Estimating the Risk of Nonunion Following Nonoperative Treatment of a Clavicular Fracture

To The Editor: We read with great interest the article, “Estimating the Risk of Nonunion Following Nonoperative Treatment of a Clavicular Fracture” (2004;86:1359-65), by Robinson et al. This is a large consecutive series of 868 patients seen at the Shoulder Injury Clinic, Orthopaedic Trauma Center in Edinburgh, Scotland. The authors are to be congratulated and commended on >75% follow-up at twenty-four weeks in such a large population. While the authors have provided a means for the reader to estimate the probability of nonunion by age, gender, and fracture type, we believe an important take-home message has been obscured by the method of written presentation. Specifically, what should orthopaedic surgeons now tell their patients about the outcome of displaced and comminuted diaphyseal fractures? The classic teaching about clavicular fractures has been that they all do well and that closed isolated injuries rarely, if ever, require operative stabilization. Several recent studies1-3 have challenged this “conventional wisdom” by demonstrating a relatively high rate of nonunion in displaced diaphyseal fractures and even unsatisfactory results in some patients who heal in a nonanatomic position. Consequently, there has been …