The significance of a concomitant clavicle fracture in flail chest patients: incidence, concomitant injuries, and outcome of 12,348 polytraumata from the TraumaRegister DGU®

Abstract

Purpose Isolated clavicle fractures (CF) rarely show complications, but their influence in the thorax trauma of the seriously injured still remains unclear. Some authors associate CF with a higher degree of chest injuries; therefore, the clavicle is meant to be a gatekeeper of the thorax. Methods A retrospective analysis of the TraumaRegister DGU® (project 2017-10) was carried out involving the years 2009–2016 (ISS ≥ 16, primary admission to a trauma center). Cohort formation: unilateral and bilateral flail chest injuries (FC), respectively, with and without a concomitant CF. Results 73,141 patients (26.5% female) met the inclusion criteria and 12,348 had flail chest injuries (FC; 20.0% CF; 67.7% monolateral FC), 25,425 other rib fractures (17.7% CF), and 35,368 had no rib fractures (6.5% CF). On average, monolateral FC patients were 56.0 ± 17.9 years old and bilateral FC patients were 57.7 ± 19 years old. The ISS in unilateral and bilateral FC were 29.1 ± 11.7 and 42.2 ± 12.9 points, respectively. FC with a CF occurred more frequently with bicycle and motorbike injuries in monolateral FC and pedestrians in bilateral FC injuries and less frequently due to falls. Patients with a CF in addition to a FC had longer hospital and ICU stays, underwent artificially respiration for longer periods, and died less often than patients without a CF. The effects were highly significant in bilateral FC. CF indicates more relevant concomitant injuries of the lung, scapula, and spinal column. Moreover, CF was associated with more injuries of the extremities in monolateral CF. Conclusion Due to the relevance of a concomitant CF fracture in FC, diagnostics should focus on finding CFs or rule them out. Combined costoclavicular injuries are associated with a significantly higher degree of thoracic injuries and longer hospital stays.

In patients with combined clavicle and multiple rib fractures, does fracture fixation of the clavicle improve clinical outcomes? A multicenter prospective cohort study of 232 patients

“…10 All patients underwent operative treatment for both injuries during the same session, which resulted in a mean ± SD HLOS of 18.8 ± 8.1 days. This is considerably higher compared with our study (median HLOS, 9 [5][6][7][8][9][10][11][12][13][14][15][16][17] days), which could be explained by differences in study population regarding the number of flail chests. However, their study would not be able to assess whether clavicula fixation would improve clinical outcome because of the small sample size and the noncomparative study design.…”

“…Therefore, patients with these combined injuries after blunt thorax trauma seem prone to (respiratory) complications and longer hospitalization. 10,11 There is an ongoing debate whether fixation of the clavicle fracture in patients with multiple concomitant rib fractures could be beneficial to provide additional stability to the chest wall and thereby improve clinical outcomes. 4 Despite the vast amount of literature describing rib fractures and clavicle fractures as individual entities, the mutual impact and subsequent management of these combined injuries remain unclear.…”

“…The combination of multiple rib and clavicle fractures could result in decreased stability, compliance, and respiratory support of the chest wall. Therefore, patients with these combined injuries after blunt thorax trauma seem prone to (respiratory) complications and longer hospitalization 10,11 . There is an ongoing debate whether fixation of the clavicle fracture in patients with multiple concomitant rib fractures could be beneficial to provide additional stability to the chest wall and thereby improve clinical outcomes 4 …”

Clinical Outcome after Clavicular Hook Plate Fixation for Displaced Medial-End Clavicle Fractures

“… 3 4 5) Several recent studies have reported that surgical stabilization of concomitant clavicle fractures in flail chest or multiple rib fractures offers good long-term benefits for return to the premorbid state. 6 7) Therefore, a shift towards operative treatment for displaced medial-end clavicle fractures has been suggested in recent research studies. 8 9) …”

“…Various operative techniques including K-wire and tension band, fixation using plates (distal radial plate, small T-plate, standard T-locking plate, and pilon plate crossing the sternoclavicular [SC] joint), resection of the medial clavicle end, and arthrodesis of the SC joint have been described. 5 6 7 8 9 10 11) However, they show complications 8 9 10 11 12) including the limited movement of the shoulder girdle, loosening, migration, nonunion, neurovascular injury, 10 11) and displacement and breakage of plates and screws. 12) …”