Risk Factors for Nonunion After Nonoperative Treatment of Displaced Midshaft Fractures of the Clavicle

Murray, Iain R.; Foster, Caroline; Erős, Adrienn; Robinson, C. M.

doi:10.2106/jbjs.k.01275

Cited by 124 publications

(83 citation statements)

References 17 publications

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“…Collation of literature on clavicle fractures suggests that the expected nonunion rate is 8.6%. This percentage was derived from the reported healing rate in 12 separate publications [59][60][61][62][63][64][65][66][67][68][69][70] spanning the period from 2004 to 2013 and including 3168 patients treated with a range of conservative and operative methods. Both samples are large, and the nonunion rate in our database again differs by less than a percentage point from the literature values.…”

Section: Discussionmentioning

confidence: 99%

Epidemiology of Fracture Nonunion in 18 Human Bones

et al. 2016

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IMPORTANCE Failure of bone fracture healing occurs in 5% to 10% of all patients. Nonunion risk is associated with the severity of injury and with the surgical treatment technique, yet progression to nonunion is not fully explained by these risk factors.OBJECTIVE To test a hypothesis that fracture characteristics and patient-related risk factors assessable by the clinician at patient presentation can indicate the probability of fracture nonunion.DESIGN, SETTING, AND PARTICIPANTS An inception cohort study in a large payer database of patients with fracture in the United States was conducted using patient-level health claims for medical and drug expenses compiled for approximately 90.1 million patients in calendar year 2011. The final database collated demographic descriptors, treatment procedures as per Current Procedural Terminology codes; comorbidities as per International Classification of Diseases, Ninth Revision codes; and drug prescriptions as per National Drug Code Directory codes. Logistic regression was used to calculate odds ratios (ORs) for variables associated with nonunion. Data analysis was performed from January 1, 2011, to December 31, 2012, EXPOSURES Continuous enrollment in the database was required for 12 months after fracture to allow sufficient time to capture a nonunion diagnosis. RESULTSThe final analysis of 309 330 fractures in 18 bones included 178 952 women (57.9%); mean (SD) age was 44.48 (13.68) years. The nonunion rate was 4.9%. Elevated nonunion risk was associated with severe fracture (eg, open fracture, multiple fractures), high body mass index, smoking, and alcoholism. Women experienced more fractures, but men were more prone to nonunion. The nonunion rate also varied with fracture location: scaphoid, tibia plus fibula, and femur were most likely to be nonunion. The ORs for nonunion fractures were significantly increased for risk factors, including number of fractures (OR, 2.65; 95% CI, 2.34-2.99), use of nonsteroidal anti-inflammatory drugs plus opioids (OR, 1.84; 95% CI, 1.73-1.95), operative treatment (OR, 1.78; 95% CI, 1.69-1.86), open fracture (OR, 1.66; 95% CI, 1.55-1.77), anticoagulant use (OR, 1.58; 95% CI, 1.51-1.66), osteoarthritis with rheumatoid arthritis (OR, 1.58; 95% CI, 1.38-1.82), anticonvulsant use with benzodiazepines (OR, 1.49; 95% CI, 1.36-1.62), opioid use (OR, 1.43; 95% CI, 1.34-1.52), diabetes (OR, 1.40; 95% CI, 1.21-1.61), high-energy injury (OR, 1.38; 95% CI, 1.27-1.49), anticonvulsant use (OR, 1.37; 95% CI, 1.31-1.43), osteoporosis (OR, 1.24; 95% CI, 1.14-1.34), male gender (OR, 1.21; 95% CI, 1.16-1.25), insulin use (OR, 1.21; 95% CI, 1.10-1.31), smoking (OR, 1.20; 95% CI, 1.14-1.26), benzodiazepine use (OR, 1.20; 95% CI, 1.10-1.31), obesity (OR, 1.19; 95% CI, 1.12-1.25), antibiotic use (OR, 1.17; 95% CI, 1.13-1.21), osteoporosis medication use (OR, 1.17; 95% CI, 1.08-1.26), vitamin D deficiency (OR, 1.14; 95% CI, 1.05-1.22), diuretic use (OR, 1.13; 95% CI, 1.07-1.18), and renal insufficiency (OR, 1.11; 95% CI, 1.04-1.17) (multivariate P < .001 for all).C...

