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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 13  |  Issue : 2  |  Page : 90-107

Study of outcome of using anatomically precontoured plates in the management of displaced fracture of midshaft clavicle


Department of Orthopaedics, Jhalawar Medical College, Jhalawar, Rajasthan, India

Date of Submission17-Mar-2019
Date of Acceptance26-Dec-2019
Date of Web Publication27-Dec-2021

Correspondence Address:
Dr. Mahaveer Meena
Department of Orthopaedics, Jhalawar Medical College, Jhalawar - 326 001, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_18_19

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  Abstract 


Introduction: Clavicle fracture is one of the most common bony injuries. The most commonly used system of classification of clavicular fractures is that of Allman. It is divided into three groups: Group I – Middle third clavicle fractures (80% of all clavicle fractures), Group II – Lateral third clavicle fractures (15% of all clavicle fractures), and Group III – Medial third clavicle fractures (5% of all clavicle fractures). The prevalence of nonunion or malunion in dislocated midshaft clavicular fractures after conservative treatment is higher than previously presumed, and fixation methods have evolved. Surgery is accepted more and more as primary treatment for dislocated midshaft clavicular fractures, mainly because the results of nonoperative treatment are interpreted as inferior to operative treatment both clinically and functionally. Primary internal fixation of displaced comminuted midshaft clavicular fractures leads to predictable and early return to function. The purpose of this study was to assess the functional outcome of midshaft clavicular fractures treated with precontoured locking compression plate. Methodology: Patients with displaced fractures of clavicle (midshaft) admitted to SRG Hospital, Jhalawar, Rajasthan, from August 2017 to August 2018 were taken up for the study after taking the required consent. Thirty-four patients of displaced fractures of clavicle, satisfying inclusion criteria, were admitted in the study period and were taken up for the study. The results were analyzed by appropriate statistical methods. Results: In our study, 34 cases of displaced middle third clavicular fractures were treated with plate osteosynthesis using anatomically precontoured clavicle plate. Of 34 cases, 16 cases united in 8 weeks, while at the end of 12 weeks, all cases united except one. Of the 34 patients, 24 patients returned day-to-day activities after 2–3 weeks. Of the 34 cases, 30 patients returned to work within 3 months. Of 34 cases, 33 had excellent score and one had fair score. Conclusion: In our study, open reduction and rigid internal fixation of displaced midshaft clavicular fracture has resulted in good fracture union rate and excellent functional outcome.

Keywords: Midshaft clavicle, clavicle fracture, precontoured, clavicle plate


How to cite this article:
Vyas U, Meena M, Jhanwar P, Sharma SB. Study of outcome of using anatomically precontoured plates in the management of displaced fracture of midshaft clavicle. J Orthop Traumatol Rehabil 2021;13:90-107

How to cite this URL:
Vyas U, Meena M, Jhanwar P, Sharma SB. Study of outcome of using anatomically precontoured plates in the management of displaced fracture of midshaft clavicle. J Orthop Traumatol Rehabil [serial online] 2021 [cited 2022 Jan 20];13:90-107. Available from: https://www.jotr.in/text.asp?2021/13/2/90/333555




  Introduction Top


Clavicle links the thorax and shoulder girdle and plays an important role in movements at shoulder girdle. Clavicle fracture is one of the most common bony injuries. The clavicle is an S-shaped bone that acts as a strut between the sternum and the glenohumeral joint. It also has a suspensory function to the shoulder girdle. The shoulder hangs from the clavicle by the coracoclavicular ligament.[1]

The most commonly used system of classification of clavicular fractures is that of Allman. It is divided into three groups:[2]

  • Group I: Middle third clavicle fractures (80% of all clavicle fractures)
  • Group II: Lateral third clavicle fractures (15% of all clavicle fractures)
  • Group III: Medial third clavicle fractures (5% of all clavicle fractures).


Several muscular and ligamentous forces act on clavicle, and familiarity of these various forces is essential to know the displacements of clavicle fractures and why some of the fracture patterns lead to cause problems if not reduced and surgically stabilized.

Embryologically, clavicle develops from two ossification centers separately and then unites, so the junction is the weakest point. Anatomically, it has two curves which make the bone vulnerable for fracture at its middle. Distribution of ligament attachment as well as muscular attachment is as such that medial portion is less mobile than lateral.

