Clavicle fracture management: A comparison of a tertiary hospital and rural telehealth sites

Abstract

The clavicle is one of the most commonly fractured bones in the adult population. Management has traditionally been conservative, however more recent research has yielded higher non-union rates associated with non-operative management. This study aims to analyse the proportion of operative and non-operative treatment methods for clavicle fracture in a tertiary hospital facility and rural health sites accessed via telehealth, comparing patient outcome between these two methods of fracture management. Following ethical approval, a retrospective review was conducted of patients presenting with clavicle fractures to the Princess Alexandra Hospital Fracture Clinics and to Orthopaedic Fracture Clinics run via teleconference with rural health sites. Only 2% of patients received operative fracture management in the telehealth group, versus 33% in the tertiary hospital sample. Patient outcome was measured in the larger tertiary hospital sample, with clinical notes reflecting good patient outcome in 70% of operatively managed patients and 85% of patients with conservatively managed clavicle fractures. For the patients in the telehealth sample that returned for follow-up appointments, 93% reported a good outcome with one of these individuals undergoing operative treatment and the rest managed conservatively.

Keywords

Remote consultation teleconsulting telehealth telemedicine teleradiology

Introduction

Clavicle fractures account for approximately 44% of all shoulder girdle injuries and approximately 2.6–5% of all fractures that present to a hospital emergency department.¹ Fractures of the clavicle are thought to be common due to the relatively thin structure and superficial location of the bone, with very little protection from muscle or fat.² Clavicle fractures are described by the location of the fracture, with the clavicle divided into thirds – medial (proximal), lateral (distal) and middle (midshaft). Literature has shown that 69–82% of all clavicle fractures occur in the midshaft,¹ with this susceptibility due to the slightly curved nature of the middle third and lack of articular support through muscles and tendons.³ The most common mechanism of injury for acute clavicle fractures is direct trauma to the site or indirect trauma – for example, force transferred through the arm when falling onto an outstretched hand.⁴

There are two primary categories for treatment of clavicle fractures – operative and non-operative. Non-operative, or conservative, treatment involves immobilisation using a sling or brace, whereas operative management can involve an open reduction internal fixation (ORIF), intermedullary fixation or external fixation.⁵ Older research conducted by Neer and Rowe in the 1960s demonstrated a non-union rate of 0.13% and 0.8% respectively in midshaft clavicle fractures treated conservatively.^3,6 More recent research however, has given rise to much higher non-union rates of up 15–20% with pain and associated loss of strength with reduced function.⁷

The Princess Alexandra Hospital (PAH) is a tertiary level hospital in Brisbane, Queensland, and has most medical specialities on-site, with the exception of paediatrics, obstetrics and gynaecology. Numerous orthopaedic out-patient clinics operate Monday to Friday – with 21,439 patients seen in the financial year between 1 July 2015–31 June 2016. Orthopaedic telehealth services have been provided by the PAH for nine years and via a dedicated telehealth centre within the hospital for the last five years. Orthopaedic telehealth clinics are provided two mornings each week to the North West Hospital and Health Service (NWHHS) and over 2500 orthopaedic consultations have taken place with patients from various rural sites including Mt Isa, Boulia, Bedourie, Lake Nash Northern Territory (NT), Julia Creek, Normanton, Mornington and Doomadgee.

The aim of this study was to analyse the proportion of operative and non-operative treatment methods for clavicle fracture in the Telehealth Orthopaedic Fracture Clinic and PAH Orthopaedic Fracture Clinic and compare patient outcome between these two methods of clavicle fracture management.

Methods

Ethical approval for the project was submitted to the Queensland Health Metro South Human Research Ethic Committee (HREC). The study was deemed a quality improvement activity and was therefore exempt from a full ethical review.

A retrospective review of patients with clavicle fractures presenting to the Telehealth and PAH Orthopaedic Clinics was conducted to establish fracture management and outcome. Radiographs and clinic notes were reviewed for each patient by the two primary investigators, a senior orthopaedic surgeon and a radiographer, and the proportion of operative and conservative treatments between the groups compared, along with the outcome of these two management methods.

A chi-square test was conducted to assess for a statistically significant difference in the gender breakdown and location of fracture between the hospital and telehealth sites. A Mann–Whitney U test was conducted to compare the age distribution between the two groups. A chi-square test was utilised to analyse for any difference in the drop-out rates between the two groups. Chi-square statistical analysis was also used to assess for statistical difference in fracture management and patient outcome between the hospital and telehealth groups. Fisher’s exact test was performed to assess for complications once the unknown outcomes due to failure to attend follow-up appointments were removed from the sample.