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Section: Discussionmentioning

confidence: 99%

Epidemiology of Fracture Nonunion in 18 Human Bones

et al. 2016

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“…Years of disability, the risk of amputation and the significant socioeconomic burden of these conditions make their treatment often frustrating to the surgeon and the patients. Their prevention is therefore the preferred option and is hinged on an understanding of the risk factors with respect to the patient, the fracture and the sociocultural environment [9,13,16]. There were more males than females in this series, and more non-unions compared to malunions.…”

Section: Discussionmentioning

confidence: 99%

Long Bone Non-Unions and Malunions: Risk Factors and Treatment Outcomes in Calabar, Southern Nigeria

Ikpeme¹,

Mkpanam²,

Abang³

et al. 2013

OJO

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Background: Diaphyseal non-unions and malunions constitute significant morbidities in fracture care. Fracture treatment modalities seek to restore anatomic orientation and functional rehabilitation as soon as possible after a fracture incident. Malunions and non unions present a treatment challenge with the need for prolonged hospitalization, multiple surgical interventions and economic burden. In the developing world, traditional bonesetting practices are popular and these often result in a host of preventable complications. The added socioeconomic costs of treating these complications present a considerable strain on the resources of these already fragile economies and households. Aim: To document the risk factors, treatment options and outcomes for diaphyseal non-unions and malunions in our environment. Patients and Methods: Fifty-two consecutive patients comprising 37 non-unions and 15 malunions who presented in the orthopaedic unit of a tertiary hospital in Southern Nigeria were evaluated. Information sought included biodata, location of pathology, type of incident fracture, local risk factors including traditional bonesetting; treatment options and final outcomes. Information obtained was analyzed using SPSS version 20 (IBM, New York). Results are presented in simple frequency tables. Results: There were 34 males and 18 females (M:F = 1.9:1) with a mean age of 38.76 ± 14.55 years. There were 37 non-unions and 15 malunions. The femur was the commonest site of pathology in 21 (40.4%) cases, and among the non-unions, the atrophic variety was the commonest type (n = 26; 70.3%). The mean fracture-to-surgery interval was 11.35 ± 7.95 months and traditional bonesetting was the commonest risk factor (n = 36; 69.2%). Plate and screw Osteosynthesis with bonegraft augmentation was the commonest treatment modality and the overall union rate was 94%. Conclusion: Traditional bonesetting plays a major role in the health seeking behaviour of many African societies. The complications are varied and add to the overall socioeconomic burden of fracture care in these developing economies. Identification of traditional bonesetting practices as an important risk factor should translate into a focus on these practices in preventive public health decisions in fracture care. Continuing public health education backed by political will and can potentially drive a paradigm shift in health seeking attitudes in the developing world.

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“…Robinson and colleagues 9 performed a prospective cohort analysis of 868 patients with clavicle fractures and identified lack of cortical apposition as being predictive of nonunion. Furthermore, a recent study by Murray and colleagues 27 identified lack of cortical contact between fracture fragments in acute DMCFs as a risk factor for nonunion. Finally, Hill and colleagues 10 identified initial shortening of 20 mm or greater to be significantly correlated with risk of nonunion through their cross-sectional study of 242 patients with clavicle fractures.…”

Section: Discussionmentioning

confidence: 99%

“…Of note, recent studies suggest that lack of cortical apposition may be an adequate surrogate measure for shortening when deciding which patients with acute DMCF would benefit from ORIF. 27,32 Use of surrogate measures for shortening may enable appropriate patient selection in the absence of a reliable radiographic measuring tool.…”

Section: Discussionmentioning

confidence: 99%

Plain film measurement error in acute displaced midshaft clavicle fractures

Archer

Hunt

Squire³

et al. 2016

Can J Surg

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Background: Clavicle fractures are common and optimal treatment remains controversial. Recent literature suggests operative fixation of acute displaced mid-shaft clavicle fractures (DMCFs) shortened more than 2 cm improves outcomes. We aimed to identify correlation between plain film and computed tomography (CT) measurement of displacement and the inter-and intraobserver reliability of repeated radiographic measurements. Methods:We obtained radiographs and CT scans of patients with acute DMCFs. Three orthopedic staff and 3 residents measured radiographic displacement at time zero and 2 weeks later. The CT measurements identified absolute shortening in 3 dimensions (by subtracting the length of the fractured from the intact clavicle). We then compared shortening measured on radiographs and shortening measured in 3 dimensions on CT. Interobserver and intraobserver reliability were calculated. Results:We reviewed the fractures of 22 patients. Bland-Altman repeatability coefficient calculations indicated that radiograph and CT measurements of shortening could not be correlated owing to an unacceptable amount of measurement error (6 cm). Interobserver reliability for plain radiograph measurements was excellent (Cronbach α = 0.90). Likewise, intraobserver reliabilities for plain radiograph measurements as calculated with paired t tests indicated excellent correlation (p > 0.05 in all but 1 observer [p = 0.04]). Conclusion:To establish shortening as an indication for DMCF fixation, reliable measurement tools are required. The low correlation between plain film and CT measurements we observed suggests further research is necessary to establish what imaging modality reliably predicts shortening. Our results indicate weak correlation between radiograph and CT measurement of acute DMCF shortening.

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Risk Factors for Nonunion After Nonoperative Treatment of Displaced Midshaft Fractures of the Clavicle

Cited by 124 publications

References 17 publications

Epidemiology of Fracture Nonunion in 18 Human Bones

Epidemiology of Fracture Nonunion in 18 Human Bones

Long Bone Non-Unions and Malunions: Risk Factors and Treatment Outcomes in Calabar, Southern Nigeria

Plain film measurement error in acute displaced midshaft clavicle fractures

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