Midshaft fractures have conventionally been treated nonoperatively. Surgical treatment of acute midshaft fractures was not favored due to relatively frequent and serious complications. However, the prevalence of nonunion or malunion in dislocated midshaft clavicular fractures after conservative treatment is higher than previously presumed, and fixation methods have evolved.

Surgery is accepted more and more as primary treatment for dislocated midshaft clavicular fractures, mainly because the results of nonoperative treatment are interpreted as inferior to operative treatment both clinically and functionally. There are chances of nonunion in widely displaced fractures of middle third of the clavicle and fractures, with initial shortening of more than 2 cm.[2]

Several studies have examined the safety and efficacy of primary open reduction and internal fixation for completely displaced midshaft clavicular fractures and have noted high union rate with a low complication rate.[3]

In a large number of complex clavicle fractures, a satisfactory outcome is possible with a low complication rate using a locked compression plate.[4] Primary internal fixation of displaced comminuted midshaft clavicular fractures leads to predictable and early return to function.[5]

The present consensus that great majority of clavicular fractures heal with nonoperative treatment is no longer valid. The amount of pain and disability during the first 3 weeks of conservative treatment has been underrated, and the common view that nonunion does not occur is no longer accepted. Pressure from a displaced fragment on the retroclavicular part of the brachial plexus may cause symptoms after conservative treatment.

The purpose of this study was to assess the functional outcome of midshaft clavicular fractures treated with precontoured locking compression plate (LCP).

Aims and objectives

  1. To assess functional outcome following surgical management by anatomically precontoured clavicular plate by superior approach in displaced midshaft clavicular fractures
  2. To study its merits and demerits
  3. To review available literature on functional outcome, following surgical management by anatomically precontoured clavicular plate by superior approach in displaced midshaft clavicular fractures.


Review of literature

Fractures of the clavicle are common, accounting for 5%–10% of all fractures and up to 44% of all injuries to the shoulder girdle. About 80% of these fractures occur in the middle third of the clavicle. Conventionally, it has been treated conservatively with “NEER” in 1960, suggesting that only 0.1% of fractures, treated nonoperatively, will fail to unite.[6],[7],[8],[9]

“In 1981, Zenni et al. concluded that in clavicle fracture, open reduction and internal fixation should be done in the following situations:

  1. Neurovascular compromise due to posterior displacement and impingement of the bone spike on the brachial plexus, subclavian vessels, and even the common carotid artery
  2. Fracture of the lateral end of the clavicle with rupture of the coracoclavicular ligament
  3. Severe angulations or comminution of a fracture in the midshaft clavicle
  4. The patients inability to tolerate prolonged immobilization
  5. Nonunion has occurred after treatment by closed methods.“[10]


“In 1987, Jupiter and Leffert reported that of all the etiological factors that were reviewed, the extent of displacement of the original fracture was the most significant cause of the nonunion. Associated complications were limited mobility of the shoulder, neurovascular symptoms, and thoracic outlet syndrome.“[11]

“In 1997, Hill et al. reviewed 52 conservatively treated adults with midshaft clavicular fractures at a mean of 38 months after injury. Sixteen patients (31%) reported unsatisfactory results after nonoperative treatment.“[12]

“In 2002, Iannotti et al. stated that clavicles plated at the superior aspect exhibit significantly greater biomechanical stability than plated at the anterior aspect.“[13]

“In 2007, Huang et al. concluded that apex of the superior bow of the clavicle is located along the lateral aspect of the bone, whereas the medial aspect of the superior surface of the clavicle remains flat, making it an ideal surface for plating. They also opined that displaced midshaft clavicular fractures which were treated with plate fixation have better functional outcomes than those that are treated nonoperatively.“[14]

“In 2008, Kulshrestha reviewed the results of 20 cases of displaced/comminuted midclavicular fractures, which were operated with primary open reduction and internal fixation with a reconstruction plate placed on the superior aspect of clavicle. All the fractures clinically united by 8 weeks. As per the Rowe criteria, 12 had excellent, 6 had good, and 2 had fair results. On an average, patients had fully functional recovery in 4 months. Primary internal fixation with platting of displaced comminuted midshaft clavicular fractures leads to predictable and early return to function, thus preventing unacceptably high complication rates of nonoperative management of these fractures.“[5]

