Acute operative stabilization versus nonoperative management of clavicle fractures. The management of acute acromioclavicular dislocation. A randomised prospective controlled trial. Elastic stable intramedullary nailing versus nonoperative treatment of displaced midshaft clavicular fractures-a randomized, controlled, clinical trial. Operative treatment of midclavicular fractures in 62 elderly patients: knowles pin versus plate. Intramedullary nailing of clavicular midshaft fractures in adults using titanium elastic nail. Sling compared with plate osteosynthesis for treatment of displaced midshaft clavicular fractures: a randomized clinical trial. Comparison between operative and nonoperative treatment methods in the management of comminuted fractures of the clavicle. Treatment of clavicular fractures. Figure-of-eight bandage versus a simple sling. [Therapy of fresh fibular ligament ruptures].
We conducted a prospective, randomized study to determine if patients with midshaft clavicle fractures would benefit from immediate operative stabilization with a modified Hagie pin in comparison with a matched group treated with nonoperative therapy. At a level II trauma center, patients with closed midshaft clavicle fractures were prospectively randomized to receive either operative or nonoperative treatment. Fifty-seven (29 operative, 28 nonoperative) patients were enrolled in the study. Operative patients underwent open reduction and internal fixation of the clavicle using a modified Hagie pin; nonoperative patients were treated with a sling for comfort. All patients were followed at regular intervals for 1 year. They were evaluated for radiographic healing and complications and were scored with the Single Assessment Numeric Evaluation and L'Insalata instruments. Injury severities and radiographs were not statistically significantly different between the 2 groups. Functional scores in the operative group were slightly higher at 3 weeks, and the nonoperative group had slightly higher scores at 6 months and 1 year. The only statistically significant difference between the groups was at 3 weeks. Percentage follow-up at 1 year was 93% for the operative group and 82% for the nonoperative group. One patient in each group developed a nonunion, and 1 patient in each group had a refracture. Complications were higher in the operative group, and most were related to pin prominence at the posterior shoulder. Results of this study suggest that, though patients with midshaft clavicle fractures had higher functional scores at short-term follow-up after internal fixation, functional scores were similar at 6 months and 1 year. In addition, internal fixation with a modified Hagie pin was associated with a higher complication rate. In a prospective study, 60 patients with acute acromioclavicular dislocation were randomly allocated to treatment with a broad arm sling or to reduction and fixation with a coracoclavicular screw. Of these 54 were followed for four years. Conservatively-treated patients regained movement significantly more quickly and fully, returned to work and sport earlier and had fewer unsatisfactory results than those having early operation. For severe dislocations, with acromioclavicular displacement of 2 cm or more, early surgery produced better results. Conservative management is best for most acute dislocations, but younger patients with severe displacement may benefit from early reduction and stabilisation. To compare elastic stable intramedullary nailing (ESIN) with nonoperative treatment of fully displaced midshaft clavicular fractures in adults.
                The study was a randomized, controlled, clinical trial.
                Level 1 trauma center.
                Sixty patients between 18 and 65 years of age participated and completed the study. They were randomized to either operative or nonoperative treatment with a 2-year follow-up.
                Thirty patients were treated with a simple shoulder sling and 30 patients with ESIN within 3 days after trauma.
                Complications after operative and nonoperative treatments, Disabilities of the Arm, Shoulder and Hand (DASH) score and Constant Shoulder Score for outcome measurement, and clavicular shortening.
                Fracture union was achieved in all patients in the operative group, whereas nonunion was observed in 3 of 30 patients of the nonoperative group. Two symptomatic malunions required corrective osteotomy in the nonoperative group. Medial nail protrusion occurred in 7 cases in the operative group. Implant failure with revision surgery was necessary in 2 patients after an additional adequate trauma. DASH scores were lower in the operative group throughout the first 6 months and 2 years after trauma, with a significant difference during the first 18 weeks. Constant scores were significantly higher after 6 months and 2 years after intramedullary stabilization. Patients in the operative group showed a significant improvement of posttraumatic clavicular shortening; they were also more satisfied with cosmetic appearance and overall outcome.
                ESIN of displaced midshaft clavicular fractures resulted in a lower rate of nonunion and delayed union, a faster return to daily activities, and a better functional outcome. Clavicular shortening was significantly lower, and overall satisfaction was higher in the operative group. This prospective, randomized trial compared treatment with Knowles pins and plates in 62 elderly patients (>50 years) with midclavicular fractures. The clinical outcomes were evaluated at 30 months postoperatively. The mean shoulder score of the Knowles pinning was 85 points and the plating was 84 points (P=.7). Knowles pinning requires significantly shorter operative time (P<.001), smaller wound size (P<.001), shorter hospital stay P=.03), less meperidine use (P=.02), lower complication rate (P=0.04), and less symptomatic hardware (P=.015). If surgery of mid-third clavicular fractures is indicated, fixation with a Knowles pin has more advantages than plate fixation in elderly patients. Objective: Studies showed elastic stable intramedullary nailing (ESIN) of displaced midclavicular fractures has excellent outcomes, as well as high complication rates and specific problems. The aim was to discuss ESIN of midshaft clavicular fractures. Methods: Totally 60 eligible patients (aged 18-63 years) were randomized to either ESIN group or non-operative group between January 2007 and May 2008. Clavicular shortening was measured after trauma and osseous consolidation. Radiographic union and complications were assessed. Function analysis including Constant shoulder scores and disabilities of the arm, shoulder and hand (DASH) scores were performed after a 15-month follow-up. Results: ESIN led to a signifcantly shorter time to union, especially for simple fractures. In ESIN group, all patients got fracture union, of which 5 cases had medial skin irritation and 1 patient needed revision surgery because of implant failure. In the nonoperative group, there were 3 nonunion cases and 2 symptomatic malunions developed requiring corrective osteotomy. At 15 months after intramedullary stabilization, patients in the ESIN group were more satisfied with the appearance of the shoulder and overall outcome, and they benefited a lot from the great improvement of post-traumatic clavicular shortening. Furthermore, DASH scores were lower and Constant scores were significantly higher in contrast to the non-operative group. Conclusion: ESIN is a safe minimally invasive surgical technique with lower complication rate, faster return to daily activities, excellent cosmetic and better functional results, restoration of clavicular length for treating mid-shaft clavicular fractures, resulting in high overall satisfaction, which can be regard as an alternative to plate fixation or nonoperative treatment of mid-shaft clavicular fractures. Few randomized controlled trials have compared operative with nonoperative treatment of clavicular fractures.
