Dual-Plate Fixation in Treatment of Clavicle Fractures in Dementia Patients: A Case Series

Introduction

Clavicle fractures are among the most common orthopedic injuries, comprising approximately 2–5% of all fractures. Midshaft clavicle fractures are common fractures of the scapular girdle and account for 81% of the total cases of clavicle fractures [1]. While nonoperative management is often appropriate [2], surgical intervention may be indicated for displaced fractures, particularly in cases of significant displacement or shortening, with significantly lower rates of non-union and mal-union and an earlier functional return [3,4]. Recent research recommends surgical treatment if the residual displacement is greater than 140% after the application of a figure-of-eight bandage, as there is an increased risk of non-union in such cases [5]. Conventionally, surgical treatment involves the application of a superior locking compression plate to stabilize the fracture. Most studies have recommended sling immobilization for 2 weeks after osteosynthesis, and gentle rehabilitation with arm sling protection until 6 weeks after surgery [6]. However, dementia is one of the major cognitive impairment-related diseases, along with delirium and Parkinson’s disease [7]. Challenges related to cooperation and postoperative compliance may necessitate modifications to standard surgical approaches in patients with dementia. Sudden uncontrolled movement can produce excessive stress on the fracture site, causing plate breakage or re-displacement of fracture site. We hypothesized that using dual plating to achieve stable fixation in dementia patients who are unable to maintain adequate immobilization on their own after surgery would reduce early failure and lead to successful treatment outcomes.

Herein, we present a case report highlighting the successful surgical management of a clavicle fracture in patients with dementia utilizing a dual plating technique. To the best of our knowledge, this is the first reported case of dual-plate fixation in the treatment of clavicle fractures in dementia patients.

Case Reports

CASE 1:

The 90-year-old woman with a known history of vascular dementia was brought to the outpatient clinic of the Orthopedic Surgery Department following a fall at home. Initial physical examination revealed tenderness, deformity, and skin tenting over the right clavicle.

Radiographic evaluation revealed a midshaft fracture of the right clavicle, with significant displacement (Figure 1). In consideration of her age, vascular dementia, and the potential for non-union with conservative management, surgical intervention was recommended. Given the patient’s cognitive impairment and inability to cooperate with postoperative instructions, surgical intervention was deemed necessary for optimal fracture stabilization and functional recovery.

The decision was made to proceed with open reduction and internal fixation using a standard superior locking compression plate (Figure 2). The surgery proceeded uneventfully, and the patient was discharged with instructions for sling immobilization and limited shoulder range of motion.

However, postoperatively, the patient’s dementia posed significant challenges. Despite attempts to enforce immobilization, she frequently attempted to move her shoulder, leading to fixation failure. Radiographic evaluation 2 weeks after surgery revealed plate migration and pull-out from the clavicle (Figure 3).

Considering the need for enhanced stability and resistance to pull-out forces, a dual plating technique was employed.

A superior locking compression plate was applied on the superior side of the clavicle, and a one-third plate was applied on the anterior aspect of the clavicle (Figure 4). Following the revision surgery, instructions were given to limit shoulder movement and adhere to strict immobilization protocols, but she still attempted to move her shoulder. Despite her dementia-related challenges, she demonstrated improved compliance with postoperative instructions, likely due to the enhanced stability provided by the dual plating technique.

At the one-year follow-up, she had satisfactory shoulder function, with almost no pain. Radiographic evaluation revealed no evidence of plate migration or pull-out, indicating successful fracture healing and stable fixation (Figure 5). Despite her advanced age and dementia, the patient maintained functional independence and reported no limitations in activities of daily living.

CASE 2:

The 75-year-old man with a known history of metastatic dementia came to the emergency room after falling on the street. He had lung cancer and hepatocellular carcinoma with multiple metastasis, including brain metastasis. He was very violent in the emergency room, and the guardian explained that this was an aggressive behavior due to cancer metastasis in the frontal lobe. Simple radiographs revealed the displaced clavicle shaft fracture with butterfly fragment on the right side (Figure 6).

He was very distressed by the pain caused by the fracture, and the patient and guardian wanted surgical treatment. It was decided to perform dual-plate fixation because it was thought he would not follow the instructions of the medical staff after the surgery (Figure 7). This proved to be the case, as he did not follow any instructions to limit the movement of the shoulder immediately after surgery, and he did not wear an arm sling at all for a week in the hospital. Nevertheless, the fracture site was well maintained without significant changes in the X-ray at 6 months after surgery (Figure 8), and he was able to use the shoulder. Sadly, however, the patient died 1 year after the surgery due to metastasis of cancer.

Discussion

Optimal management of a displaced midshaft clavicle fracture remains controversial. According to recent studies, surgical treatment has a lower rate of non-union than conservative treatment and shows better results in early pain reduction and functional recovery. However, in the long term, there is no significant difference in clinical outcomes compared to conservative treatment, and surgical complications have been reported in up to 29% of cases [8,9].

Proper immobilization or rest is necessary for stability and pain control while a fracture is healing. However, patients may not be able to immobilize properly if they have mental disorders such as dementia or schizophrenia, or involuntary movement such as tics. For patients with involuntary movement, we can treat problematic activity by using drugs or intramuscular injections of botulinum toxin [10]. However, in the case of cognitive abnormalities, there is no special way other than to make the fixation stronger.

Dementia is a syndrome characterized by gradually progressive impairment in cognitive function and finally result in behavioral abnormalities [7]. In the current progressively aging society, dementia prevalence increases exponentially with age. The prevalence of dementia is projected to increase from 57.4 million cases globally in 2019 to 152.8 million cases in 2050 [11]. Surgical management of clavicle fractures in patients with dementia poses unique challenges due to impaired cooperation and compliance.

Traditional plating fixation for clavicle midshaft fracture is to use a single 3.5-mm locking compressed plate placed superiorly or anteriorly [12]. Dual plating is commonly used in the non-union cases of clavicle fracture [13]. Some studies showed that dual plating is biologically more suppressed, yet its performance is equivalent to single plating [14,15]. However, the ability of a dual plate to withstand multi-plane bending forces is better than that of a single plate, especially cantilever bending force in biomechanical studies.

While single plating techniques are commonly employed, the use of dual plating may offer advantages in dementia patients by providing additional stability and resistance to implant failure, thereby reducing the risk of non-union or mal-union. Moreover, dual plating allows for a more evenly distributed load across the fracture site, potentially minimizing stress shielding and promoting more rapid healing. However, the disadvantage of dual plating is that its technical complexity can lead to longer operative times compared to single plating. Additionally, the increased soft tissue dissection makes it difficult to preserve the biology around the fracture site, which is crucial for bone healing and may impact the union process. Despite the technical complexity and potential for increased operative time associated with dual plating, our cases demonstrate its feasibility and favorable outcomes in patients with dementia.

This study has the limitation of being a case report, which does not provide sufficient evidence to validate our hypothesis. Future prospective comparative studies are needed to establish appropriate guidelines for the treatment of clavicle fractures in dementia patients.

Conclusions

Clavicle fractures in patients with dementia require careful consideration of surgical management strategies to avoid complications. The use of dual plating techniques, as illustrated in this case report, may offer an effective solution for achieving stable fracture fixation and facilitating successful rehabilitation in dementia patients.