“In 1999, Shen et al. treated on 251 fresh completely displaced midclavicle fractures in adults. The fractures were plated with a Mizuho C-type plate/an AO 3.5-mm reconstruction plate. The mean time to radiographic union was 10 weeks. Seven patients (3%) had developed nonunion. Healing with angulation occurred in 14 patients. Deep infection developed in one patient and superficial infection in four cases; 21 patients reported soreness with changes in the weather and activity; 28 patients had residual skin numbness caudal to the incision. No patient had shoulder droop, and none had impairment of range of motion or shoulder strength. None developed new or late neurovascular impairment: 171 patients eventually had the hardware removed at an average of 401 days postoperatively. Overall, 94% were satisfied with the procedure. For completely displaced clavicle fracture in adults, plating is a reliable procedure.“[15]

“Between April 2003 and October 2009, Modi et al. operated on 62 clavicle fractures using LCPs through infraclavicular approach. All patients were followed till radiological union was achieved. At final follow-up, 53 patients were available for review. There were 42 male and 11 female patients with an average age of 45 years. The fractures were classified using the system described by Robinson. The average union time was 4.6 months. There was one infection treated with oral antibiotics. There was one stress fracture medial to the plate which was treated nonoperatively and the fracture united. There were two failures of plate which required revision, one at 8 days postoperative and other at 6 weeks.“[4]

“In 2010, Cho et al. did a comparative study of reconstruction plate and reconstruction LCP for the treatment clavicle midshaft fractures. Forty-one patients with clavicle midshaft fractures were operated by internal fixation with a reconstruction plate (19 patients) and reconstruction LCP (22 patients). The mean time to union was 14.6 weeks in the reconstruction plate group compared to 13.2 weeks in the reconstruction LCP group. The mean score to QuickDASH was 33.85 points in the reconstruction plate group compared to 34.81 points in the reconstruction LCP group. The complications in the reconstruction plate were hypertrophic scarring in two cases, painful shoulder in two cases, limitation of shoulder motion in two cases, and screw loosening in three cases. In addition, the complications in the reconstruction LCP group were hypertrophic scarring in four cases, painful shoulder in one case, and a limitation of shoulder motion in one case. This study showed radiologically and clinically good results in both groups. Overall, operative treatment with a reconstruction plate or reconstruction LCP for clavicle fractures can be used to obtain a stable fixation.“[16]

“In 2011, Drosdowech in a biomechanical study compared four different techniques of fixation of middle third clavicular fractures. Twenty fresh fractures of clavicle were randomized into four groups. Each group used a different fixation device (3.5 Synthes reconstruction plate, 3.5 Synthes LCDCP, 3.5 Synthes LCP, and 4.5 DePuy Rockwood clavicular pin). All constructs were mechanically tested in bending and torque modes both with and without a simulated inferior cortical defect. Bending load failure was also conducted. The four groups were compared using analysis of variance test. The plate constructs were stiffer than the pin during both pure bending and torque loads with or without an inferior cortical defect. Bending load to failure with an inferior cortical defect revealed that the reconstruction plate was weaker compared with the other three groups.“[17]

“In 2015, Schemitsch et al. reported that the use of precontoured plates can decrease the rate of hardware removal after primary fixation of displaced fractures of the midshaft clavicle.“[18]

“In 2016, Patra et al. reported in their study that all young patients with displaced middle one-third clavicle fractures should be considered for surgical fixation. Patients with nonunion of clavicle with compromised shoulder function can also return to their normal shoulder function following surgery. In the conservative group, shoulder function was always less in the affected side compared to their normal side.“[19]


  Anatomy Top


The clavicle or collar bone is introduced as one of the bones of shoulder girdle in human and in those in mammals who used their upper limbs for prehension. It has no homolog in pelvic girdle. The clavicle possesses the following functions:[20],[21]

  1. It acts as a strut to place the scapula laterally so that the upper limb can swing clearly from side of trunk
  2. It transmits the forces from the upper limb through the coracoclavicular ligament and medial thirds of the bone to axial skeleton
  3. Concave posterior surface of the medial two-thirds of the clavicle protects the neurovascular structures of the root of the neck
  4. It helps in various scapular movements and performs axial rotation around its long axis during elevation of arm above the head.


