Comparison of the functional outcome of intramedullary nailing versus plating in displaced midclavicular fractures

Introduction

Fracture of clavicle accounts for approximately 3.2% of all the fractures and about 35% of all injuries of shoulder girdle.^[1] About 80% of fractures involved the middle third region and about 50% are displaced. The mean age of patients sustaining clavicular fracture is about 33 years, and males are more commonly involved. Most common mechanism of injury is a fall or direct blow to shoulder, leading to axial compressive force.^[2,3] Displaced midclavicular fractures were treated conservatively because early reports suggesting that nonunion fractures are very rare and malunion fractures are without any functional deficit and for radiographic interest only. Clavicle keeps upper limb away from torso for efficient function so work as “strut.”^[4] However, recent studies concern about higher rates of delayed union, shoulder weakness, residual pain and deficits, and terminally affected movements associated with nonoperative treatment. Internal plate fixation and intramedullary nailing are essential operative techniques. Either technique provides superior functional results compared to the conventional method. In recently randomized studies results shows.maintaing the clavicular length in displaced mid clavicular fractures is very crucial for the best fuctional outcome of terminally affected movemnts.^[5]

However, prospective randomized controlled trials (RCT) comparing these practical techniques for displaced midclavicular fractures were lacking.^[6-8] The aim of this study was designed to examine the effectiveness of intramedullary nailing and fixation by locking plates in displaced midclavicular fractures and comparison of functional outcome and complications of two standard operative procedures.

Materials and Methods

This is a prospective comparative study done between October 2013 and September 2015, to study the functional outcome and complications of displaced midclavicular fracture treated either by intramedullary nailing or by internal locking plate fixation. A total of 100 unilateral displaced midclavicular fractures were admitted and 66 patients included in this study along with 1-year follow-up protocol. Intramedullary nailing included tense elastic nail and Rush pin used in 33 patients, whereas locking plates included anatomically precontoured locking plates and locking reconstruction plates used in rest 33 patients. Patients randomized into two groups by alternate (one by one) methods. Robinson classification treasured in choosing therapy as well as it is prognostically significant. Patients were followed monthly for the 1^st 4 months and then 3 monthly. Assessment of shoulder function was carried out postoperatively clinically and radiologically.

The patient's pain profile was assessed using a visual analog scale; functional outcomes were evaluated using the constant shoulder score and range of motion (ROM) at shoulder joint: clinical assessment included ROM measurement using a goniometer – abduction, forward flexion, elevation, adduction, and internal and external rotation were measured on both sides. Only unilateral complete displaced mid-clavicular fractures in the age group between 18 and 60 years with <2 week old, mark shortening of <2 cm and angulation >30 degree includes in the study. Bilateral, undisplaced, compound, severe comminiation, multitrauma patient, previously operated, malunited and nonunion fractures, and pathological fractures along with neurovascular injuries were excluded from our study.

Results

A total of 66 patients were analyzed who completed at least 1 year of complete follow-up. As per inclusion criteria, we had 33 patients in the plate group [Figure 1] and 33 in the nail group [Figure 2] for comparison. In the plate group, we had 7 (21.2%) female patients, whereas there were 10 (30.03%) female patients in the nail group. Statistically, there was no significant difference between two groups on gender (P = 0.398). Mean age of patients in Group I (31.79 ± 11.05 years) was slightly higher as compared to that of patients in Group II (28.88 ± 7.89 years), but the difference between two groups was not statistically significant (P = 0.223). In both the groups, the majority had involvement of the right side. Left side was involved in 36.4% of Group I and 39.4% of Group II patients. Statistically, this difference did not account significantly (P = 0.800).

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Figure 1

Skiagrams of a left clavicle of a 20–year-old male patient showing (a) midshaft clavicle fracture, (b) immediate postoperative X-ray with plate in situ, (c) 3 months postoperative with fracture union, and (d) after implant removal

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Figure 2

Skiagrams of left clavicle of a 15–year-old male patient showing (a) clavicle fracture, (b) immediate postoperative X-ray with IM TEN in situ, (c) fracture united 3 months postoperatively, and (d) after implant removal