Given the retrospective nature of the data collection and rate of patients who fail to arrive for appointments at rural telehealth sites, treatment outcome was only able to be collected in totality from the tertiary hospital sample. For the patients that failed to meet this criterion, patient outcome was considered to be unknown. To be included in this sample, patients needed to be at least 12 weeks post-fracture (if conservative management) or surgery (if operative management), and to have attended at least one outpatient fracture clinic appointment at this time. If there were any complications at this time, in order to be included in the study, further follow-up appointments at four months plus, had to have occurred.

Inclusion criterion for the study was patients presenting with isolated clavicle fractures. Patients with other significant injuries or injuries to the shoulder girdle that might complicate the treatment or outcome were excluded from the study.

Results

A sample of 100 patients presenting to the PAH Orthopaedic Fracture Clinic and a sample of 50 patients presenting to the Orthopaedic Telehealth Fracture Clinic were included in the study (Table 1).

Table 1.

Patient demographics and fracture specifics.

	Telehealth (50)	Tertiary hospital (100)
Gender
Male	38	79
Female	12	21
Age at fracture
Minimum	5	16
Maximum	82	83
Median	20.5	39
Mechanism of injury
Motor Bike Accident	6	30
Motor Vehicle Accident	4	20
Push Bike Accident	4	21
Fall	10	16
Sport	4	12
Quad bike	2	1
Horse	2	0
Assault	1	0
Undeclared	17	0
Location of fracture
Medial	0	2
Middle	36	68
Lateral	14	30
Management of fracture
Operative	1	27
Non-operative	49	67
Complex treatment	0	6

Whilst the ratio of males to females presenting to the hospital was greater, there was no statistically significant difference in the gender breakdown between the telehealth and hospital groups (chi-square test: χ² = 0.32, df = 1, p = 0.57).

There was a highly significant difference between the age distributions of the two groups (Mann–Whitney U test: Standardised Test Score (STS) = 5.69, p < 0.001). There is an inherent bias in the age distribution of the two groups as the PAH only deals with adult patients (from 16 years of age). This age difference remains consistent when further broken down by gender, with no age by gender interaction.

There was statistically no difference in fracture location between the telehealth and hospital groups (chi-square test: χ² = 0.11, df = 1, p < 0.74) with proportions differing by a few percentage points.

There was a highly significant difference in fracture management (Table 2) between the two groups (chi-square test: χ² = 18.30, df = 2, p < 0.001). For the telehealth group, there was only one patient that was managed surgically, whereas one-third of the patients in the hospital sample received operative management with ORIF or complex management involving surgical intervention.

Table 2.

Treatment outcome and fracture management.

	Telehealth	Tertiary hospital
Operative	1	27
Good treatment outcome	1	19
Complications	0	8
Unknown	0	0
Non-operative	49	67
Good treatment outcome	27	57
Complications	2	10
Unknown	20	0
Complex treatment	0	6
Good treatment outcome	0	5
Complications	0	1
Unknown	0	0
Total	50	100

The 100 patients in the sample from the PAH Orthopaedic Fracture Clinic were assessed for treatment outcome. For the benefits of this study, a good treatment outcome is defined as full range of movement (ROM) and no pain. Non-operative management involved conservative treatment with use of a figure of eight splint and/or sling (Figure 1). Operative treatment for all patients in the sample was a surgical ORIF with plates and screws (Figure 2).

Figure 1.

Clavicle radiograph demonstrating conservative fracture management with callous formation.

Figure 2.

Clavicle radiograph demonstrating open reduction internal fixation surgery with plate and screws.

Complications within the operative group included infection (one patient), pain (six patients) and loosening of metalwork (one patient). Complications within the non-operative group included frozen shoulder (one patient), pain (eight patients) and paraesthesia (one patient). Within the complex treatment group, patient outcome was good in three cases when metalwork was removed due to infection (one patient), pain (three patients), metalwork breaking (one patient) and re-fracture (one patient). Pain continued for one patient following removal of metalwork, due to complications with infection, pain and poor vasculature resulting from the initial ORIF surgery.

Those patients with unknown treatment outcomes failed to attend follow-up appointments.

A highly statistically significant difference was demonstrated in the drop-out rates (Table 3) between the two groups (chi-square test: χ² = 46.12, df = 1, p < 0.001). None of the hospital patients failed to attend follow-up appointments, whereas 40% of the telehealth sample failed to report for follow-up. It might be assumed that the majority of these did not return for follow-up because of no complications with the initial treatment, and therefore a good outcome.

Table 3.

Failure to attend follow-up appointments.

	Telehealth	Tertiary hospital
Attended follow-up appointment	30	100
Failed to attend for follow-up	20	0
Total	50	100

Including unknown patient outcomes, there was a highly significant difference in outcome between the two groups (chi-square test: χ² = 42.22, df = 2, p < 0.001) but it is difficult to draw strong conclusions due to the missing data from the unknown outcome group. Presumably follow-up appointments would have been attended had there been complications.

