Pneumothorax After Clavicle Fixation: Do We Need Intraoperative Chest X-Ray? M. Kareem Shaath, MD; Joseph A. Ippolito, MD; Michael S. Sirkin, MD; Mark C. Reilly, MD; Mark R. Adams, MD Rutgers University – New Jersey Medical School Department of Orthopaedic Surgery Introduction • Approximately 5% of all fractures • Greater than 50% of shoulder girdle injuries1,2 • Pneumothorax is a dreaded complication – Rare, incidence unknown – Less than 10 cases in English literature1-8 – Increased risk with superior plating Purpose • Identify risk factors for pre-operative or post-operative pneumothorax in patients undergoing ORIF of the clavicle • Assess the value, of an intraoperative chest x-ray, (CXR) Methods • IRB approval obtained • 162 consecutive patients reviewed from 2006-2016 • 11 Patients with pre-operative pneumothorax excluded • Patients divided into 2 groups: – Intraoperative CXR (IO) – Postoperative CXR (PO) • Data Collected: – Age – BMI – Time to Fixation – Mechanism of Injury – OTA Fracture Classification – Method of Fixation – Presence/Abscenece of Postoperative Pneumothorax Results Demographics IO PO p Gender Female 16 Female 21 0.73 Male 52 Male 61 Age 35.6+1.8 34.8+1.5 0.72 BMI 26.0+0.6 26.2+0.6 0.84 Time to Fixation 8.1+3.0 9.5+1.8 0.69 Mechanism of Injury Mechanism IO PO p Assault 3 3 0.263 Cyclist 3 2 Fall 25 31 MCC 6 17 MVC 13 17 Ped. Struck 10 6 Sports 4 4 Unknown 4 2 Total 68 82 Fracture Location (OTA) 15 IO PO p Medial (A) 1 0 Diaphyseal (B) 61 73 0.547 Distal (C) 6 8 Fracture Configuration (OTA) 15-B IO PO p value Noncomminuted (1) 21 29 Wedge (2) 31 29 0.547 Segmental (3) 9 15 Method of Fixation Method of Fixation IO PO p Anterior 24 35 Superior 17 32 Ant/Superior 23 6 Inferior 3 6 0.532 IM Nail 0 1 Distal Clavicle Plate 1 2 Total 68 82 Pneumothorax? • No patients in our population experienced a intraoperative pneumothorax • 12 patients with existing pneumothorax, did not have a worsening of condition • Rib fracture at presentation with concomitant clavicle fracture increased risk for pneumothorax (p<.00001) – OR 61.7 Intraoperative CXR by Subspecialty Subspecialty IO PO p Trauma 57 51 Hand 2 16 .0007 Sports 9 12 Pediatrics 0 2 Oncology 0 1 Total 68 82 Operative Time • Mean time from incision closure to leaving the operating room was prolonged by 18.9 + 1.9 minutes in the IO group (p<.0001) • Prolonged time under anesthesia – Anesthesia costs $15-20/minute9 • Additional $285-380 – OR charges average of $62/minute ($22-133/min)9 • $1,178 ($418-2,527) • Delays room turnover • Increased healthcare costs Conclusion • None of the patients developed a post-operative pneumothorax • Orthopaedic traumatologists are more likely to obtain intraoperative CXR • If a patient has concomitant rib fractures, increased suspicion for pneumothorax at presentation • Intraoperative CXR should only be obtained only if there is a clinical suspicion for pneumothorax intraoperatively minimizing potential risks of prolonged time under anesthesia and increased healthcare costs. References 1. Yates DW. Complications of fractures of the clavicle. Injury. 1976 Feb;7(3):189-93. 2. Khan LA, Bradnock TJ, Scott C, Robinson CM. Fractures of the clavicle. J Bone Joint Surg Am. 2009 Feb;91(2):447-60. 3. Meeks RJ, Riebel GD. Isolated clavicle fracture with associated pneumothorax: a case report. Am J Emerg Med. 1991 Nov;9(6):555-6. 4. Dath R, Nashi M, Sharma Y, Muddu BN. Pneumothorax complicating isolated clavicle fracture. Emerg Med J. 2004 May;21(3):395-6. 5. Steenvoorde P, van Lieshout AP, Oskam J. Conservative treatment of a closed fracture of the clavicle complicated by pneumothorax: a case report. Acta Orthop Belg. 2005 Aug;71(4):481-3. 6. Gandham S, Nagar A. Delayed pneumothorax following an isolated clavicle injury. BMJ Case Rep. 2013;2013. 7. van Laarhoven JJ, Ferree S, Houwert RM, Hietbrink F, Verleisdonk EM, Leenen LP. Demographics of the injury pattern in severely injured patients with an associated clavicle fracture: a retrospective observational cohort study. World J Emerg Surg. 2013;8(1):36. 8. Skedros JG, Knight AN, Mears CS, Langston TD. Temporary sternoclavicular plating for an unusual double clavicle fracture (medial nonunion, lateral acute) complicated by an intraoperative pneumothorax. Case Rep Orthop. 2014;2014:206125. 9. Macario, A. (2010). What does one minute of operating room time cost? Journal of Clinical Anesthesia, 22(4), 233-236. Thank You.