From the Guidelines
Absolute surgical indications for elderly patients with clavicular fractures include open fractures, fractures with neurovascular compromise, skin tenting with impending open fracture, floating shoulder injuries, and significantly displaced fractures with soft tissue interposition preventing closed reduction. These indications are based on the potential for poor functional outcomes and increased risk of complications with non-surgical management. According to the American Academy of Orthopaedic Surgeons clinical practice guideline summary on the treatment of clavicle fractures 1, surgical treatment of displaced midshaft clavicle fractures in adult patients is associated with higher union rates and better early patient-reported outcomes than non-surgical treatment. However, the decision for surgical intervention in elderly patients must carefully balance these indications against the patient's overall health status, bone quality, and functional demands.
Some key considerations for surgical indications in elderly patients with clavicular fractures include:
- Open fractures
- Fractures with neurovascular compromise
- Skin tenting with impending open fracture
- Floating shoulder injuries
- Significantly displaced fractures with soft tissue interposition preventing closed reduction
- Pathological fractures
- Fractures with associated scapular neck fractures that create instability of the shoulder girdle
- Greater than 2 cm of shortening or complete displacement, as these conditions typically lead to poor functional outcomes and nonunion when treated conservatively.
When surgery is indicated, options include plate fixation with screws or intramedullary fixation, with the specific approach determined by fracture pattern, bone quality, and surgeon expertise, as noted in the treatment guidelines 1. Postoperative management typically includes early protected range of motion exercises starting 1-2 weeks after surgery, with strengthening exercises beginning at 6-8 weeks, and full activities resumed at 3-4 months based on clinical and radiographic healing.
From the Research
Absolute Surgical Indications for Elderly Clavicular Fracture
The absolute surgical indications for elderly patients with clavicular fractures include:
- Neurovascular compromise due to posterior displacement and impingement of the bone fragments on the brachial plexus, subclavian vessels, and even the common carotid artery 2
- Fracture of the distal third of the clavicle with disruption of the coracoclavicular ligament 2
- Severe angulation or comminution of a fracture in the middle third of the clavicle 2
- The patient's inability to tolerate prolonged immobilization (required by closed treatment) because of Parkinson's disease, a seizure disorder, or other neuromuscular disease 2
- Symptomatic non-union following treatment by closed methods 2
- Acute vascular injury and complete brachial plexus palsy 3
Considerations for Operative Treatment
Operative treatment has to be discussed with patients with displaced clavicle fractures, especially in the young and active patient 4. However, for elderly patients, the decision to operate should be based on the presence of absolute surgical indications.
Indications for Surgical Treatment
Good results can only be obtained considering clearly defined indications and correct surgical techniques 5. The indications for surgical treatment of clavicular fractures include neurovascular compromise, fracture of the distal third of the clavicle with disruption of the coracoclavicular ligament, and severe angulation or comminution of a fracture in the middle third of the clavicle.
Complications of Surgical Treatment
Brachial plexus injury caused by open reduction and internal fixation (ORIF) of a clavicle fracture is very rare, but if it is not treated in time, the function of the brachial plexus will be challenging to recover 6. Therefore, patients with clavicle fractures usually need to undergo a careful physical examination before surgery to determine whether symptoms of brachial plexus injury have occurred.