title: Does delay matter? The restoration of objectively measured shoulder strength and patient-oriented outcome after immediate fixation versus delayed reconstruction of displaced midshaft fractures of the clavicle.
abstract: Outcome after surgical treatment for nonunion and malunion of midshaft displaced clavicle fractures has generally been described as favorable and equal to results of acute repair. This assumption has been based on subjective criteria, however, and no direct comparison is available in the literature. This study used objective measurements of limb function to compare outcome in patients who underwent delayed operative intervention for nonunion and malunion with the outcome of patients who underwent immediate open reduction and internal fixation after displaced clavicle fracture. All patients had sustained completely displaced, closed, isolated midshaft clavicle fractures, of whom 15 had undergone acute open reduction and internal fixation with a compression plate at a mean of 0.6 months after injury (acute group). Another 15 patients had undergone delayed reconstruction with open reduction, bone grafting, and compression plate fixation for nonunion or malunion a mean of 63 months after injury (delayed group). The 2 groups were similar in age, gender, original fracture characteristics, and mechanism of injury. Complete assessment included standard history and physical examination, the Disabilities of the Arm, Shoulder and Hand (DASH) score and Constant Shoulder Score, subjective rating of outcome satisfaction, and objective muscle strength testing using a previously validated and published protocol on the Baltimore Therapeutic Equipment (BTE) work simulator. There were no significant differences between acute fixation and delayed reconstruction groups with regard to strength of shoulder flexion (acute, 94%; delayed, 93%; P = .82), shoulder abduction (acute, 97%; delayed, 97%; P = .92), external rotation (acute, 97%; delayed, 90%; P = .11), or internal rotation (acute, 98%; delayed, 96%; P = .55). Constant scores in the acute group were superior (acute, 95; delayed, 89; P = .02), but differences in DASH scores were not significant (acute, 3.0; delayed, 7.2; P = .15). Shoulder flexion muscle endurance was significantly decreased in the delayed group (acute, 109%; delayed, 80%; P = .05). Differences in muscle endurance in other planes were not significantly different (abduction endurance: acute, 107%; delayed, 81%; P = .24). Both groups rated their satisfaction with the procedure as excellent. Late reconstruction of nonunion and malunion after displaced midshaft fractures of the clavicle is a reliable and reproducible procedure that results in restoration of objective muscle strength similar to that seen with immediate fixation; however, there are subtle decreases in endurance strength and outcome compared with acute fracture repair. This information should not be used to justify primary operative repair in isolation but is useful in decision-making when counseling patients with displaced midshaft fractures of the clavicle.
authors.affiliation: Division of Orthopaedics, St. Michael's Hospital and the University of Toronto, Toronto, Ontario, Canada.
authors.forename: Jeffrey M
authors.initials: JM
authors.lastname: Potter
authors.forename: Caroline
authors.initials: C
authors.lastname: Jones
authors.forename: Lisa M
authors.initials: LM
authors.lastname: Wild
authors.forename: Emil H
authors.initials: EH
authors.lastname: Schemitsch
authors.forename: Michael D
authors.initials: MD
authors.lastname: McKee
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002968:Clavicle / Q000293:injuries* / Q000601:surgery; D015331:Cohort Studies; D005260:Female; D005593:Fracture Fixation, Internal / Q000379:methods*; D017102:Fracture Healing / Q000502:physiology; D006801:Humans; D004204:Joint Dislocations / Q000000981:diagnostic imaging / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D017060:Patient Satisfaction; D010807:Physical Endurance / Q000502:physiology; D011336:Probability; D011379:Prognosis; D011859:Radiography; D016059:Range of Motion, Articular / Q000502:physiology; D020127:Recovery of Function; D012785:Shoulder Joint / Q000503:physiopathology*; D013997:Time Factors