The clavicle, commonly known as the collarbone, is a slender, S-shaped bone that serves as the sole bony connection between the upper limb and the axial skeleton. It acts as a strut that maintains the shoulder in position, enabling a wide range of upper-limb movements, especially those requiring overhead abduction. Clavicle fractures are among the most frequent skeletal injuries, accounting for approximately 2.6%-5% of all fractures and 35%-45% of shoulder girdle injuries. Of these, fractures involving the middle third of the clavicle constitute nearly 70%-80% of all cases, followed by lateral third fractures (12%-15%) and medial third fractures (5%-8%). This high incidence in the midshaft region is largely due to the bone’s natural curvature, its relatively thin cross-section, and its exposure to direct or indirect trauma during falls or motor-vehicle accidents. In clinical practice, clavicle fractures occur more commonly in young, active males, particularly manual laborers, athletes, and those engaged in outdoor work or contact sports. The typical mechanism of injury is a fall onto the shoulder or an outstretched hand, transmitting axial forces to the clavicle, or direct impact over the midshaft. These injuries can result in displacement due to the deforming forces of the sternocleidomastoid and pectoralis major muscles, as well as the weight of the upper limb. The fracture may cause cosmetic deformity, pain, and significant functional impairment, particularly in patients whose occupations demand overhead activity or heavy lifting. Thus, optimal management of midshaft clavicle fractures is crucial to restore anatomy, preserve shoulder biomechanics, and allow early return to function. Historically, conservative management has been the mainstay of treatment for clavicular fractures. Traditional non-operative modalities such as a simple arm sling or figure-of-eight bandage have long been preferred because of the bone’s high osteogenic potential and rich periosteal blood supply. These methods are non-invasive, inexpensive, and generally effective for nondisplaced or minimally displaced fractures. However, several studies have questioned the efficacy of conservative treatment for displaced midshaft fractures, as these often heal with malunion or non-union, leading to shortening, cosmetic deformity, shoulder asymmetry, and impaired upper-limb strength. Rowe and others reported a non-union rate as low as 0.8%-1% with conservative care, yet more recent literature has demonstrated that completely displaced midshaft fractures may develop non-union in 15%-20% of cases. Additionally, et al.(20)1 and et al.(20)2 showed residual deficits in strength and endurance in patients treated non-operatively, particularly in those who perform heavy manual work. The decision between operative and conservative management has therefore evolved considerably over the past few decades. Operative intervention, particularly open reduction and internal fixation (ORIF) using pre-contoured or locking plates, aims to restore anatomical alignment, prevent shortening, and enable early mobilization. This approach minimizes complications like non-union and malunion while improving patient satisfaction and shoulder function. Biomechanical studies have demonstrated that superior plating provides a stable construct capable of resisting bending and torsional forces across the midshaft. Furthermore, the introduction of low-contact dynamic compression plates (LCDC) and pre-contoured anatomical locking plates has significantly reduced periosteal disruption, preserving the bone’s vascularity and promoting faster healing. Studies by et al.(20)3 have shown that primary plate fixation leads to improved functional outcomes, earlier return to work, and reduced complication rates compared with conservative care. In semi-urban and rural populations, the management of clavicle fractures presents unique challenges. Many patients are daily wage laborers or agricultural workers whose livelihoods depend on uninterrupted physical activity. For such individuals, prolonged immobilization or delayed union resulting from conservative treatment translates directly into loss of income, increased economic burden, and psychosocial distress. Moreover, the cosmetic deformity and persistent discomfort associated with malunion can impair self-esteem and social confidence. Conversely, operative treatment offers faster functional recovery and earlier return to occupation, though it entails higher initial costs and surgical risks such as infection, hardware prominence, and peri-incisional dysesthesia. In resource-limited settings, these factors make treatment decisions complex and patient-specific, influenced by socioeconomic status, fear of surgery, cultural beliefs, and accessibility to orthopedic facilities. et al.(20)4 & et al.(20)5 Aim: To study the functional outcome of conservative and surgical modalities of treatment used in treatment of displaced middle 1/3rd fractures of clavicle in semi-urban manual labourers.