Peculiarities

  1. The clavicle is a modified long bone, specially its medial two-thirds, because it transmits the forces or weight from the upper limb to the axial skeleton. This is, however, an exception violating the following principles of long bone:


    1. It possesses no medullary cavity
    2. Ossifies in membrane
    3. It is sometimes pierced by cutaneous (supraclavicular) nerve.


  2. It is the first bone to start ossification in the 5th or 6th week of intrauterine life and the last bone to complete ossification usually after 21st year
  3. It is horizontally placed and is subcutaneous as well as subplatysmal because it is covered by a sheet of platysma bundle. Therefore, the skin glides freely over the clavicle and fracture of the bone does not usually penetrate the skin to make the fracture compound.


Presenting parts

The clavicle presents two ends, sternal and acromial, and a shaft which is curved with the convexity in front of lateral two-third [Figure 1].
Figure 1: Right clavicle

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The sternal end is much enlarged and directed medially with a slight forward and downward tilt. It articulates with the clavicular notch of manubrium sterni and the first costal cartilage to form the sternoclavicular (SC) joint. Its articular surface is convex vertically and slightly concave from before backward. It is covered with fibrocartilage and gives attachment at the periphery to the fibrous capsule, above and behind to the articular disc which divides the joint into two compartments. Close to the sternal end, the undersurface of the shaft presents a depression for the attachment of costoclavicular ligament by which it is connected to the first rib and its cartilage.

The acromial end is flat and bears an oval facet which is directed laterally and downward. It articulates with a similar facet on the anterior part of the medial border of the acromial process of scapula to form acromioclavicular (AC) joint. When the acromion is dislocated, it is driven under the clavicle.

The shaft of the clavicle is functionally divided into two parts:

  1. Flattened lateral one-third which suspends the scapula by attachment of strong coracoclavicular ligament
  2. Cylindrical or prismatic medial two-thirds which actually transmits the force from the upper limb and acts along bone.


Lateral one-third presents concave anterior border, subcutaneous upper surface, and lower surface, which is provided with a conoid tubercle close to the posterior border at the junction between medial two-thirds and lateral one-third and with a trapezoid ridge extending forward and lateral from the conoid tubercle.

Anterior border and the adjoining upper surface give origin to the anterior part of deltoid muscle; posterior border and the adjacent upper surface receive insertion of the anterior fibers of trapezius muscle [Figure 2]. The conoid tubercle and the trapezius ridge of the lower surface give attachment, respectively, to the conoid and trapezius part of coracoclavicular ligament.
Figure 2: Right clavicle – Muscular attachments

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Medial two-third presents anterior, posterior, superior, and inferior surfaces without any limiting border.

Inferior surface exhibits a longitudinal groove in the middle one-third for the attachment of subclavius muscle, and the two lips of the groove give attachment to clavipectoral fascia [Figure 2]. Close to the sternal end, the inferior surface presents a depressed area for the attachment of coracoclavicular ligament.

Anterior surface gives origin to the pectoralis major in the medial half, between pectoralis major and deltoid; the clavicle forms the base of deltopectoral triangle [Figure 2] and [Figure 3].
Figure 3: Anterior surface of clavicle

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Superior surface gives origin to the clavicular head of sternocleidomastoid in the medial one-third; the gap between the trapezius and sternocleidomastoid forms the base of posterior triangle of the neck and gives attachment to the two lamellae of the investing layer of deep cervical fascia enclosing a supraclavicular space.

In between the attachment of four muscles, the entire anterosuperior surface of the clavicle is palpable, covered by the skin and platysma, and crossed by three branches of supraclavicular nerve (C3, C4); occasionally, the intermediate branch pierces the bone.

Posterior surface is smooth and concave, close to the sternal end; it gives origin to a part of sternohyoid muscle.

