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Surgical Techniques   |    
Nonoperative Treatment Compared with Plate Fixation of Displaced Midshaft Clavicular FracturesSurgical Technique
Sahal A. Altamimi, MD, FRCS(C)1; Michael D. McKee, MD, FRCS(C)1
1 Upper Extremity Reconstructive Service, St. Michael's Hospital, 55 Queen Street East, Suite 800, Toronto, ON M5C 1R6, Canada. E-mail address for M.D. McKee: McKeeM@smh.toronto.on.ca
View Disclosures and Other Information
The original scientific article in which the surgical technique was presented was published in JBJS Vol. 89-A, pp. 1-10, January 2007
DISCLOSURE: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the Orthopaedic Trauma Association and Zimmer. Neither they nor a member of their immediate families received 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, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
A video supplement to this article has been produced by the Video Journal of Orthopaedics (VJO). This production is included on the bound-in DVD as part of this issue and will also be available in streaming video format at the JBJS website, www.jbjs.org. VJO can be contacted at (805) 962-3410, web site: www.vjortho.com.
The line drawing in this article is the work of Joanne Haderer Müller of Haderer & Müller (biomedart@haderermuller.com).
Investigation performed at St. Michael's Hospital, Toronto, Ontario, Canada

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2008 Mar 01;90(Supplement 2 Part 1):1-8. doi: 10.2106/JBJS.G.01336
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Abstract

BACKGROUND: Recent studies have shown a high prevalence of symptomatic malunion and nonunion after nonoperative treatment of displaced midshaft clavicular fractures. We sought to compare patient-oriented outcome and complication rates following nonoperative treatment and those after plate fixation of displaced midshaft clavicular fractures.

METHODS: In a multicenter, prospective clinical trial, 132 patients with a displaced midshaft fracture of the clavicle were randomized (by sealed envelope) to either operative treatment with plate fixation (sixty-seven patients) or nonoperative treatment with a sling (sixty-five patients). Outcome analysis included standard clinical follow-up and the Constant shoulder score, the Disabilities of the Arm, Shoulder and Hand (DASH) score, and plain radiographs. One hundred and eleven patients (sixty-two managed operatively and forty-nine managed nonoperatively) completed one year of follow-up. There were no differences between the two groups with respect to patient demographics, mechanism of injury, associated injuries, Injury Severity Score, or fracture pattern.

RESULTS: Constant shoulder scores and DASH scores were significantly improved in the operative fixation group at all time-points (p = 0.001 and p < 0.01, respectively). The mean time to radiographic union was 28.4 weeks in the nonoperative group compared with 16.4 weeks in the operative group (p = 0.001). There were two nonunions in the operative group compared with seven in the nonoperative group (p = 0.042). Symptomatic malunion developed in nine patients in the nonoperative group and in none in the operative group (p = 0.001). Most complications in the operative group were hardware-related (five patients had local irritation and/or prominence of the hardware, three had a wound infection, and one had mechanical failure). At one year after the injury, the patients in the operative group were more likely to be satisfied with the appearance of the shoulder (p = 0.001) and with the shoulder in general (p = 0.002) than were those in the nonoperative group.

CONCLUSIONS: Operative fixation of a displaced fracture of the clavicular shaft results in improved functional outcome and a lower rate of malunion and nonunion compared with nonoperative treatment at one year of follow-up. Hardware removal remains the most common reason for repeat intervention in the operative group. This study supports primary plate fixation of completely displaced midshaft clavicular fractures in active adult patients.

LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

ORIGINAL ABSTRACT CITATION: "Nonoperative Treatment Compared with Plate Fixation of Displaced Midshaft Clavicular Fractures. A Multicenter, Randomized Clinical Trial" (2007;89:1-10).

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    Accreditation Statement
    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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