Clavicle fractures represent 2.5-10% of all fractures in adults (1-4). The risk is higher in young male patients aged less than 30 years and patients aged over 70. The main causes are a direct blow to the shoulder or a fall onto an outstretched hand (5), especially during sport activities or road traffic accidents. Middle third fracture represents 69% to 82 % of all clavicle fractures (4, 6, 7) and they often present some degree of displacement (8).

Nonsurgical treatment was considered the best option for most clavicle fractures with a good prognosis and a low incidence of nonunion cases (9-15). Other authors suggest acute fixation of displaced midshaft fractures (16, 17), reporting more favorable outcomes over the past two decades and a higher patient’s satisfaction.

Mandatory indications for surgical fixation of middle third clavicle fractures are open fractures, neurological or vascular compromise, skin tenting, widely displaced and comminuted fractures (18-20). Literature suggest that shortening of more than 2 cm, patients with multiple traumatic injuries, high-energy mechanism, younger athletic patients, and patients at risk of nonunion should address the surgeon’s choice to surgical fixation (21-28). Displaced middle third clavicle fractures result in poor clinical outcomes, which include decreased strength and range of motion (ROM), ongoing pain, and patient dissatisfaction, especially in conservatively treated patients (17, 29). Malunion of middle third clavicle fractures impair shoulder bio- mechanics (21, 23, 24, 30, 31) as well as, in some cases, Causes neurovascular complications (30, 32).

The aim of our study is to compare the clinical outcomes of surgical and conservative treatment for middle third clavicle fractures in patients with a skeletal maturity, admitted from January 2024- January 2025 in our department, evaluating the incidence of complications such as patient’s pain, aesthetic skin scarring, patient satisfaction, painful skin scarring and shoulder ROM.

this prospective observational study done in department of orthopedics, Shri Rawatpura Sarkar Institute of Medical Sciences and Research, Atal Nagar Nawa Raipur, Chhattisgarh from January 2024- January 2025. 87 patients with 2 displaced clavicle fractures fragments were included in study, evaluating the clinical and functional outcomes and the complication rate with a follow-up average of 48 months.

Inclusion criteria: people older than 17 years old evaluated at the Emergency Room and treated with figure of eight bandage or with surgical fixation.

Exclusion criteria: comminuted fractures, multiple fragment or pathologic fractures, corrective osteotomies, pediatric patients, intramedullary pin fixation.

Patients with a median follow-up time of 48 months were evaluated clinically, with the DASH questionnaire (33) and the Constant score (34). DASH questionnaire was composed by 30 questions rated 1 to 5 regarding the upper limb ROM. The responses were rated by a scale from 0 to 100, with 0 indicating no loss of ROM and 100 indicating complete loss of ROM. The Constant score, a 100-points scale composed of a number of individual parameters, defines the level of pain and the ability to perform patient’s normal daily activities. Lastly, we considered the complication rate in the non-operative sample and in the group who underwent plate fixation, considering the following: pain, anatomical defects, malunion, secondary fractures, neurovascular injuries, surgical wound dehiscence, and delayed union.

Statistical analysis was executed with an unpaired t-test in order to assess the significant differences be- tween the 2 groups.

We analyzed 50 patients who underwent plate fixation within 2 weeks from the injury (45 males and 5 females) and 37 patients who underwent conservative treatment (9 females and 28 males). The mean age at the time of the injury, respectively for the first and second group, was 36.8 years old (ranging between 17 and 71 y/o) and 46.8 years old (ranging between 17 and 86 y/o).

In our cohort of patients, the mean Constant Score was 94.36 ± 9,85 for surgical fixation, while it was 91.56 ± 14,66 for figure of eight bandage treated patients. Considering the DASH score, the first group reported a mean score of 4.63 ± 5,21; whereas the second group reported a mean score of 3.86 ± 5,84. No correlation was found among the two groups despite our analysis and the p-value resulted of >0.5 in both DASH and Constant score.