Rest of the posterior surface is related to the following:

  1. Internal jugular, subclavian, and beginning of brachiocephalic vein in the medial part
  2. Subclavian artery and trunks of brachial plexus in the lateral part
  3. Apex of the lung covered by cervical pleura and suprapleural membrane
  4. Supraclavicular vessels pass laterally along the upper part of the surface
  5. Grants space is formed by investing layer of cervical fascia anteriorly and omohyoid fascia posteriorly. Here, external jugular vein joins subclavian vein at its confluence with internal jugular vein.


Joints related to clavicle

  1. SC joint


  2. It is a saddle type of synovial joint [Figure 4]. Bones forming the joint are sternal end of clavicle and clavicular notch of manubrium sterni and upper surface of the first costal cartilage. The sternal end of clavicle is covered by a fibrocartilage. The articular surface of clavicle is convex from above downward and slightly concave from before backward. An articular disc made of fibrocartilage intervenes between the clavicle and the sternal notch. The articular disc prevents medial displacement of clavicle when a force is applied to the shoulder region.
    Figure 4: Sternoclavicular joint

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    Range of motion is approximately 30°–35° of upward elevation about 35° in the anteroposterior (Ap) direction and rotation along long axis is about 40°. Most SC elevation occurs between 30° and 90° of arm elevation. Fusion of SC joint limits abduction to 90°.

  3. AC joint


  4. It is a synovial joint [Figure 5]. Bones forming the joint are lateral end of the clavicle and clavicular facet on the medial margin of the acromian process of scapula. Both bones possess small, oval articular surfaces which are covered with fibrocartilage. The clavicular facet faces laterally and downward to meet the acromion facet which is inclined at opposite direction. Therefore, in dislocation of the joint, the acromion process is driven below the lateral end of clavicle. The joint cavity is divided by an articular disc which projects from the upper part of fibrous capsule. Rockwood et al. reported 5°–8° of elevation or depression at AC joint with forward elevation and abduction to 180°. On full overhead elevation, the clavicle rotates about 40° along its axis.
Figure 5: Acromioclavicular joint

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Ligaments related to clavicle

  1. Medial ligaments [Figure 3]


    1. Interclavicular ligament


    2. The interclavicular ligament attached between medial end of clavicle and superior sternum and opposite clavicle. Shoulder elevation loses this ligament.

    3. Costoclavicular ligament


    4. This is a ligament extending from the first rib to sternum and clavicle. It has anterior and posterior fibers. It stabilizes the medial end of clavicle during movements.

    5. Capsular ligaments


    6. These are specific thickening of the SC joint capsule. This is the strongest, especially anterosuperior and posterior fibers that prevent upward displacement of medial end of clavicle and downward displacement of lateral end of clavicle.


  2. Lateral ligaments


    1. AC ligaments [Figure 4]


    2. The AC joint capsule thickens to form the AC ligaments. It prevents the Ap movement of the distal end of clavicle.

    3. Coracoclavicular ligaments


    4. It extends from the base of the coracoid process to the inferior aspect of lateral end of clavicle. It has two parts: the trapezoid part and the conoid part. They are thick strong ligaments. It provides vertical stability and suspends the shoulder girdle from the clavicle.


Anatomical position

Place the enlarged sterna end medially, and somewhat forward and downward, rough markings of the shaft and groove for subclavius inferiorly, and the curvature of the anterior surface is convexo–concave from medial to lateral side.

Ossification

The shaft is ossified from two primary centers, medial and lateral, in membrane between the 5th and 6th weeks of intrauterine life; the centers subsequently fuse to form a single center. It is the first bone to start ossification.

A secondary center for the sterna end appears in cartilage at about 18 years; its fusion with the shaft starts at about 21 years and is completed as late as 31 years. Therefore, it is the last bone to complete ossification. The sternal end is the growing end and the nutrient vessels are directed laterally.

Sometimes, a secondary center appears for the acromial end.

Functions of clavicle

  1. Power and stability of the arm


  2. Clavicle provides stability as well as power to the shoulder girdle during the movement of arm above the shoulder level. It also keeps the shoulder in a more lateral position and thus helps in dealing with the three-dimensional environment.

  3. Motion of the shoulder girdle


  4. It is the connecting link between shoulder and sternum.

  5. Muscle attachments


  6. It provides origin of pectoralis major, sternocleidomastoid, and deltoid muscle and insertion of trapezius and subclavius.

