Klavikula orta 1/3 diafiz kırıkları: operatif ve nonoperatif tedavi

Year 2025, Volume: 8 Issue: 6, 1171 - 1175, 25.10.2025

Zafer Güneş , Eralp Erdoğan

Abstract

Amaç: Biz bu çalışmada, klavikula orta 1/3 diafiz kırığı olan ve cerrahi ya da konservatif yöntemlerle tedavi edilmiş hastalarda, en az bir yıllık takip sonuçlarını değerlendirilmeyi ve karşılaştırmayı amaçladık. Cerrahi tedavi uygulanan hastaların, erken klinik sonuçlarının daha iyi olacağını ve kaynama oranlarının daha yüksek olacağını öngördük.
Gereç ve Yöntem: Çalışmamızda hastane dijital kayıt sistemi ve hasta dosyalarından şu değişkenler belirlendi: yaş, cinsiyet, kırık tipi, uygulanan tedavi yöntemi, radyografik kaynama süresi, Constant-Murley skoru ve Görsel Analog Skala (VAS) ağrı skoru. Ayrıca, hastalar son kontrolleri için kliniğe davet edildi ve bu ziyaret sırasında son kontrollerine ait Constant-Murley ve VAS skorları kaydedildi.
Bulgular: Ocak 2016 ile Aralık 2023 tarihleri arasında, dahil edilme kriterlerini karşılayan toplam 98 hasta değerlendirildi. Cerrahi yapılan grupta (n=34) konservatif gruba (n=64) göre kaynama zamanı (16.4 vs 24.3 hafta, p=.000), 3. ve 6. aydaki Constant-Murley skorları (3. ay için 79.4 vs 72.2 p=.000 ve 6. ay için 89.6 vs 86.8 p=.000), 3. ve 6. aydaki VAS skorlarının (3. ay için 18.8 vs 22.9 p=.000 ve 6. ay için 12.9 vs 15.3 p=.000) istatiksel anlamlı daha iyi olduğu görülmüştür.
Sonuç: Bu çalışma, orta 1/3 klavikula diafiz kırıklarında cerrahi tedavinin kaynama süresi ve erken klinik skorlar açısından konservatif tedaviye kıyasla istatistiksel olarak üstün olduğunu göstermektedir. Bununla birlikte, 12. ay itibarıyla her iki grupta da tam kemik kaynaması sağlandıktan sonra benzer klinik sonuçlara ulaştıkları görülmüştür.

Keywords

Klavikula , orta diafiz , cerrahi tedavi , konservatif tedavi

Clavicle midshaft fractures operative vs nonoperative treatment

Abstract

Aims: Midshaft clavicle fractures are common injuries in young, active adults. Although nonoperative management has traditionally been preferred, recent evidence suggests that surgical fixation may yield faster recovery and lower rates of nonunion. This study aimed to compare the clinical and radiological outcomes of operative versus nonoperative treatment of midshaft clavicle fractures.
Methods: A retrospective cohort of 98 patients (34 surgically, 64 conservatively treated) with Robinson type 2B1-2B2 midshaft clavicle fractures was analyzed. Patients aged 18-65 years and followed for at least 12 months were included. Surgical indications comprised displacement >2 cm, comminution, skin tenting, or neurovascular compromise. Radiographic union, Constant-Murley, and Visual Analog Scale (VAS; 0-100 mm) scores were compared at 3, 6, and 12 months. Kaplan-Meier survival analysis was used to evaluate time to union, with intergroup comparison by log-rank test.
Results: Mean union time was 16.4±3.2 weeks in the surgical group and 24.3±4.6 weeks in the conservative group (p<0.001). Kaplan-Meier analysis showed significantly faster union in the surgical cohort (log-rank χ²=17.46, p<0.001). Constant-Murley scores were significantly higher and VAS scores lower at 3 and 6 months after surgery (p<0.001 for both), but differences were not significant at 12 months. Complications occurred in 14.7% of surgical and 17.2% of conservative cases (p=0.260*). Nonunion (14%) and malunion (3%) were observed only in the conservative group.
Conclusion: Operative fixation of displaced midshaft clavicle fractures provides faster radiologic healing and better early functional outcomes, while long-term results are comparable to conservative management. Surgical treatment should be preferred in young, active patients or markedly displaced fractures, whereas nonoperative care remains suitable for minimally displaced, low-demand cases.