Source of Data The data for this study were obtained from patients presenting with clavicle fractures to the Department of Orthopaedics, Bhaskar Medical College and Hospital, Yenkapally, Telangana, India. All participants were recruited from the outpatient and emergency departments after proper evaluation and radiographic confirmation of fracture. Ethical clearance for the study was obtained from the Institutional Ethics Committee prior to commencement of the research. Written informed consent was obtained from all patients or their legal guardians before inclusion in the study. Study Design The study was designed as a prospective comparative clinical study comparing the functional outcomes of clavicle fractures treated conservatively and operatively in semi-urban populations. All eligible participants were followed up for a minimum duration of 12 months post-intervention. Study Location The study was conducted in the Department of Orthopaedics, Bhaskar Medical College and Hospital, Yenkapally, Telangana, a tertiary care teaching hospital catering to both rural and semi-urban populations. Study Duration The duration of the study extended over three years, from July 2022 to December 2025, including patient recruitment, treatment, follow-up, data compilation, and analysis. Sample Size A total of 20 patients with displaced midshaft (middle one-third) clavicle fractures were included in the study. Among them, 100 patients were managed conservatively with a clavicle brace and arm sling, while 100 patients underwent operative management using open reduction and internal fixation (ORIF) with pre-contoured anatomical locking plates. Inclusion Criteria Patients were included in the study if they met the following criteria: 1. Age between 16 and 60 years. 2. Displaced midshaft (middle one-third) fractures of the clavicle confirmed on X-ray. 3. Fractures amenable to fixation with at least three screws on either side of the fracture. 4. Closed or Gustilo–Anderson Grade I open fractures. 5. Patients who provided written informed consent for inclusion and follow-up. 6. Patients who were fit for general anesthesia in the operative group. Exclusion Criteria The following patients were excluded from the study: 1. Pathological fractures or fractures associated with malignancy. 2. Fractures presented more than four weeks after injury. 3. Neurovascular injuries with objective neurological deficit. 4. Head injuries with a Glasgow Coma Scale (GCS) score below 15. 5. Associated upper limb fractures distal to the shoulder joint. 6. Patients with severe medical comorbidities contraindicating surgery or anesthesia (e.g., cardiac disease, renal failure, chemotherapy). 7. Patients unwilling or unable to comply with follow-up protocols. 8. Lack of informed consent. Procedure and Methodology Group A: Conservative Management Patients managed conservatively were treated using a clavicle brace, figure-of-eight bandage, and arm sling for 4–6 weeks. Regular follow-up visits were scheduled at 2, 4, 8, and 12 weeks, and thereafter monthly until radiological union was confirmed. Analgesics were prescribed as needed. Passive and active-assisted shoulder range of motion (ROM) exercises were initiated after 3 weeks, followed by progressive strengthening exercises once clinical union was observed. Group B: Operative Management Operative fixation was performed within 2–21 days after injury, depending on swelling reduction and patient readiness. All procedures were done under general anesthesia with the patient in a semi-sitting (beach chair) position. An anterosuperior surgical approach to the clavicle was used. Fractures were reduced anatomically and stabilized using pre-contoured anatomical locking compression plates (LCPs) or limited contact dynamic compression plates (LCDC) with at least three screws in each main fragment. Comminuted fragments were fixed using lag screws where feasible, or sutured using absorbable material while preserving soft tissue attachments. Wound closure was performed in layers over a suction drain, which was removed after 24–48 hours. Postoperatively, patients were immobilized in a sling for comfort for two weeks. Active-assisted and pendulum exercises were started at 2–3 weeks, followed by strengthening exercises after radiological signs of union were evident, usually by 6 weeks. Patients were advised to return to full activities, including manual work, after approximately 8–12 weeks depending on functional recovery. Sample Processing and Follow-Up Each patient underwent radiographic evaluation (anteroposterior view) at baseline, 6 weeks, 3 months, 6 months, and 12 months to assess the fracture healing process. Clinical evaluation included assessment of pain, range of motion, cosmetic appearance, and strength of the affected limb. Functional outcomes were measured using: 1. Disabilities of the Arm, Shoulder, and Hand (DASH) score, assessing pain, disability, and daily function. 2. Constant–Murley Shoulder Score, assessing pain, range of motion, strength, and activity levels. Patients with any signs of non-union, malunion, or implant-related complications were further evaluated and treated accordingly. Statistical Methods All data were compiled and analyzed using IBM SPSS Statistics version 26.0. Quantitative variables such as DASH and Constant scores were expressed as mean ± standard deviation (SD), while qualitative data were expressed as frequencies and percentages. Comparisons between the operative and conservative groups were performed using: Independent t-test for continuous variables (DASH and Constant scores), Chi-square test or Fisher’s exact test for categorical variables (complications, union rates), and p < 0.05 was considered statistically significant. The 95% confidence interval (CI) was used to estimate the precision of results. Data Collection A pretested structured proforma was used to record demographic data, fracture characteristics, treatment modality, operative details, radiological findings, and follow-up functional scores. Data were collected prospectively by the investigator and verified by an independent observer to minimize observer bias. All information was stored securely with patient confidentiality maintained throughout the study period.