Excluding the unknown outcomes, there were substantially less complications for the telehealth group than for the hospital group, however, this was not considered statistically significant (Fisher’s exact test, p = 0.15) due to the small number of patients with complications in the telehealth group (two patients).

Discussion

The majority of patients within both samples were male, and there were comparable percentages with 76% male in the telehealth group and 79% in the tertiary hospital sample. These results can also be seen in the literature, with men almost three times more likely than women to sustain a clavicle fracture.⁸

The midshaft of the clavicle was the most common site of fracture in both the telehealth and tertiary hospital samples with 72% and 68% respectively. These results are reflected in the literature, along with the finding that fractures of the distal end of the clavicle are more common than fractures of the medial end.¹

In the sample of patients seen via telehealth facilities, 2% were managed operatively versus 98% conservatively. These statistics are also indicative of patient access to orthopaedic services. Within the tertiary hospital group, 33% were managed operatively (six of these patients undergoing removal of metalwork at a later date). In the tertiary hospital, orthopaedic services were readily available to all patients. For patients seen at the NWHHS (in particular Mt Isa) having telehealth consultant consultation, the nearest referral for orthopaedic services was The Townsville Hospital, 900 km away. Rural and remote patients have a preference not to travel long distances for medical or surgical interventions, unless absolutely necessary, due to expense and accommodation issues and time away from work and family.

In the telehealth sample, patients were all given regular follow-up appointments after initial assessment and application of sling, figure of eight splint, or both. All patients received follow-up and if they did not arrive at the follow-up appointment, were offered a second follow-up. None of the patients in the hospital group failed to attend at least one follow-up appointment, however 40% of the telehealth sample failed to attend for follow-up. Patients who did not return for medium or long-term follow-up were considered to have had a satisfactory outcome.

There were no non-unions documented in the NWHHS group. One patient left the Northwest (and was therefore unable to be included in this study) and underwent ORIF surgery in Grafton, northern New South Wales as his parents lived in the area. The patient in the telehealth sample in this study had relatives in Townsville, North Queensland and it is understood that this patient had ORIF surgery at The Townsville Hospital.

Union rates were difficult to assess retrospectively, however mal-union and non-union have been demonstrated to occur less when clavicle fractures are managed surgically. Union is assessed via various criteria, but can be described clinically through movement of the shoulder girdle as one, or radiologically by appearance of fracture line. Non-union is rarely asymptomatic, so would be demonstrated in this study in the patients with complications due to pain.

Patient outcome complications within the hospital sample of the study related mostly to surgical treatment, however more complications in the non-operative group cannot be ruled out, as functional or pain management complications may have occurred without the progression to surgery for some patients. It is still recognised that conservative treatment yields the best patient outcome for non-displaced clavicle fractures.⁹ This study demonstrated good patient outcome with normal ROM and no pain in 70% of patients managed operatively and in 85% of patients managed conservatively within the hospital group. Overall, in the sample of patients presenting to a tertiary hospital facility, good patient outcome was seen in 79% of all cases. The most common complaint affecting good patient outcome was pain, accounting for 81% of treatment complications in the hospital group.

Within the telehealth sample, good patient outcome was reported in 93% of the patients that returned for follow-up appointments with two patients (7%) reporting back with ongoing pain. The patient that underwent surgical management also reported a good outcome with normal ROM and no pain.

Limitations exist within this study due to the retrospective nature of the data collection and small sample size. During the period of data collection, digital patient records were introduced with all pre-existing patient notes scanned into the individual digital records. It is possible that during this transfer data was missed and could not be included in the study outcome. The samples were unable to be matched for demographics due to the relatively small number of patients presenting to the telehealth clinic with clavicle fractures. Paediatric patients form part of the telehealth sample, however, the PAH is an adult hospital with no individuals seen who were less than 16 years of age. This could impact on the location of fracture and outcome data due to differing anatomy and healing responses at a younger age.

Despite the small sample size of this study, the results align with the literature demonstrating similar patient outcome in both surgical and conservatively managed patients with clavicle fractures. The majority of patients are still managed non-operatively in both tertiary hospital facilities and rural health sites, however, access to operating theatres allows for surgical management when necessary.

Footnotes

Acknowledgements

The authors wish to thank staff at the PAH Telehealth Centre, Princess Alexandra Orthopaedics Department and the NWHHS for their assistance and support with this project.

Declaration of conflicting interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship and/or publication of this article: The authors have no competing interests or relevant financial relationships to disclose. J North acts as a Senior Medical Visiting Officer for both the PAH Orthopaedic Fracture Clinic and Mt Isa Telehealth Orthopaedic Fracture Clinic. M McKerrow is a radiographer working in both the PAH Orthopaedic Department and Orthopaedic Telehealth Clinic.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

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