Keywords

Clavicle fracture , midshaft , open reduction and internal fixation , conservative treatment , Kaplan-Meier , functional outcome , union time

References

• Lenza M, Faloppa F. Surgical interventions for treating acute fractures or non-union of the middle third of the clavicle. Cochrane Database Syst Rev. 2015;2015(5):CD007428. doi:10.1002/14651858.CD007428.pub3
• Robinson CM. Fractures of the clavicle in the adult. Epidemiology and classification. J Bone Joint Surg Br. 1998;80(3):476-484. doi:10.1302/0301-620x.80b3.8079
• Bandovic I, Holme MR, Black AC, Futterman B. Anatomy, Bone Markings. In: StatPearls. Treasure Island (FL): StatPearls Publishing; May 6, 2024.
• Oki S, Matsumura N, Kiriyama Y, Iwamoto T, Sato K, Nagura T. Three-dimensional deformities of nonoperative midshaft clavicle fractures: a surface matching analysis. J Orthop Trauma. 2017;31(11):e385-e389. doi:10.1097/BOT.0000000000000931
• Hoogervorst P, van Schie P, van den Bekerom MP. Midshaft clavicle fractures: current concepts. EFORT Open Rev. 2018;3(6):374-380. doi:10. 1302/2058-5241.3.170033
• Frima H, van Heijl M, Michelitsch C, et al. Clavicle fractures in adults; current concepts. Eur J Trauma Emerg Surg. 2020;46(3):519-529. doi:10. 1007/s00068-019-01122-4
• Nowak J, Holgersson M, Larsson S. Sequelae from clavicular fractures are common: a prospective study of 222 patients. Acta Orthop. 2005; 76(4):496-502. doi:10.1080/17453670510041475
• Naveen BM, Joshi GR, Harikrishnan B. Management of mid-shaft clavicular fractures: comparison between non-operative treatment and plate fixation in 60 patients. Strategies Trauma Limb Reconstr. 2017;12(1): 11-18. doi:10.1007/s11751-016-0272-4
• Zlowodzki M, Zelle BA, Cole PA, Jeray K, McKee MD; Evidence-Based Orthopaedic Trauma Working Group. Treatment of acute midshaft clavicle fractures: systematic review of 2144 fractures: on behalf of the evidence-based orthopaedic trauma working group. J Orthop Trauma. 2005;19(7):504-507. doi:10.1097/01.bot.0000172287.44278.ef
• Song HS, Kim H. Current concepts in the treatment of midshaft clavicle fractures in adults. Clin Shoulder Elb. 2021;24(3):189-198. doi:10.5397/cise.2021.00388
• Biz C, Pozzuoli A, Belluzzi E, et al. An ınstitutional standardised protocol for the treatment of acute displaced midshaft clavicle fractures (ADMCFs): conservative or surgical management for active patients? Healthcare (Basel). 2023;11(13):1883. doi:10.3390/healthcare11131883
• Li L, Yang X, Xing F, Jiang J, Tang X. Plate fixation versus intramedullary nail or Knowles pin fixation for displaced midshaft clavicle fractures: a meta-analysis of randomized controlled trials. Medicine (Baltimore). 2020;99(39):e22284. doi:10.1097/MD.0000000000022284
• Hung LW, Lu HY, Chen TY, Wang TM, Lu TW. Residual kinematic deviations of the shoulder during humeral elevation after conservative treatment for mid-shaft clavicle fractures. Front Bioeng Biotechnol. 2024;12:1413679. doi:10.3389/fbioe.2024.1413679
• Matsumura N, Ikegami H, Nakamichi N, et al. Effect of shortening deformity of the clavicle on scapular kinematics: a cadaveric study. Am J Sports Med. 2010;38(5):1000-1006. doi:10.1177/0363546509355143
