Thanks for the thoughtful response.
I have to say though, that I find it somewhat amusing that your first
words on this subject were:
"Gotta love the anecdotal data."
I present you with a peer reviewed paper that undertakes a study of
over 860 patients and your response was that it conflicts with your
experience, which although it is long term, is admittedly not as
comprehensive. Isn't your response one long anecdote?
This isn't the only paper that indicates that the traditional, blanket
"just leave it alone it'll heal just fine" approach isn't necessarily
best. In the "letters to the editor" for the paper (which are free to
read) you'll see that there are at least 3 other papers which indicate
that the probability of non-unions is higher than typically reported.
On the point about needing to look at the rate of complications of the
surgical procedure on clavicles that are internally fixed; One needs
to compare the surgical complication rate NOT to the overall risk of
non-union (i.e. ~6% at 24 weeks) but to the risk of non-union for the
PARTICULAR CONDITIONS of the case. Like I said above, in my case, the
risk of non-union at 24 weeks was STILL almost 20% (at 12 weeks, 2X the
time normally given for healing, the risk was a whopping 60%!). If I
thought my surgeon had a complication rate greater than 20% for this
procedure, I definitely would've waited...or found a more capable
surgeon! That's the true value of the paper I linked to you...it
allows EACH CASE to be evaluated separately.
Mike, I truly appreciate your input to this thread, but I have to say
that I found it very frustrating listening to the "traditional view"
about "just let it heal" while I was suffering for 4 weeks with a
severly overlapped, comminuted break that had one end of the bone
actually tenting the skin. It was obvious to me early on that there
was no way that this injury was going to be satisfactory from a
structural or cosmetic standpoint if allowed to remain "as is". The
"traditional view" on clavicle fractures had failed me.
I'm glad you agree that every case is different and I truly understand
that a blanket recommendation for surgery isn't prudent. However, I
think you also have to agree that perhaps the blanket recommendation of
"do nothing and it'll be just fine" has it's limitations as well.
According to the most recent research in this field, it's also much
more limited than initially thought.
Tom
Mike Murray said:My impression of that particular paper is that it is in conflict with my
personal experience. I have been in practice for 25 years. I have only
seen 4 clavicle non-unions in that period, 2 of which might have healed
non-operatively if given more time. I have also seen another patient with a
radiographic non-union of a midshaft (diaphyseal) fracture who was entirely
without symptoms and satisfied with his result. I do not formally see
patients in follow up as I am an emergency physicians. This, of course,
makes it so that I would be less aware of patients that develop non-unions.
On the other hand, I have been racing bicycles for 35 years and because of
this I am more aware of the follow up for clavicle fractures and AC
separations than for any other injury or illness that I treat as I do see
these people again, at least if they stay involved in bike racing. Only one
of the 4 non-unions I have seen was a bike racer. In that group, even
including Masters Fatties, there is a considerably less then the reported
6.2% rate on non-union. In addition my experience with regard to comminuted
fractures is generally the opposite of what is reported. It seems to me
that, although it is somewhat counter intuitive, comminuted fractures tend
to heal faster. I do agree that fractures with significant overlap or
shortening do tend to have more long term problems with development of
impingement syndromes and chronic pain or limitation of movement. I
question if these problems might be avoided by surgical fixation to keep the
clavicle out to length. All this is, of course, anecdotal and not formally
studied and subject to the problems of that type of information. I am too
cheap to purchase the full text of the article but I would have to call into
question any prediction of non-union rate of 95% at 6 weeks for any type of
fracture in any age group. In contrast to what Tom stated, many if not most
clavicle fractures are comminuted and they do happen frequently in "older"
patients, at least in the Masters Fatties that I see regularly. I can
remember at least one guy in his 60s with a comminuted fracture back racing
4 weeks later.
A second point is that even if we are convinced that the non-union rate is
as high as this paper indicates it says noting about what the rate of
non-union or other complications is for fractures treated surgically.
