Clavicular Fractures, Epidemiology, Union, Malunion, Nonunion

Abstract: During a three-year period (1989-91), all patients living in the county of Uppsala, Sweden, with a radiographically verified fracture of the clavicle were prospectively, consecutively followed (n=245). The epidemiological study (I) was restricted to the two first years with 187 fractures in185 patients. The short term study (II) with 6 months follow-up included 222 patients. The long term study (III) with 10 years follow-up included 208 patients. The malunion study (IV) included eight patients and the nonunion study (V) 24 patients all of whom were consecutively operated between 1988-2000.Displacement, especially with no bony contact in the initial radiographs, was a statistically significant risk factor for sequelae.Comminute fractures, especially if including transversally placed fragments, were associated with a significantly increased risk of remaining symptoms. An increasing number of fragments was also associated with an increased risk of sequelae.Patients with remainig symptoms after 6 months were on average older at the time of injury as compared to patients without remaining symptoms. Advancing age was also a significant risk factor for sequelae – specifically pain at rest – still after 10 years.There was no difference between gender with respect to the risk of sequelae, except for nonunion.Fracture location did not predict outcome, except for more cosmetic defects (middle part).Shortening defined as overlapping at the fracture site was a significant risk factor for cosmetic defects after 10 years.Patients who experience pain at rest and/or cosmetic defects more than twelve weeks after the fracture have a higher risk for sequelae.The radiographic examination should always consist of two projections: the AP (0°) view and the 45° tilted view. Transversally placed fragments are not seen in the 0° view.Removal of excessive callus in patients with persistent symptoms even several years after the fracture showed a good outcome. One does not have to stabilize the clavicle when excising the hypertrophic callus.Symptomatic clavicular nonunions should be treated with surgery. Reconstruction plate combined with cancellous bone gives a faster and more reliable healing rate than external fixation.