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Z-type Clavicle Fractures in Adults: A Retrospective Comparative Study of Outcomes
Maaz Muhammad1, Jacob S Borgida, Robert K Wagner
1From the Harvard Medical School Orthopaedic Trauma Initiative, Massachusetts General Hospital, Boston, MA (Muhammad, Borgida, Wagner, Griffin, Sierra-Arce, Musick, Gregg, Policicchio, van Duuren, Lehle, Ly, and Aneja), the Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Muhammad, Borgida, Wagner, Griffin, Sierra-Arce, Musick, Gregg, Policicchio, van Duuren, Lehle, Ly, and Aneja), the Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY (Griffin), and the Leiden University Medical Center, Leiden, The Netherlands (van Duuren).
Introduction:
Midshaft clavicle fractures with a "Z" deformity have historically been considered a surgical indication, although evidence is limited. This study compared rates of surgery to promote fracture healing between Z-type and non-Z-type clavicle fractures managed nonoperatively (nonsurgical cohort) and all-cause unplanned (re)operation rates among operatively and nonoperatively managed Z-type fractures (Z-type cohort).
Methods:
This retrospective cohort study included adult patients with midshaft clavicle fractures treated at two level 1 trauma centers between 2010 and 2023. Z-type fractures were defined as comminuted fractures with complete displacement and a vertically oriented butterfly fragment of ≥1 cm. The primary outcome was the rate of surgery to promote fracture healing in the nonsurgical cohort and the all-cause unplanned surgery rate in the Z-type cohort.
Results:
In total, 35 nonsurgical Z-type fractures, 157 nonsurgical non-Z-type fractures, and 95 surgical Z-type fractures were included. Rates of surgery to promote healing were similar between nonoperatively managed Z-type and non-Z-type fractures (17% vs. 22%, P = 0.552). Multivariable analysis showed no association between Z-type fractures and surgery to promote fracture healing (odds ratio, 0.84; 95% confidence interval, 0.29 to 2.17; P = 0.737). Among Z-type fractures, all-cause unplanned surgery rates were comparable between nonsurgical and surgical management (20% vs. 28%, P = 0.333). However, when excluding implant removal, nonoperatively managed Z-type fractures had a significantly higher all-cause unplanned surgery rate (20% vs. 4.2%, P = 0.009). Surgical management of Z-type fractures had a lower rate of surgery to promote fracture healing compared with nonsurgical management (1.1% vs. 17%, P = 0.002).
Conclusions:
Among fractures initially treated nonoperatively, Z-type and non-Z-type midshaft clavicle fractures had similar rates of surgery to promote fracture healing. Surgical management of Z-type fractures demonstrated a lower rate of surgery to promote fracture healing compared with nonsurgical management. Regardless of initial treatment, all-cause unplanned surgery rates were comparable for Z-type fractures.
Level Of Evidence:
Therapeutic Level III.
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