Decision-making in the treatment of diaphyseal clavicle fractures: is there agreement among surgeons? Results of a survey on surgeons’ treatment preferences

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Clavicle fractures are common, representing 5% of all adult fractures. Up to 80% occur in the middle third of the clavicle (diaphyseal). Traditionally, nonoperative treatment has been recommended, with older studies showing very low nonunion rates of less than 1%. However, more recent studies have shown nonunion rates for nonoperative treatment up to 15% and unsatisfactory results in 23% to 31%. The differences in the outcomes could be due to changes in follow-up, improvements in diagnostic techniques, modifications to outcome criteria, and increases in fracture severity. Treatment with a simple sling or a figure-of-eight bandage is the preferred treatment of undisplaced diaphyseal clavicle fractures. A systematic Cochrane Review of 2009 found no statistically significant evidence for a clear advantage of either option in the current literature, even though specific advantages and disadvantages are named for each method.

Recently, operative treatment has been recommended in certain instances, such as higher degrees of displacement and shortening >20 mm. With surgical treatment, mean nonunion rates of 2% to 3% were found for plate fixation and 0% to 10% for intramedullary fixation methods. Unsatisfactory results still range from 5% to 36% of cases. Another Cochrane Review found no difference in outcomes with either intramedullary fixation or plate fixation. Nevertheless, certain advantages and disadvantages are associated with both methods. These more recent studies may have influenced the decision-making process of surgeons, particularly for displaced fractures in active patients. The purpose of this study, therefore, was to assess surgeons’ decision-making in the treatment of diaphyseal clavicle fractures. At the time of the study design, the most recent recommendations regarding indications for operative treatment of diaphyseal clavicle fractures in very specific cases have been published by Altamimi and McKee following an evidence-based approach.

The objectives of this study were to assess agreement of orthopaedic surgeons regarding their current treatment preferences of acute diaphyseal clavicle fractures and also to look at concordance with current treatment recommendations. This study included a retest review to examine intraobserver agreement. We hypothesized that there would be slight interobserver and intraobserver agreement among surgeons in the decision-making for treatment of diaphyseal clavicle fractures.

Full Article: Decision-making in the treatment of diaphyseal clavicle fractures: is there agreement among surgeons? Results of a survey on surgeons’ treatment preferences

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