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Deficits Following Nonoperative Treatment of Displaced Midshaft Clavicular Fractures
Michael D. McKee, MD, FRCS(C)1; Elizabeth M. Pedersen, MD1; Caroline Jones, BSc, PT1; David J.G. Stephen, MD, FRCS(C)2; Hans J. Kreder, MD, FRCS(C)2; Emil H. Schemitsch, MD, FRCS(C)1; Lisa M. Wild, BScN1; Jeffrey Potter, BSc1
1 Division of Orthopaedics, Department of Surgery, St. Michael's Hospital and the University of Toronto, 55 Queen Street East, Suite 800, Toronto, ON M5C 1R6, Canada. E-mail address for M.D. McKee: mckeem@smh.toronto.on.ca
2 Division of Orthopaedic Surgery, Sunnybrook and Women's College Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada
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The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Division of Orthopaedics, Department of Surgery, St. Michael's Hospital and the University of Toronto, Toronto, Ontario, Canada

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2006 Jan 01;88(1):35-40. doi: 10.2106/JBJS.D.02795
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Background: Displaced fractures of the midpart of the clavicular shaft are generally treated nonoperatively, and few functional deficits have been reported. Whereas prior investigators have presented radiographic and surgeon-based outcomes, we used a patient-based outcome questionnaire and objective muscle-strength testing to evaluate a series of patients who had received nonoperative care for a displaced midshaft fracture of the clavicle.

Methods: We identified thirty patients (twenty-two men and eight women with a mean age of thirty-seven years) who had sustained a displaced midshaft fracture of the clavicle. All patients were treated nonoperatively. At a mean of fifty-five months, and a minimum of twelve months, outcomes were measured with the Constant shoulder score and the DASH (Disabilities of the Arm, Shoulder and Hand) patient questionnaire. In addition, objective shoulder muscle-strength testing was performed with the Baltimore Therapeutic Equipment Work Simulator, with the uninjured arm serving as a control.

Results: The range of motion was well maintained, with flexion averaging 170° ± 20° and abduction averaging 165° ± 25°. Compared with the strength of the uninjured shoulder, the strength of the injured shoulder was reduced to 81% for maximum flexion, 75% for endurance of flexion, 82% for maximum abduction, 67% for endurance of abduction, 81% for maximum external rotation, 82% for endurance of external rotation, 85% for maximum internal rotation, and 78% for endurance of internal rotation (p < 0.05 for all values). The mean Constant score was 71 points, and the mean DASH score was 24.6 points, indicating substantial residual disability.

Conclusions: Traditionally, good results with minimal functional deficits have been reported following nonoperative treatment of clavicular fractures. However, surgeon-based methods of evaluation may be insensitive to loss of muscle strength. We detected residual deficits in shoulder strength and endurance in this patient population, which may be related to the significant level of dysfunction detected by the patient-based outcome measures.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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