Surgical fixation is not a guarantee of producing a good union and is not
without complication. It is entirely possible that the rate of non-union
for fractures treated with acute surgery is even higher and/or that there
are complications, such as bone infections, neurologic injuries, etc. which
offset any potential benefit. It would take another study to investigate
this question.
All this said, treating a clavicle fracture surgically, even acutely, is not
wrong although it is not needed in most cases. Some may benefit from acute
surgery but many will not. There does appear to be a trend in orthopedics
towards treating more surgically but that is on the background of never
treating them surgically just a few years ago. Each individual case needs
to be evaluated and then a guess needs to be made. Like just about
everything else in medicine any opinion offered will be just that, a guess.
Studies like the one cited help improve the accuracy of the guess but what
will happen in the future for that individual patient is always to a
significant degree unknown. In a medical economic setting like the mostly
fee-for-service system in the US often these decisions are influenced by
things that really should not matter, like the fact that the surgeon gets
paid a lot more for operating then he does for waiting. It appears that for
some of the people in this NG the decision to treat surgically turned out
well. That, of course, should not turn into a blanket recommendation for
surgery.
--
Mike Murray
"Tom_A" <[email hidden]> wrote in message
news:[email hidden]...
Quoted message said:Dr. Murray,
What is your opinion of the following:
http://www.ejbjs.org/cgi/content/abstract/86/7/1359
Be sure to read the "letters to the editor" as well.
As you state, "most" clavicle fractures heal quickly. However, it
seems that statistic is misleading since "most" clavicle fractures are
not displaced, don't have multiple pieces, and mostly happen to younger
people.
For a Masters Fattie like Mark (and myself) who suffered from displaced
and comminuted (multiple piece) fractures, the outlook isn't as rosy.
In fact, using the "predictive index" calculation shown in that paper,
for my clavicle fracture, the probabilities of non-union where 95% at 6
weeks, 58% at 12 weeks, and still 19% at 24 weeks. Armed with this
knowledge I was able to convince my orthopedic surgeon to operate after
initially having to wait 4 weeks after the injury. It's a good thing I
did too...the surgeon told me after the operation that one area of the
break showed absolutely no sign of fusing after that time period and
would likely resulted in a non-union. In other words, he would have
had to operate anyway. With the surgery I was able to "get on with my
life" rather than have a cloud hanging over me about whether or not it
would heal and having my activities and life hampered for up to 6
months.
Just thought I'd add my anecdote to the mix with a touch of scientific
research as well ;-)
Tom
Mike Murray said:Gotta love the anecdotal data.
Most clavicle fractures heal quickly, in 6 weeks or so, without surgery.
Literature supports use of slings as opposed to figure-8 braces. There
is
no difference in healing position or healing time but, in general, the
sling
group has less pain. This is, of course, not true in every individual so
I
give people both a sling and a figure-8 and tell them to wear whatever
feels
best at the time. Surgery is recommended generally not related to how
many
pieces there were in the fracture or even how much displacement there is
but
more dependant on where the bone fractured. Very distal fractures are
less
likely to heal and surgery is often suggested earlier if they remain
symptomatic. Non-union, i.e. non-healing, is another reason for surgery.
This should be based on symptoms and not X-ray findings. Personally I
would
wait a long time, more than 6 months, before I considered my clavicle
fracture to be a non-union.
--
Mike Murray MD
"Donald Munro" <[email hidden]> wrote in message
news:[email hidden]...
> Bill Lloyd wrote:
>> Surgery for broken clavicles is pretty rare -- typically less than 5%
>> of cases (in the US at least -- I believe European "norms" for
>> treatment are more aggressive).
>
> Personally I would normally recommend surgery, as mine healed in under
> 5
> weeks with surgery while a friend who had a less severe break and opted
> for no surgery ended up having to have surgery anyway after it didn't
> heal
> properly and had to be re-broken.
>