• Hillen RJ, Burger BJ, Pöll RG, van Dijk CN, Veeger DH. The effect of experimental shortening of the clavicle on shoulder kinematics. Clin Biomech (Bristol). 2012;27(8):777-781. doi:10.1016/j.clinbiomech.2012. 05.003
• Weinberg DS, Vallier HA, Gaumer GA, Cooperman DR, Liu RW. Clavicle fractures are associated with arthritis of the glenohumeral joint in a large osteological collection. J Orthop Trauma. 2016;30(11):605-611. doi:10.1097/BOT.0000000000000654
• Pailhes RG, Bonnevialle N, Laffosse J, Tricoire J, Cavaignac E, Chiron P. Floating shoulders: clinical and radiographic analysis at a mean follow-up of 11 years. Int J Shoulder Surg. 2013;7(2):59-64. doi:10.4103/0973-6042.114230
• Potter JM, Jones C, Wild LM, Schemitsch EH, McKee MD. Does delay matter? The restoration of objectively measured shoulder strength and patient-oriented outcome after immediate fixation versus delayed reconstruction of displaced midshaft fractures of the clavicle. J Shoulder Elbow Surg. 2007;16(5):514-518. doi:10.1016/j.jse.2007.01.001
• Kluijfhout WP, Tutuhatunewa ED, van Olden GDJ. Plate fixation of clavicle fractures: comparison between early and delayed surgery. J Shoulder Elbow Surg. 2020;29(2):266-272. doi:10.1016/j.jse.2019.06.022
• Sanchez PH, Fleury IG, Parker EA, et al. Early versus delayed surgery for midshaft clavicle fractures: a systematic review. Iowa Orthop J. 2023; 43(1):151-160.
• Constant CR, Gerber C, Emery RJ, Søjbjerg JO, Gohlke F, Boileau P. A review of the Constant score: modifications and guidelines for its use. J Shoulder Elbow Surg. 2008;17(2):355-361. doi:10.1016/j.jse.2007.06.022
• Delgado DA, Lambert BS, Boutris N, et al. Validation of digital visual analog scale pain scoring with a traditional paper-based Visual Analog Scale in adults. J Am Acad Orthop Surg Glob Res Rev. 2018;2(3):e088. doi:10.5435/JAAOSGlobal-D-17-00088
• Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am. 2007; 89(1):1-10. doi:10.2106/JBJS.F.00020
• Han X, Zhang Y, Zhang X, Tan J. Comprehensive comparison between conservative therapy and surgical management for completely displaced and comminuted mid-shaft clavicle fractures. Int Orthop. 2024;48(7): 1871-1877. doi:10.1007/s00264-024-06198-1
• Shields E, Behrend C, Beiswenger T, et al. Scapular dyskinesis following displaced fractures of the middle clavicle. J Shoulder Elbow Surg. 2015; 24(12):e331-e336. doi:10.1016/j.jse.2015.05.047
• Kim D, Lee D, Jang Y, Yeom J, Banks SA. Effects of short malunion of the clavicle on in vivo scapular kinematics. J Shoulder Elbow Surg. 2017; 26(9):e286-e292. doi:10.1016/j.jse.2017.03.013
• Hung LW, Lu HY, Chang CH, Chen TY, Wang TM, Lu TW. Effects of ınternal fixation for mid-shaft clavicle fractures on shoulder kinematics during humeral elevations. Front Bioeng Biotechnol. 2021;9:710787. doi: 10.3389/fbioe.2021.710787
• Woltz S, Krijnen P, Schipper IB. Plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures: a meta-analysis of randomized controlled trials. J Bone Joint Surg Am. 2017;99(12):1051-1057. doi:10.2106/JBJS.16.01068
• Wijdicks FJ, Van der Meijden OA, Millett PJ, Verleisdonk EJ, Houwert RM. Systematic review of the complications of plate fixation of clavicle fractures. Arch Orthop Trauma Surg. 2012;132(5):617-625. doi:10.1007/s00402-011-1456-5