EXPERIMENTAL AND THERAPEUTIC MEDICINE 19: 451-458, 2020 Comparison of four different internal fixation methods in the treatment of distal clavicle fractures LIANG LI*, HONGXIAO WU*, PEICHAO JIANG, XIAOCHUAN HAN, SHIYUAN CHEN and XUEZHONG YU Department of Orthopaedics, Dongying People's Hospital, Dongying, Shandong 257091, P.R. China Received March 15, 2019; Accepted August 8, 2019 DOI: 10.3892/etm.2019.8233 Abstract. This study compared the clinical efficacy of four of shoulder pain, an increase in the range of motion of the internal fixation methods in the treatment of distal clavicle shoulder, and a reduction in complications, and thus, are pref- fractures, in an effort to guide appropriate selection and erable for the early functional recovery of limbs. application in the clinic. Eighty‑four patients with distal clav- icle‑comminuted fractures were treated with a distal clavicle Introduction anatomic plate (group A), clavicular hook plate (group B), double‑plate vertical fixation (group C), or T‑shaped steel Due to its subcutaneous location, clavicle is one of the bones plate internal fixation (group D). The Constant‑Murley scoring that are most frequently fractured in the upper body due to car system was used to evaluate the shoulder joint function. The accidents and sports trauma. The incidence of distal clavicle fracture healing time, VAS, and postoperative complications fractures accounts for 12‑21% of all clavicular fractures (1). were compared and analyzed among the four groups. According Distal clavicle fractures are typically attributed to a direct to the Constant‑Murley evaluation standard, the excellent and blow to the point of the shoulder or a fall on an outstretched good rates of the four groups were 94.4, 73.1, 95 and 80% hand. In Craig class II type II and class II type V fractures of in groups A‑D, respectively. The excellent and good rates of the distal one-third which are unstable fractures, the force of Constant‑Murley evaluation standard in groups A and C were the sternocleidomastoid muscle moves the proximal fragment significantly better than those in groups B and D (P<0.05). upward and the weight of the arm moves the distal fragment VAS in the distal clavicle anatomic plate group (group A), downward; these forces cause displacement and difficulty in double‑plate vertical fixation group (group C), and T‑shaped maintaining reduction with conservative treatment. Although steel plate internal fixation group (group D) were significantly non‑surgical strategies can be effective for the treatment of better than the clavicular hook plate group (group B) (P<0.05). Craig class II type II and class II type V fractures of the distal The incidence of postoperative complications in the clavicular one-third, they lead to higher rates of non-union. Non-union hook plate group (group B) was 15.4% and in the T‑shaped is painful and symptomatic, which has made many to suggest steel plate internal fixation group (group D) was 15%, which a series of early surgical treatments of Craig class II type II were significantly higher than those of the distal clavicle and class II type V fractures of the distal one-third of the anatomic plate group (group A) and double‑plate vertical clavicle (2). Early surgical treatments have been developed internal fixation group (group C) (P<0.05). The treatment of in order to reduce the complication rate of bone resorption, distal clavicle fractures using either one of the four internal prominent deformity, and improve the functional outcome. fixation techniques can obtain better clinical results. The The unstable fractures seem to represent a challenge because distal clavicle anatomic plate and double‑plate vertical internal of the loss of the attachment of the coracoclavicular ligaments fixation techniques are associated with a decreased incidence to the clavicle. In recent years, a variety of methods of surgical fixa- tion to treat these unstable fractures have been reported, including the distal clavicle anatomic plate, clavicular hook plate, double‑plate vertical fixation, and T‑shaped steel plate Correspondence to: Dr Xiaochuan Han or Dr Shiyuan Chen, internal fixation, which provide rigid fixation and good Department of Orthopaedics, Dongying People's Hospital, 317 Nanyi bony union rates. With the extensive use of the surgical fixa- Road, Dongying, Shandong 257091, P.R. China tion, the fracture healing rate and functional recovery have E-mail: [email protected] E-mail: [email protected] improved; however, there is no current consensus regarding which method is the most suitable. None of the internal fixa- *Contributed equally tion techniques described has been characterized as the ‘gold standard’. Choosing among these four internal fixators is Key words: clavicle, fracture fixation, bone plates, dual plate still controversial. Each of these treatment modalities has its advantages and disadvantages. All these four surgical methods could provide good functional results