In particular, 15 out of the 38 patients who underwent conservative treatment (39,5%) were unsatisfied regarding the aesthetic appearance of the shoulder, however regarding the surgically treated patients, 6 out of 50 patients reported cosmetic dissatisfaction (12%) In the first group, the 13,9th % of patients (5 out of 36) had to be treated surgically to solve the malunion. In the second group, 10 out of the 50 patients (20%) had to undergo secondary surgery in order to remove the metallic implant. Surgical wound dehiscence was present in 1 case among surgically treated patients, while hyperesthesia around the scar was reported by 7 patients.

The aim of this study was analyzing whether patients with a displaced midshaft clavicular fracture are better managed with a plate fixation or a non-surgical treatment considering clinical results, functional out- comes and complication rate in patients treated at our department and comparing them to the literature.

In the last decades of 20th century, the conservative treatment was considered the gold standard be- cause of the high rates of non-union following both treatments reported in the past. In fact, according to Neer and Rowe in 1960, non-union rate was less than 1% in patients conservatively treated, whereas the rates in surgically treated patients were higher (2, 14).

More recent studies show the changes of the indications, evaluating the reduction of nonunion cases in surgically treated inpatients. In the literature, multiple studies report lower rates of nonunion after plate fixation than conservative treatment (35), reporting a relatively higher incidence of non-unions following to conservative treatment, causing a shift towards surgical treatment. Robinson et al. (36) performed secondary plate fixation in 81% of patients with non-union fracture after 6 months. In Schemistch series for Canadian Orthopedic Trauma Society (COTS), all patients with a non-union after 1 year follow-up period, underwent plate fixation (37). Melean et al. described secondary plate fixation in all 4 patients with a non-union, but the timing was not listed (38). In the study by Woltz et al. (39), 5 patients were operated with a nonunion within a follow-up period of 1 year, underlining that the patients with a non-union, who were about to undergo surgery, had a lower functional score than patients with a united fracture.

Our analysis confirms the results reported in more recent studies, showing less rates of nonunion in surgical group than in the conservative treatment group, all solved by secondary delayed surgery.

We reported that 10 patients in the operative group had to undergo secondary surgery to remove metallic implants, which is usually technically simpler, imposes less risk of complications, and provides short- er recovery time than other surgical procedures, such as secondary plate fixation with bone-grafting.

Considering the clinical scores in the previous studies, the Constant and DASH scores showed better results in the surgically treated group, than in the conservative group although the differences were only respectively 4.4 and 5.1 points, largely less than the 10 to 15 points, generally defined as the minimal difference for the clinical relevance (40-42). It remains controversial whether shortening of the clavicle after non-surgical treatment of a middle third fracture can affect shoulder ROM: in literature, there is no correlation between shortening and functional outcomes, even though the difference exceeds 2 cm (41).

Finally, the cosmetic issues were considered just in a few studies but, as well as we recorded in our cohort of patients, even in 2007 Canadian Orthopedic Trauma Society study, the surgically treated group of patients was more likely satisfied with the appearance of the shoulder (42) than the conservative group of patients.

In fact, although the surgical scar is largely visible over the shoulder, patients are more likely to consider the good clinical outcomes and rapid functional recovery, disregarding the cosmetic defect.

There were several limitations in our study: first we were not able to find statistically significant differences, probably because of the small sample size. Then, we did not evaluate the shortening of the clavicle. In conclusion, we noticed that the difference in the mean age between the two groups can affect the results, al- though very little. A larger number of patients and a longer follow-up timeframe is preferred in the future in order to assess a statistically significant difference between the 2 groups

Plate fixation of a displaced clavicular fracture does not result in improved clinical and functional outcome at 4-year follow-up period, but significantly reduces the risk of non-union.

Therefore, we suggest an individualized patient- by-patient treatment, taking into consideration the functional demand, the general clinical diseases, the fracture characteristics and the nonunion risk factors such as large displacement.

We suggest surgical treatment as gold standard in young patients, who demand a fast recovery and a good upper limb ROM and should non-union risk fac- tors be <present, whereas conservative treatment can be considered a good option for elderly or less active patients, especially in case of risk factors that can contraindicate surgery.

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