Fractures around the shoulder girdle: Unsolved fractures?

This thesis is about the treatment of clavicle and proximal humeral fractures and is the result of a Swiss-Dutch collaboration. Clavicle and proximal humeral fractures are very common and used to be treated non-operatively. The last two decades we have seen a shift however towards more operative treatment. Despite many trials and other studies, until now there is still an ongoing debate about what the best treatment modality is for these fractures. ‘Patient selection’ together with ‘shared decision making’ are hot topics and are probably the key to future indications for operative or non-operative treatment of these fractures. This thesis presents several studies that aim to provide further evidence that can aid in making a decision for the best treatment for every single patient.
The first part is about medial, shaft and lateral clavicle fractures. Medial clavicle fractures are rare injuries and generally treated non-operatively. We present an operative technique for displaced medial clavicle fractures. In this retrospective study we found excellent functional results. Furthermore, two studies about the intramedullary treatment of clavicle fractures were performed. One about the application of an end cap and one about the suitability of displaced clavicle shaft fractures. We concluded that the application of an end cap did not result in less implant related irritation and that fractures more lateral from the middle were less suitable for this technique from medial. Another study compared two implants for the treatment of instable lateral clavicle fracture. We concluded that whenever possible the superior plate with lateral extension should be used but that the Hook plate was a good alternative for very lateral fractures. And lastly, the current concepts for the treatment of collar bone fractures are discussed and treatment algorithms proposed.

The second part covers the treatment of proximal humeral fractures. A systematic review and meta-analysis on displaced proximal humeral fractures (DPHF) was performed comparing the operative and non-operative treatment. As we found no difference in functional outcome, we concluded that for the typical patient presenting with a DPHF we recommend the non-operative treatment. In addition, a study on the long-term functional outcome and implant-related irritation after minimally invasive plate osteosynthesis (MIPO) of DPHF was performed. Satisfying functional outcomes after a mean of 8 years follow-up were found. However, about one third of the patients had a second operation for implant removal due to implant-related irritation.
We also present a minimally invasive technique for proximal humeral fracture-dislocations. Functional results were promising and in 86% the humeral head was preserved. However, there is a high rate of re-operations either because of complications or for implant removal.
In a last study we present the current concepts of proximal humeral fracture treatment. In general, non- or slightly-displaced proximal humeral fractures are treated non-operatively. Also, DPHF with elderly, osteoporotic and polymorbid patients can be treated conservatively. Older patients with a proximal humeral fracture-dislocation should be treated with a prosthesis, young and active patients with an osteosynthesis. For active and fit patients with a DPHF there is no consensus.