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Pneumothorax After Clavicle Fixation: Do We Need Intraoperative Chest X-Ray? M. Kareem Shaath, MD; Joseph A. Ippolito, MD; Michael S. Sirkin, MD; Mark C. Reilly, MD; Mark R. Adams, MD Rutgers University New Jersey Medical School Department


  1. Pneumothorax After Clavicle Fixation: Do We Need Intraoperative Chest X-Ray? M. Kareem Shaath, MD; Joseph A. Ippolito, MD; Michael S. Sirkin, MD; Mark C. Reilly, MD; Mark R. Adams, MD Rutgers University – New Jersey Medical School Department of Orthopaedic Surgery

  2. Introduction • Approximately 5% of all fractures • Greater than 50% of shoulder girdle injuries 1,2 • Pneumothorax is a dreaded complication – Rare, incidence unknown – Less than 10 cases in English literature 1-8 – Increased risk with superior plating

  3. Purpose • Identify risk factors for pre-operative or post-operative pneumothorax in patients undergoing ORIF of the clavicle • Assess the value, of an intraoperative chest x-ray, (CXR)

  4. Methods • IRB approval obtained • 162 consecutive patients reviewed from 2006-2016 • 11 Patients with pre-operative pneumothorax excluded • Patients divided into 2 groups: – Intraoperative CXR (IO) – Postoperative CXR (PO) • Data Collected: – Age – BMI – Time to Fixation – Mechanism of Injury – OTA Fracture Classification – Method of Fixation – Presence/Abscenece of Postoperative Pneumothorax

  5. Results

  6. Demographics IO PO p Female 16 Female 21 Gender 0.73 Male 52 Male 61 35.6+1.8 34.8+1.5 0.72 Age 26.0+0.6 26.2+0.6 0.84 BMI 8.1+3.0 9.5+1.8 0.69 Time to Fixation

  7. Mechanism of Injury Mechanism IO PO p 3 3 Assault 0.263 3 2 Cyclist 25 31 Fall 6 17 MCC MVC 13 17 Ped. Struck 10 6 4 4 Sports 4 2 Unknown Total 68 82

  8. Fracture Location (OTA) 15 IO PO p 1 0 Medial (A) 61 73 0.547 Diaphyseal (B) 6 8 Distal (C)

  9. Fracture Configuration (OTA) 15-B IO PO p value Noncomminuted (1) 21 29 Wedge (2) 31 29 0.547 Segmental (3) 9 15

  10. Method of Fixation Method of Fixation IO PO p Anterior 24 35 Superior 17 32 Ant/Superior 23 6 Inferior 3 6 0.532 IM Nail 0 1 1 2 Distal Clavicle Plate Total 68 82

  11. Pneumothorax? • No patients in our population experienced a intraoperative pneumothorax • 12 patients with existing pneumothorax, did not have a worsening of condition • Rib fracture at presentation with concomitant clavicle fracture increased risk for pneumothorax (p<.00001) – OR 61.7

  12. Intraoperative CXR by Subspecialty Subspecialty IO PO p 57 51 Trauma 2 16 Hand .0007 Sports 9 12 0 2 Pediatrics 0 1 Oncology 68 82 Total

  13. Operative Time • Mean time from incision closure to leaving the operating room was prolonged by 18.9 + 1.9 minutes in the IO group (p<.0001) • Prolonged time under anesthesia – Anesthesia costs $15-20/minute 9 • Additional $285-380 – OR charges average of $62/minute ($22-133/min) 9 • $1,178 ($418-2,527) • Delays room turnover • Increased healthcare costs

  14. Conclusion • None of the patients developed a post-operative pneumothorax • Orthopaedic traumatologists are more likely to obtain intraoperative CXR • If a patient has concomitant rib fractures, increased suspicion for pneumothorax at presentation • Intraoperative CXR should only be obtained only if there is a clinical suspicion for pneumothorax intraoperatively minimizing potential risks of prolonged time under anesthesia and increased healthcare costs.

  15. References 1. Yates DW. Complications of fractures of the clavicle. Injury. 1976 Feb;7(3):189-93. 2. Khan LA, Bradnock TJ, Scott C, Robinson CM. Fractures of the clavicle. J Bone Joint Surg Am. 2009 Feb;91(2):447-60. 3. Meeks RJ, Riebel GD. Isolated clavicle fracture with associated pneumothorax: a case report. Am J Emerg Med. 1991 Nov;9(6):555-6. 4. Dath R, Nashi M, Sharma Y, Muddu BN. Pneumothorax complicating isolated clavicle fracture. Emerg Med J. 2004 May;21(3):395-6. 5. Steenvoorde P, van Lieshout AP, Oskam J. Conservative treatment of a closed fracture of the clavicle complicated by pneumothorax: a case report. Acta Orthop Belg. 2005 Aug;71(4):481-3. 6. Gandham S, Nagar A. Delayed pneumothorax following an isolated clavicle injury. BMJ Case Rep. 2013;2013. 7. van Laarhoven JJ, Ferree S, Houwert RM, Hietbrink F, Verleisdonk EM, Leenen LP. Demographics of the injury pattern in severely injured patients with an associated clavicle fracture: a retrospective observational cohort study. World J Emerg Surg. 2013;8(1):36. 8. Skedros JG, Knight AN, Mears CS, Langston TD. Temporary sternoclavicular plating for an unusual double clavicle fracture (medial nonunion, lateral acute) complicated by an intraoperative pneumothorax. Case Rep Orthop. 2014;2014:206125. 9. Macario, A. (2010). What does one minute of operating room time cost? Journal of Clinical Anesthesia, 22 (4), 233-236.

  16. Thank You

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