                Patients with displaced midshaft clavicular fractures were randomized either to nonoperative treatment with a sling or to operative treatment with a stainless steel 3.5-mm reconstruction plate. Outcome measures were the Constant shoulder score, DASH (Disabilities of the Arm, Shoulder and Hand) score, pain, fracture-healing, and complications. The null hypothesis was that the Constant and DASH scores would not differ between the groups at the one-year follow-up evaluation.
                In accordance with the power analysis, we included sixty patients in the study; thirty-two were randomized to the nonoperative group and twenty-eight to the operative group. We found no difference in the Constant score (p = 0.75), the DASH score (p = 0.89), or pain (p = 0.98) between the groups at the one-year follow-up evaluation. All fractures in the operative group healed, but six nonunions (24%) occurred in the nonoperative group.
                One year after a displaced midshaft clavicular fracture, nonoperative treatment resulted in a higher nonunion rate but similar function and disability compared with operative treatment. To evaluate the outcome and satisfaction of closed treatment versus open reduction and internal fixation in comminuted clavicular fractures.
                Sixty patients with displaced clavicular fractures were randomized into operative (29 patients) and nonoperative (31 patients) groups. Three patients in the operative group did not accept the surgery, and seven patients in the nonoperative group did not complete the one-year follow-up. Outcomes were assessed using the Disability of the Arm, Shoulder and Hand (DASH) score, Constant shoulder score, specific questions regarding patients' final satisfaction, physical examination, measurement of the shortening of the clavicular length, and plain radiographs.
                There was one nonunion in the operative group and one in the nonoperative group. The nonunion in operative group was the result of the only infection in this group. Four malunions were developed in the operative group and nineteen malunions in the nonoperative treatment, (p<0.001). Three patients in the operative group were completely dissatisfied with their treatment. Eighteen patients in the nonoperative group were partially satisfied. Pain was the main reason for dissatisfaction in this group. The mean shortening of the clavicle was 26.5 mm in the nonoperative group and 4.0 mm in the operative group. The mean DASH score for the operative and nonoperative groups were 8.6 and 21.3, respectively (p<0.001); and the Constant shoulder scores were 89.8 and 78.8 (p<0.001).
                Open reduction and internal fixation of comminuted fractures of the clavicle using a reconstruction plate is an effective treatment modality. Despite the variety of complications, this method has a higher satisfaction rate than conservative treatment. Seventy-nine out-patients with midclavicular fractures were included in a prospective, randomized trial comparing treatment with a figure-of-eight bandage and a simple sling. Sixty-one patients completed the study and were reevaluated clinically and radiographically after 3 months. We found that treatment with a simple sling caused less discomfort and perhaps fewer complications than with the figure-of-eight bandage. The functional and cosmetic results of the two methods of treatment were identical and alignment of the healed fractures was unchanged from the initial displacement. In a prospective, random study carried out at the Casualty Clinic of the University Hospital of Hannover from 15 April 1986 to 31 July 1986, 200 patients were randomly selected from four treatment groups, according to treatment: operative-immobilized (group A, n = 52), operative-functional (group B, n = 50), conservative-immobilized (group C, n = 48) and conservative-functional (group D, n = 50). Follow-up examinations were made in 92.5% of patients after 3 months and 64% after 12 months. At the 3-month and 1-year follow-ups, no statistically significant differences were found in the total evaluation (100-point checklist) Moderately significant instability (6 degrees -10 degrees talar tilt and 6-10 mm anterior talar dislocation) in the conservative groups C and D was observed only in the clinical-radiological instability test. This statistically significant difference is, however, only evident in stress tenographically confirmed dual-ligament lesions. No functional physiological differences can be found after 12 months; on average, the period of incapacitation is 3 weeks shorter than with primary functional treatment, but so far there are no long-term results. Until late results are available, we conclude that conservative treatment, even for professional athletes, can be recommended as the procedure most free of risk and most economical; if at all, operative therapy should only be carried out when the instability is very serious.
There is insufficient evidence from randomised controlled trials to determine which methods of conservative treatment are the most appropriate for acute middle third clavicle fractures in adolescents and adults. Further research is warranted.