Overtreatment of displaced midshaft clavicle fractures

Figures & data

Figure 1. A typical displaced midshaft fracture with a displacement of more than 1 bone width, some degree of shortening, and several intermediary fragments.

Table 1. Factors important for allocation of operative treatment at the 80 hospitals that could consider operative treatment based on specific risk factors. Values are number of hospitals

	The factor is a significant criterion for treating operatively at the specific hospital:
	Yes	No
Fracture displacement by more than 1 bone width	80	0
Fracture shortening by more than 20 mm	71	9
Presence of one or more larger intermediary fragments	57	23
Presence of profound fracture angulation without displacement	19	61
Patient age	20	60
Smoking habits	20	60
Alcohol abuse	54	26
Severe comorbidity (ASA 3 or more)	63	17

Table 2. Preferred treatment of 6 various hypothetical patient cases according to different centers. Values are number of hospitals

	The preferred treatment of centers across
	Sweden		Denmark		Finland		all centers
	Operative	Non-op.	Operative	Non-op.	Operative	Non-op.	Operative	Non-op.
Case 1:
30-year-old male, active cyclist. ASA grade 1.
High level of daily function.
Radiograph shows a midshaft clavicle fracture
displaced by approx. 1½ bone width without
significant shortening or intermediary fragments.	21	18	8	13	14	11	43	42
Case 2:
32-year-old woman, mother of 3 children.
ASA grade 1. Normal level of daily function,
does not do sports.
Radiograph: same as case 1.	9	30	8	13	3	22	20	65
Case 3:
Same woman as case 2.
Radiograph shows a midshaft clavicle fracture
displaced by approx. 1½ bone width, and approx.
2 cm of shortening and 2 intermediary fragments.	30	9	16	5	19	6	65	20
Case 4 (Figure 1):
62-year-old man. ASA grade 2 (medically treated
hypertension). Normal level of daily function.
Fell in the garden.
Radiograph: same as case 3.	26	13	17	4	11	14	54	31
Case 5 (Figure 1):
62-year-old active woman. ASA grade 2 (medically
treated hypertension). High level of daily function.
Plays badminton 3 times weekly.
Radiograph: same as case 3.	28	11	16	5	17	8	61	24
Case 6 (Figure 1):
62-year-old woman. ASA grade 3 (mild COLD and
previous AMI x 2). Smoking daily. Mild impairment
of daily function. Lives alone in own home, and
manages most daily activities herself.
Radiograph: same as case 3.	9	30	8	13	23	2	40	45

ASA grade: American Society of Anaesthesiologists Physical Status Classification System; COLD: chronic obstructive lung disease; AMI: acute myocardial infarction. 

Table 3. Data from the Danish Fracture Database (DFDB) linking primary treatment of clavicle fractures to secondary intervention. Time period: October 2012 to end of December 2013

	No. of primary treated clavicle fracture	No. of secondary interventions
Medial clavicle fractures	7	1
Midshaft clavicle fractures	287	42
Lateral clavicle fractures	64	13
Total	358	56^a

a The 56 secondary interventions were due to: soft tissue pain/irritation (n = 30), secondary fracture dislocation (n = 13), non-union (n = 5), deep infection (n = 5), suboptimal osteosynthesis (n = 2), and a secondary fracture (n = 1).