GS10 - Concomitant Clavicle and Rib Fractures: A Review of Pulmonary Prognosis

Introduction/Purpose: The most widely accepted classification of clavicle fractures was postulated by Allman in 1967 then further classified by Neer in 1968 (Allman), (Neer). Concomitant rib fractures are not a current absolute indication for rib ORIF(open reduction internal fixation) but are associated with clavicle fractures in 20%-60% of cases and have increased rates of pulmonary complications (Tsung-Han Yang, Fokin, Cheau-Feng Lin, Langerbach). Trauma to the chest wall often has associated internal thoracic injuries, and prolonged rehab is required in 33% of patients (Kasotakis). Flail chest ORIF offers shorter intensive care unit length of stays and duration of mechanical ventilation (Tanaka). Further, the rates of pneumonia are only 35% in patients who received surgical fixation of their flail chest compared with 80% in patients who had non-operative management (Martin). But what of the clavicle? Can surgical fixation of the clavicle in patients with concomitant clavicle and rib fractures provide similar results as found with ORIF of ribs?

Methods or Case Description: This retrospective review serves to review concomitant clavicle and rib fractures with attention to the pulmonary outcomes of this fracture population. A literature search was performed on pubmed using key words to ascertain the current evidence regarding concomitant clavicle and rib fractures. Exclusion criteria included articles published more than 10 years ago, as well as non-human studies. Results were then filtered by title and abstract to only include articles that specifically discussed concomitant rib and clavicle fractures, the complications these patients face and chest wall function.

Outcomes: The outcomes of clavicle fracture fixation are widely centered around resultant shoulder function, with no mention of pulmonary recovery (Gilde), (Langenbach). Clavicle fractures in trauma patients have higher incidence of thoracic injuries (van Laarhoven). 28.7% of patients with a clavicle fracture have a chest wall injury and this was correlated with the number of concomitant rib fractures (Tsung-Han). Concomitant rib and clavicle fractures result in more pulmonary complications, injury severity score (ISS), ICU (Intensive Care Unit) admission/length of stay, and hospital length of stay (Fokin).

Conclusion: The association of these pulmonary complications in patients with concomitant clavicle and rib fractures has only scarcely been studied (Tsung-Han, Fokin, Cheau-feng Lin). The clavicle has been described as the “gatekeeper” of the thorax but its role in the kinematics of the thorax has not greatly been studied (van Laarhoven, Langenbach). Researchers postulate that operative fixation of the clavicle in patients with concomitant clavicle and rib fractures may result in fewer pulmonary complications, lower LOS, ICU admission and LOS. This may lead to an absolute indication to operate on a clavicle with a concomitant rib fracture.