Clavicle Fractures : Epidemiology, classification, treatment and outcome, with emphasis on displaced lateral clavicle fractures

The rate of surgical treatment for clavicle fractures has increased dramatically in the past 20 years, but the necessity for this remains obscure, particularly for displaced lateral clavicle fractures. The overall aim of the thesis is to acquire knowledge that may help guide treatment decisions for clavicle fractures, with an emphasis on displaced lateral fractures. Study I was a register-based observational cohort study of 2 422 clavicle fractures from the Swedish Fracture Register (SFR), describing the epidemiology, classification and initial treatment of clavicle fractures in Sweden from 2013–2014. Patients were often young males. Simple falls and bicycle accidents were the most common injury mechanisms. Displaced midshaft fractures were the most common fracture type. Twenty-nine % of displaced midshaft fractures and 20% of displaced lateral fractures were treated surgically. Study II was an observational cohort study reviewing local medical records of patients with lateral clavicle fractures treated at Uppsala University Hospital in 2013–2015. Twenty-two of the 58 displaced or potentially unstable lateral clavicle fractures were treated surgically, and half required secondary surgery for implant removal. Only 2 of 36 non-surgically treated fractures required delayed surgery because of symptomatic nonunion. In a subgroup of 30 patients seen at a follow-up visit 3 years post-injury, surgically treated patients had worse Constant scores, complained about infraclavicular sensory deficits and were less satisfied with the cosmetic result than non-surgically treated patients. Study III was a register-based validation study that evaluated the accuracy of the Robinson classification for clavicle fractures applied in the SFR. Radiographs of 115 randomly selected clavicle fractures were independently classified by three experts on two occasions, creating a gold standard classification that was compared to the classifications in the SFR. The degree of agreement between the two classifications (accuracy), was only fair. However, the inter- and intraobserver agreement among the expert raters was almost perfect, indicating that accuracy may be improved if the classification instructions in the SFR are revised. Study IV was an observational register study of 113 patients with fully displaced lateral clavicle fractures identified through the SFR and linked to the National Patient Register. Thirty-five of 52 surgically treated patients required secondary surgery, primarily for implant removal. Only 3 of 61 non-surgically treated patients required delayed surgical treatment due to nonunion or malunion. Functional outcome did not differ between treatment groups. We conclude that patients with displaced lateral clavicle fractures should generally be considered for non-surgical treatment