for patients according to 452 LI et al: DIFFERENT INTERNAL FIXATION METHODS IN THE TREATMENT OF DISTAL CLAVICLE FRACTURE our clinical experience. However, there is no previous report of appropriate length was selected and pre‑bent. The clavicle on their comparison in the literature reviews. hook was inserted into the lower rear part of the acromion, From January 2015 to May 2017, a total of 84 patients with and the plate was placed close to the clavicle. Holes were then distal clavicle Craig class II type II and class II type V fractures drilled along the proximal and distal ends of the clavicle. The were treated with a distal clavicle anatomic plate, clavicular distal clavicle comminuted fracture was fixed with screws hook plate, double‑plate vertical fixation, or T‑shaped steel after reduction and absorbable line was used to bundle up plate internal fixation. The aim of this study was to retrospec- when fixation was not possible (Fig. 2). tively evaluate the clinical results and compare the efficacy of Double‑plate vertical internal fixation group (group C): these four surgical methods for the treatment of acute unstable The fracture end was exposed in layers by a transverse inci- distal clavicle fractures. A retrospective analysis of the patient sion above the clavicle. After reduction of the fracture, two data was carried out. microplate systems (2.0 mm or 2.5 mm T or L type) were implanted in the superior and anterior clavicle according Patients and methods to the length from the fracture line to the articular surface. Screws were selected to fix the distal and proximal ends of General information. Complete data of 84 patients with Craig the fracture. For comminuted fractures of the distal clavicle, it class II type II and class II type V fractures of the distal was not necessary to fully expose the acromioclavicular joint, one‑third of the clavicle, treated with four types of internal which could be strapped with absorbable non‑invasive sutures fixation methods, from January 2015 to May 2017, were or temporarily fixed with Kirschner needles. The plate could analyzed retrospectively. Of the 84 patients, 54 were males be bent and shaped according to the condition of the fracture and 30 were females, 52.6±28.4 years of age. The causes of to enhance attachment to the clavicle profile, and the distal end injury were as follows: Traffic injury, 47 cases; and fall injury, of the fracture was fixed with at least 3 screws (Fig. 3). 37 cases. The fracture classification according to Craig was as T‑shaped steel plate internal fixation group (group D): A follows: Class II type II, 70 cases; and class II type V, 14 cases. direct incision from the distal clavicle to the acromion was The appropriate internal fixation method was selected based made, ~5-6 cm in length, layer-by-layer. The fracture end of on the length of the distal clavicle fracture fragment on X‑ray the clavicle and the acromioclavicular joint were exposed, pre‑operatively. Four patients with comminuted fractures and the acromioclavicular ligament was protected, one Kirschner distal fractures <0.5 cm in length underwent double‑plate needle was inserted into the acromioclavicular joint, and screw vertical fixation. The remaining cases were sequentially penetration was avoided into the acromioclavicular joint. The divided into four groups based on the internal fixation method size of the distal fracture bone was inspected and determined used, as follows: Distal clavicle anatomic plate fixation group whether or not the fracture was comminuted. The distal bone (group A), 18 cases; clavicular hook plate internal fixation mass was confirmed to be fixed with at least 3 screws to reset group (group B), 26 cases; double‑plate vertical fixation the fracture end. According to the fracture line, the straight group (group C), 20 cases; and T-shaped steel plate internal T or oblique T‑shaped steel plate was selected intraoperatively, fixation group (group D), 20 cases. There were no signifi- and the plate was placed above the clavicle. The suitable length cant differences in sex, age, Craig classification of fracture, screw was twisted after drilling the hole. At least 3 screws were cause of injury, and time from injury to operation among the screwed in the distal end of the clavicle and 3‑4 cortical screws four groups (P>0.05, Table Ⅰ). were screwed into the proximal end of the clavicle (Fig. 4). The study was approved by the Ethics Committee of Dongying People's Hospital (Dongying, China). Patients who Postoperative management. Patients in each group were treated participated in this research had complete clinical data. Signed with wrist bands to acockbill shoulder joints. Functional activi- informed consents were obtained from the patients or their ties, such as forearm rotation and elbow flexion and extension, guardians. were performed 6 h postoperatively. Functional exercises, such as anteflexion, back extension, and shrugging of the upper Operative method.