Mid- Clavicular Fractures- A Change in Treatment Strategies?

Dear Editor,

The author of the original article “Primary Plating of Displaced Mid-shaft Clavicular Fractures” published in July 2008, must be congratulated and commended for drawing the attention of the Armed Forces medical community to the rapid changes occurring in the well established traditional treatment of one of the commonest fractures of upper limb.

However, I have my concerns about the author's technique of superior placement of plates in clavicle fractures. The main blood supply of middle third of clavicle is periosteal which is predominantly from superior and anterior borders [1]. Superior plating is likely to disturb this already tenuous blood supply increasing risk of non-union. In addition, the serving soldiers have to wear shoulder straps and the prominent hardware irritates the overlying skin and soft tissues leading to frequent requirement of another surgery for implant removal. Antero-inferior placement of the plate will offer an alternative in form of stable bony fixation, relatively much lower incidence of implant prominence problems and sharp instrumentation directed away from potentially risky infraclavicular structures [2].

The author has used reconstruction plates for fixation when they do not offer adequate biomechanical stability and strength. Contoured LC-DCPs would offer a biomechanically better implant choice [3]. The use of postoperative drains is also extremely controversial. It has been proven beyond doubt that use of postoperative drain increases the risk of infection. There is no firm basis for the use of drain available in literature [4].

I do not agree with the author's contention that the literature relating to pin fixation of clavicle fractures is rare. There is enough emerging literature that supports intra-medullary fixation as an alternative to plate or screw fixation or nonsurgical treatment, as it produces excellent cosmetic and functional results regardless whether patients suffered from isolated clavicular fractures or polytrauma [5, 6, 7]. It may be noted that these studies have much larger patient groups and longer follow-ups.

I would not be in a hurry to reach a conclusion based on this study in view of the small study group i.e. only 20 patients. The inclusion and exclusion criteria for patients in the study are not clearly stated. There was no control group of the patients with which the results can be compared. Contralateral limb doesn't make a good comparison in view of the differences in muscle strength of dominant and non-dominant limbs. Most of the patients who were operated upon were polytrauma cases and not isolated clavicle fractures. Polytrauma is already a well-established indication for operative intervention in clavicle fracture cases.

An important specific question that this study raises is: What should orthopaedic surgeons now tell their patients about the outcome of displaced and comminuted diaphyseal fractures of clavicle? Perhaps the answer is that we really don't know yet! The last word is yet to be said on this issue. Further randomized, prospective trials are needed to provide better data on which to base treatment decisions.