his multicenter study involving 8 centers randomized 132 patients with midshaft clavicle fractures to either sling immobilization for 6 weeks (65 pts) or operative plate fixation (67 pts). Overall, the patients in the operatively treated group had significantly uperior Constant Shoulder Scores and Dash Scores at all time points tested for 1 year post fracture. In addition, there was faster time to fracture union at 16.4 weeks in the operative group compared to 28.4 weeks in the nonoperative group. There were 2 nonunions in the operative group and 7 in the non-operative group. Patients were more likely to be satisfied with their outcome and overall appearance in the operative group. Three patients in the operative group did develop a wound infection and dehiscence managed with antibiotics and local wound care. Five patients underwent hardware removal due to plate irritation. There was found to be an association between the total displacement at the fracture site with higher Dash Scores, i.e. more patient related disability.
This study adds to the growing base of knowledge for consideration of operative management of displaced midshaft clavicle fractures. It calls in to question the classic recommendations of Neer and Rowe made in the 1960’s of predominantly nonoperative treatment for midshaft clavicle fractures with presumed low nonunion rate and minimal morbidity. In fact, this study suggests a higher nonunion rate as other more recent studies have shown in the non-operative group than in the operative group as well as greater patient satisfaction and overall appearance despite the scar necessary for operative stabilization. In addition, time to union was significantly lower in the operative group. Patients, however, need to be counseled on the inherent risk of infection and the potential need for hardware removal.