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Mean injury time was 3.61 ± 3.28 days in Group I as compared to 3.64 ± 2.76 days in Group II. Statistically, this difference between two groups was not significant (P = 0.968). However, mean duration of hospital stay, as well as mean amount of blood loss, was higher in Group I (2.36 ± 1.03 days and 115.25 ± 30.54 ml) as compared to that in Group II (1.64 ± 0.78 days and 55.30 ± 16.77 ml), and this difference was statistically significant (P < 0.05). The mean length of incision was longer in Group I (10.35 ± 1.06 cm) as compared to that in Group II (4.38 ± 0.75 cm). For both these parameters, the difference between two groups was significant (P < 0.001). Mean pain score was higher in Group I (3.33 ± 1.47) as compared to that, in Group II (2.91 ± 1.42), yet this difference was not statistically significant (P = 0.238). Time taken for union ranged from 3 to 11 months with a mean value of 5.91 ± 1.89 months. Union time was slightly longer in Group I (6.00 ± 2.41 months) as compared to Group II (5.82 ± 1.89 months), but the difference between two groups was not statistically significant (P = 0.701).

In plate group patients, one (3.03%) had hypertrophic skin scar, infection was found in one patient (3.03%), and major revision surgery was found in 2 (6.06%) patients. Nonunion and refracture after implant removal were not encountered in this group. In nail group, infection was found in 1 patient (3.03%), implant failure occurred in 1 patient (3.03%), and major revision surgery was found in 1 (3.03%) patient [Table 1]. The functional outcome was assessed by Constant and Murley score. In this study, out of 33 patients treated with plate and screws, 21 patients (63.33%) had excellent functional outcome, good functional outcome in 2 patients (6.06%), and fair functional outcome in 6 patients (18.18%). Among 33 patients receiving nail method, 27 patients (81.81%) had excellent functional outcome results, 4 patients (12.12%) had fair functional outcome, and 2 patients (6.06%) had poor functional outcome [Table 2].

Table 1 Surgical complication

Table 2 Functional outcome

Discussion

Traditionally, displaced midclavicular fractures had been managed nonoperatively.^[9] NEER and ROWER found minuscule incidence of nonunion (0.1% and 0.8%, respectively) in their studies in 1960 and recommended conservative treatment for clavicular fractures.^[6]

Recent studies have shown that higher nonunion rate in nonoperatively treated patients is approximately 5%. Recent studies also show poorer functional outcome in displaced midclavicular fractures that treated traditionally when compared to surgically treated patients. Furthermore, the best treatment for displaced midclavicular fractures remains unclear and becomes a topic of debate. However, the current recommendation for displaced midclavicular fracture treatment is by operative fixation. Many authors advocate plate fixation as a standard operative procedure for displaced midclavicular fractures.^[4,7,10] Plate fixation choice included 3.5 mm dynamic compression plates and anatomically precontoured locking plates. Locking reconstruction plates applied either anterosuperiorly or anteroinferiorly and fixed by three screws on either side of the fracture. Recent emerging mode of fixation is intramedullary nailing fixation either by anterograde or by retrograde technique.^[11] Biomechanically, nailing is weak regarding better rotation control of fragments during early movement of the shoulder and thus allows the primary union. Patients can be allowed full ROM as soon as soft-tissue healing occurs.^[6,9] The disadvantage of plating includes damage to the supraclavicular nerve, slight higher infection rates, more soft-tissue stripping, and significant refracture after plates removal. The advantage of intramedullary nailing is less soft-tissue trauma and enhanced bone healing. The higher advantage of intramedullary nailing is ease in implant removal and lesser scar in cosmetically conscious patients.^[12-14] In our study, constant shoulder scores were significantly higher in the plating group when compared to intramedullary nailing group during the 1^st 12 weeks of the follow-up period. However, no significant difference of standardized shoulder scores was found between the two groups after 6 months of follow-up period. Fu et al.^[15] compared nail and reconstruction plate fixation in displaced midclavicular fractures and found no significant difference in functional outcome after 18 months of follow-up evaluated using DASH score. Azar et al.^[16] compared low-contact dynamic compression plates and Rockwood pin fixation in displaced midclavicular fractures and no significant difference found in functional outcome at 1 year of follow-up.

The limiting factor of our study is small sample size and study done at a single center. Longer RCT is needed at the various centers to evaluate the outcomes and complications further. What we can conclude from our study is that both intramedullary nailing and fixation by locking plate are equally alternative methods for treating displaced midclavicular fractures as for as functional outcome is concerned. Although from our study we recommended the use of minimally invasive anterograde intramedullary nailing in displaced midclavicular fractures in light of faster fracture union, easier plant removal and better cosmetic result in cosmetically conscious patients.

Conclusions

Intramedullary nailing for midclavicular displaced fracture is advantageous as compared with the clavicular platting as it provides fast healing, easy to remove, less cumbersome, and cosmetically good for patient.