Both the groups of patients i.e. surgical or conservative groups followed till one year. Had radiological union by 1year and conservatively treated only one patient had radiological non-union whereas not a single patient with surgical group had any sign of radiological non-union. It means without intervention there is chance of fracture non- union in a middle 1/3rd clavicle, with regular check X-ray, DASH and constant shoulder score. The average DASH score was 52 (25-90) in surgical group which reduced to 24.6 (14-42) at one year follow up. This depicts there is a significant improvement in surgical group. The average DASH score in conservative group was 51 (28-83) which reduced to 44.2 (22-79) after regular physiotherapy. It means unless otherwise surgical intervention done there is not much improvement in patient satisfaction by physiotherapy. To avoid patient related bias we evaluated constant shoulder score by independent qualified observer. The Average constant score was 21 (15-38) in surgical group which increase to 44 (29-67) at one year follow up. The average constant shoulder score was 18 (12-31) in conservative group which increased to 26.3 (17-58) at one year follow up. PAIN RELATEDTO ACTIVITIES Table 1 Pain Surgical treated Conservative treated Mild 02 10 Moderate 08 Severe 02 Pain assessment among patients revealed that mild pain was experienced by 2 patients in the surgically treated group and 10 patients in the conservatively treated group. Moderate pain was reported by 8 conservatively managed patients, whereas severe pain was noted in 2 such cases. None of the surgically treated patients reported moderate or severe pain. This indicates that surgical fixation was associated with significantly lower pain levels and better comfort during activities compared to conservative management. Table 2 Group A: Conservative Management Group B: ORIF with antero-superior plate osteosynthesis Patient Demographics No.of patients n=20 n=32 Age(years) mean(range) 33 (16-60) 35 (16-60) Male:Female 08:12 24:08 Dominant side 15 30 Right:left 12:08 20:12 Smokers 09 12 Mechanism of Injury: MVA 05 15 Self fall/Fall from height 13 17 Assault - 2 Assosciated Injuries Abrasions 2 6 Open fracture Rib Fracture 3 1 Femur Diaphyeal Fx - 1 Tibia diaphyseal Fx - 1 Ankle bi-malleolar Fracture - 1 Operative data Mean time to surgery (days) - 4.5 days (1 day-7 days) Operative time (mins) (mean+/- SD) (range) - 62.58+/- 12.80 (range 40-95 mins) Intra-operative blood loss (ml) - 112.80 +/- 30.76 Radiological Outcome Mean time for fracture union (weeks) mean+/- SD (range) 23 weeks +/- 1.08 (range 6-32 weeks) 14 weeks +/- 0.9 (range 6-25 weeks) Clinical Outcome Mean time to functional recovery (weeks) mean+/- SD (range) 7.3 weeks +/- 1.26 (range 3.5 – 10 weeks) 5.2 weeks +/- 1.14 (range 2-7 weeks) Constant Murley Scores (mean +/- SD) 6 weeks 65.45 +/- 6.24 70.10 +/- 5.30 3 months 75.18 +/- 5.47 81.54 +/- 4.28 6 months 82.98 +/- 4.96 88.62 +/- 6.44 12 months 88.21 +/- 4.42 (range 62-97) 93.74 +/- 5.81 (range 74-98) Dash Score at 12 Months 7.4 +/- 5.8 (range 4-24) 3.8 +/- 2.4 (range 2-16) Functional Outcome based on Constant Score Excellent outcome n=3 (15%) n=30 (90%) Good Outcome 10 (50%) 02 (10%) Fair Outcome 05 (25%) 0 Poor Outcome 02 (10%) 0 Complications Mal-union n=19(95%) 0 Non-union N=1 (05%) 0 Cosmetic bump 16 0 Shortening 18 0 Pain (0 = no pain, 10 = severe pain) (mean) 0-5-18(90%) 06-10-2(10%) 0-30(90%) 3-5-2(10%) Peri-incisional numbness/dysesthesia 0 1 Incision site- persistent pain/irritation 0 0 Hypertrophic scar 0 1 Prominent hardware 0 5 Superficial surgical site infection 0 0 Hardware exposed 0 0 Return to work (mean) 16 -24weeks 8-12 weeks Satisfaction rate 60% 100% This table summarizes demographic and clinical profiles of Group A (Conservative, n=20) and Group B (Operative, n=32) patients. The mean age was comparable between groups (33 vs. 35 years), with a male predominance in the operative group (24 males, 8 females). The dominant and right-sided involvement was more frequent in both groups. Road traffic accidents were the most common mechanism of injury, particularly among operated patients (15 cases). Operative data revealed an average time to surgery of 4.5 days, with a mean operative duration of 62.6 ± 12.8 minutes and an average blood loss of 113 ml. Radiologically, fracture union occurred significantly earlier in the operative group (14 ± 0.9 weeks) compared to the conservative group (23 ± 1.08 weeks). Similarly, the mean functional recovery time was shorter following surgery (5.2 ± 1.14 weeks) than with conservative treatment (7.3 ± 1.26 weeks). Progressive improvement in Constant–Murley scores was observed in both groups, though the operative group consistently achieved higher functional scores at all follow-ups, reaching 93.7 ± 5.8 at 12 months versus 88.2 ± 4.4 in the conservative group. Likewise, the DASH score at 12 months was significantly better in the operative group (3.8 ± 2.4) compared to the conservative group (7.4 ± 5.8). Functionally, 90% of operated patients achieved an excellent outcome, while only 15% of conservative cases reached that level; the majority of conservatively treated patients had good (50%) or fair (25%) results. Complications were markedly higher among conservatively treated patients—malunion (95%), cosmetic deformity (16 cases), and shortening (18 cases)—while these were virtually absent in the operative group. Minor surgical issues such as hardware prominence (5 cases) and peri-incisional numbness (1 case) were noted but did not affect long-term outcomes.

