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Scientific Article   |    
Midshaft Malunions of the Clavicle
Michael D. McKee, MD, FRCS(C); Lisa M. Wild, BScN; Emil H. Schemitsch, MD, FRCS(C)
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Investigation performed at the Upper Extremity Reconstructive Service, Division of Orthopaedics, Department of Surgery, St. Michael's Hospital and the University of Toronto, Toronto, Ontario, Canada

Michael D. McKee, MD, FRCS(C)
Lisa M. Wild, BScN
Emil H. Schemitsch, MD, FRCS(C)
Upper Extremity Reconstructive Service, Division of Orthopaedics, Department of Surgery, St. Michael's Hospital and the University of Toronto, 55 Queen Street East, Suite 800, Toronto, ON M5C 1R6, Canada. E-mail address for M.D. McKee: mckee@the-wire.com

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

J Bone Joint Surg Am, 2003 May 01;85(5):790-797
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Abstract

Background: The purpose of this study was to analyze the functional results of corrective osteotomy of a malunited clavicular fracture in patients with chronic pain, weakness, neurologic symptoms, and dissatisfaction with the appearance of the shoulder.

Methods: We identified fifteen patients (nine men and six women with a mean age of thirty-seven years) who had a malunion following nonoperative treatment of a displaced midshaft fracture of the clavicle. The mean time from the injury to presentation was three years (range, one to fifteen years). Outcome scores revealed major residual deficits. The mean amount of clavicular shortening was 2.9 cm (range, 1.6 to 4.0 cm). All patients underwent corrective osteotomy of the malunion through the original fracture line and internal fixation.

Results: At the time of follow-up, at a mean of twenty months (range, twelve to forty-two months) postoperatively, the osteotomy site had united in fourteen of the fifteen patients. All fourteen patients expressed satisfaction with the result. The mean DASH (Disabilities of the Arm, Shoulder and Hand) score for all fifteen patients improved from 32 points preoperatively to 12 points at the time of follow-up (p = 0.001). The mean shortening of the clavicle improved from 2.9 to 0.4 cm (p = 0.01). There was one nonunion, and two patients had elective removal of the plate.

Conclusions: Malunion following clavicular fracture may be associated with orthopaedic, neurologic, and cosmetic complications. In selected cases, corrective osteotomy results in a high degree of patient satisfaction and improves patient-based upper-extremity scores.

Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Michael D McKee
    Posted on October 29, 2003
    Dr. McKee responds to Dr. Mittal
    St. Michael's Hospital

    Thank you for your letter.

    The DASH is a patient based questionnaire, whereas the Constant is surgeon based. Also the DASH measures global upper extremity function while the Constant Score measures specific shoulder outcome. Thus, there are some differences between the two scores.

    We agree that a single universal score would be ideal.

    Rajeev Mittal
    Posted on September 11, 2003
    DASH SCORE VS CONSTANT SCORING SYSTEM
    PGIMS, Rohtak

    Sir, We would like to raise the issue about which the criteria are used for evaluating upper limb disabilities . The British use the Constant scoring system while Americans use the DASH Scoring system.

    It would be better for the orthopaedic community as a whole if a single uniform system were used so that readers could better compare the results of different treatments.

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