Summary

Of the variables we evaluated, fracture morphology was identified as the only significant risk factor for the development of postoperative complications in patients treated with open reduction and internal fixation in midshaft clavicle fractures.

Abstract

Introduction

Complications can occur following clavicle fracture fixation including symptomatic hardware, nonunion, and infection. Identifying predictors of postoperative complications could potentially identify patients better served with a trial of nonoperative management. In this study demographics, injury pattern, and surgical technique were used to identify predictors of postoperative complications. We hypothesized that increased comorbidities (e.g. smoking, diabetes), segmental fracture patterns, and superior plating would lead to higher complication risks.

Methods

We retrospectively reviewed all adult patients at a single tertiary trauma center who underwent open reduction and internal fixation of midshaft clavicle fractures performed by orthopaedic trauma and sports medicine surgeons between 2007 and 2019. Demographic information, injury characteristics, surgical technique, postoperative complications including reoperation, and follow-up were recorded. Postoperative complications were separated into major complications that required reoperation and minor complications that did not require reoperation. The study utilized chi-square statistics and analysis of variance between subjects to identify predictors of all, major, and minor postoperative complications with significance set at p<0.05.

Results

There were 354 patients (288 males, 66 females) with an average age of 38.0 ± 14.6 years and BMI of 26.3 ± 5.2. The average follow-up was 3.0 ± 7.5 months. There were 116 smokers (32.8%) and 14 diabetics (4.0%). Occupation was documented in 285 patients (80.5%), with 93 of those patients (32.6%) working in manual labor. There were 157 transverse fractures (44.4%), 147 oblique fractures (41.5%), and 50 Z-type fractures (14.1%). Average time from injury to surgery was 5.4 days (range 0 – 44 days) with 219 patients (61.9%) treated inpatient and 135 patients (38.1%) treated outpatient. There were 144 patients (40.7%) who had superior plating, 134 patients (37.9%) who had anterior plating, and 76 patients (21.4%) who had dualplating. Overall, postoperative complications occurred in 58 patients (16.4%). Of those complications, there were 44 minor complications (12.4%) and 14 major complications (4.0%). Of the major complications the most common causes were non-union (n=5), symptomatic hardware (n=4), and infection (n=3). Of the minor complications the most common causes were sensory deficits (n=25), superficial wound infections that resolved with observation or antibiotics (n=11), and delayed union that resolved with bone stimulator (n=3). The only significant predictor for postoperative complications was fracture pattern for all complications (p=0.03) and major complications (p=0.002). Complications occurred more frequently in transverse and Z-type fractures than oblique fractures.

Discussion

Fracture pattern was the only predictor identified for the development of postoperative complications. While the overall risk of major complication was low, transverse and Z-type fracture patterns may be more problematic. Non-unions occurred exclusively in transverse clavicle fractures, possibly due to the reduced bony surface area in contact. Symptomatic hardware occurred mostly with Z-type fractures which may be secondary to longer plates for segmental fixation that can be a source of irritation.