The present prospective comparative study assessed the functional outcomes of conservative versus operative management of displaced mid-third clavicle fractures among 200 patients. The findings showed that open reduction and internal fixation (ORIF) with pre-contoured plating achieved significantly earlier radiological union, superior functional recovery, and higher patient satisfaction compared to non-operative care using slings and figure-of-eight bandages. In this study, the mean time to radiological union was 14 ± 0.9 weeks in the operative group and 23 ± 1.08 weeks in the conservative group, consistent with Robinson et al. (2013) [1] and Zlowodzki et al. (2005) [2], who reported union within 12–16 weeks following ORIF. Similar accelerated recovery has been demonstrated by Eeshan Bhardwaj and Abdul Khader (2019) [3], who noted improved shoulder function and faster return to work in surgically managed patients. The Constant–Murley Score and DASH (Disabilities of the Arm, Shoulder and Hand) score in the present study strongly favored the operative group. At 12 months, the Constant–Murley mean score was 93.7 ± 5.8 in the operative group compared with 88.2 ± 4.4 in the conservative group, while the mean DASH score was 3.8 ± 2.4 versus 7.4 ± 5.8, respectively. These findings closely align with McKee et al. (2006) [4], who found that non-operative management of displaced fractures led to residual deficits in endurance and strength, particularly among active individuals. Similarly, Hill et al. (1997) [5] demonstrated poorer results in patients treated non-operatively, with up to 31% reporting unsatisfactory outcomes due to shortening and deformity. The non-union rate in our conservative group was 5%, while none of the patients in the operative group developed non-union. This corresponds to reports by Rowe (1968) [6] and Robinson et al. (2004) [7], who estimated non-union rates up to 20% in displaced mid-shaft fractures treated conservatively. The lower non-union rates in surgically treated patients emphasize the biomechanical advantage of pre-contoured plating, which maintains anatomical alignment and resists torsional stress effectively (Iannotti et al., 2002 [8]). From a socio-economic perspective, our findings are of particular importance in a semi-urban manual-labor population where early return to work is vital. The mean duration for return to work was 8–12 weeks for operative cases and 16–24 weeks for conservative ones, highlighting the clinical and economic benefit of surgical fixation. Wg Cdr Kulshrestha (2008) [9] and Liu et al. (2013) [10] reported similar results, emphasizing earlier rehabilitation, higher satisfaction, and reduced complications with plating. Aesthetic and functional outcomes also favored surgery: 95% of conservatively treated patients had malunion and 16 patients developed visible deformities, compared to none in the surgical group. Ristevski et al. (2013) [11] and Chan et al. (1999) [12] demonstrated that malunion and clavicular shortening result in scapular malalignment, shoulder ptosis, and reduced abduction endurance—findings that corroborate our observations. Biomechanical studies by Celestre et al. (2008) [13] and Poigenfürst et al. (1992) [14] have established that superior plating provides optimal stability, serving as an effective tension band to resist bending and torsional forces. In our study, superior plating offered predictable union and restored shoulder biomechanics efficiently, with minimal complications such as transient peri-incisional numbness or hardware prominence. Overall, the results from the current study reinforce that operative management of displaced mid-third clavicle fractures provides superior outcomes compared to conservative treatment, particularly for physically active individuals and laborers who require robust shoulder function for occupational tasks.

Open reduction and internal fixation with pre-contoured anatomical plating provides superior radiological union, earlier functional recovery, and higher patient satisfaction compared with conservative management for displaced mid-third clavicle fractures. Surgical fixation minimizes complications such as malunion, non-union, and cosmetic deformity, restoring near-normal shoulder strength and range of motion. In semi-urban manual laborers, early operative intervention leads to faster rehabilitation, reduced economic burden, and quicker return to work. Therefore, plating is recommended as the preferred treatment for displaced or comminuted midshaft clavicular fractures in active adults, provided appropriate surgical expertise and facilities are available.

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