaced Distal Clavicle Fractures: A Multicenter Randomized Controlled Trial. J Orthop Trauma. 2021 Dec 1;35(12):660-666. doi: 10.1097/BOT.0000000000002211. PMID: 34128498.
Uittenbogaard SJ, van Es LJM, den Haan C, van Deurzen DFP, van den Bekerom MPJ. Outcomes, Union Rate, and Complications After Operative and Nonoperative Treatments of Neer Type II Distal Clavicle Fractures: A Systematic Review and Meta-analysis of 2284 Patients. Am J Sports Med. 2023 Feb;51(2):534-544. doi: 10.1177/03635465211053336. Epub 2021 Nov 15. PMID: 34779668.
Rokito AS, Zuckerman JD, Shaari JM, Eisenberg DP, Cuomo F, Gallagher MA. A comparison of nonoperative and operative treatment of type II distal clavicle fractures. Bull Hosp Jt Dis. 2002-2003;61(1-2):32-9. PMID: 12828377.

Table I: Relative indications of 4 different surgeons

	Conservative endication	Surgical endication
Surgeon 1	All fractures are conservative	Surgery if symptomatic nonunion develops
Surgeon 2	Conservative in sedentary patients who are fond and have low expectations	- Surgery if the patient is active and expectant - Surgery if symptomatic nonunion develops
Surgeon 3	Over 40 years old conservative	- Surgery under 40 years of age - Surgery if symptomatic nonunion develops
Surgeon 4	Displaced less than 10 mm is conservative	- Surgery If more than 10 mm is displaced - Surgery if symptomatic nonunion develops

Table II: Demographic data of all patients and parameters that are followed

		Conservative (Group 1) n= 36	Surgical (Group 2) n = 31	P value
Age	Avg±Ss	40,47±14,63	34,25±10,7	0,024*
Age	Min-Max	18-65	19-59	0,024*
Gender	Female	9	4	0,209
Gender	Male	27	27	0,209
Fracture side	Right	23	18	0,632
Fracture side	Left	13	13	0,632
Follow-up time (months)	Avg±Ss	70,88±17,25	64,45±16	0,118
Follow-up time (months)	Min-Max	39-98	34-95	0,118
Preoperative fracture displacement (mm)	Avg±Ss	10±6,08	15,29±5,39	0,0003*
Preoperative fracture displacement (mm)	Min-Max	3-23	7-24	0,0003*
Fracture side CC distance (mm)	Avg±Ss	11,02±3,54	13±3,15	0,018*
Fracture side CC distance (mm)	Min-Max	4-17	8-21	0,018*
Normal side CC distance (mm)	Avg±Ss	9,25±1,02	10,7±1,29	0,002 0,0005*
Normal side CC distance (mm)	Min-Max	7-11	9-14	0,002 0,0005*
Constant-Murley score	Avg±Ss	95,94±3,32	93,48±7,17	0,086
Constant-Murley score	Min-Max	90-100	72-100	0,086
Nonunion		12 patients (%33)	0 patient (%0)	-

*P<0,05

**Comparison of the fractured side and the non-fractured side of patients treated conservatively

***Comparison of the fractured side and the non-fractured side of patients who underwent surgical treatment

Table III: Demographic data of patients with nonunion and the parameters that are followed

		Nonunion patients n = 12
Age	Avg±Ss	36,25±15,06
	Min-Max	18-63
	<40 years	8 patients
	>40 years	4 patients
Gender	Female	5
	Male	7
Fracture side	Right	6
	Left	6
Follow-up time (months)	Avg±Ss	79,75±14,8
	Min-Max	52-98
Preoperative fracture displacement (mm)	Avg±Ss	11,08±7,17
	Min-Max	3-20
	<10 mm	6 patients
	>10 mm	6 patients
Fracture side CC distance (mm)	Avg±Ss	12,66±3,67	0,008*
	Min-Max	8-17
Normal side CC distance (mm)	Avg±Ss	9,41±1,24
	Min-Max	7-11
Constant-Murley score	Avg±Ss	93,5±4,18
	Min-Max	90-100

*P value=0.008 ; Comparison of the fractured side and non-fractured side of patients who developed nonunion in Group 1 conservative treatment follow-up

No competing interests reported.

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You are reading this latest preprint version

Radiological and clinical comparison of surgical and conservative treatment of distal fractures of the clavicle (Neer type 2b)

Status:

Version 1

Abstract

Introduction:

Patients and Methods:

Results

Conclusion

Level of evidence:

Figures

Introduction

Patients and Methods

Data collection

Results

Discussion

Declarations

References

Tables

Additional Declarations

Status:

Version 1