  7. Protection of neurovascular structures


  8. The neurovascular structures (subclavian vessels, brachial plexus) and pleura lie just behind the medial three-fifth of the posterior cortex of clavicle. The tubular structure along with the muscle attachments protects the underlying neurovascular structures.
  9. Protection to lungs


  10. Along with rib cage, clavicle protects the superior aspect of lungs.


Mechanism of injury

Fall on the shoulder is the most common cause for the fractures of the middle shaft fractures of the clavicle. It can occur in many ways such as fall from a vehicle or during a sports event. As we know, clavicle acts as a strut between shoulder and sternum. Hence, any direct force which is more than the ability of the bone to withstand it causes failure in three ways. First is fracture of the clavicle, AC joint disruption, or SC joint disruption [Figure 6].
Figure 6: Fall on Outstretched Hand

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Other cause is fall on outstretched hand. Most of the fractures of clavicle occur at mid-third region because it is the narrowest portion and soft tissue coverings are little. If the mechanism of injury is trivial, then one should rule out pathological fractures.

Fracture biomechanics

The clavicle is the origin and insertion for so many structures, and the same structures cause displacement of fracture fragments [Figure 7].
Figure 7: Deformity Forces on Clavicle fracture

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SC ligaments stabilize the medial segment and sternocleidomastoid pulls it upward. Body weight acting through the coracoclavicular ligament pulls down the distal fragment.

Clinical findings

Patient or relatives usually give a history of direct or indirect injury to the shoulder. The vast majority of fractures will result from a simple fall, a fall from a height, a fall during a sport activity, or a motor vehicle accident.

Patient may tilt their head toward the affected side of injury to relax the trapezius muscle. By gravity and pull of pectoralis minor muscle, the affected arm droops downward and forward. Because of this, the posterosuperior angulation increases which is usually seen in displaced clavicular fractures.

Contusions may be seen over the fracture site. Marked displacement of fracture fragments may produce tenting of the skin. Examination shows tenderness at the fracture site. Gentle manipulation usually produces crepitus. Movements of the shoulder will be painful in all directions.

Associated injuries

Associated injuries can occur along with fracture of the clavicle. It can be divided into:

  1. Injury to the skeletal structure
  2. Lung and/or pleural injury
  3. Injury to the vessels
  4. Injury to the brachial plexus:


  1. Skeletal injuries may include


    1. Dislocation or fracture dislocation of SC or AC joints
    2. Injury to the craniofacial skeleton
    3. Fractures of the ribs
    4. Fracture of clavicle along with the scapula is known as floating shoulder.


    The combination of ipsilateral fracture of the clavicle and scapular neck has conventionally been called the “floating shoulder.” It is considered as an unstable injury and may require operative fixation. This injury is considered as a subgroup of superior shoulder suspensory complex. It includes both bone and soft tissue circle or ring of the glenoid, coracoid process, coracoclavicular ligament, clavicle, AC joint, and acromion. This is important biomechanically and maintains the anatomic relationship between upper extremity and axial skeleton. If operative intervention is chosen, then anatomic reduction and internal fixation of the clavicle is performed first and the shoulder is then reimaged. If the fixation result in indirect reduction of the glenoid, no further intervention is required. If the glenoid remains in unacceptable position, then fixation of glenoid neck is indicated.[22]

  2. Pleura and lung: Apical pleura lies close to clavicle. Hence, fracture of the clavicle may produce pneumothorax or hemothorax
  3. Vascular injuries rarely occur. It can cause laceration, occlusion, or spasm of vessels. The most commonly injured vessels are subclavian artery or vein and internal jugular vein
  4. Injury to brachial plexus is often associated with subclavian vascular injury.


Radiographic evaluation

Evaluation of middle third clavicle fractures

The clavicle not only shortens but also becomes angulated inferiorly and rotated medially and the deformity is truly in two planes. To get a clear-cut position of fragment position, at least two projections of the clavicle are needed. These are an Ap view and a 45° cephalic tilt view.

Evaluation of acromioclavicular joint and distal clavicle

Ap oblique stress film with the patient standing and 10 pound weights is suspended from each wrist should be sufficient to diagnose an unstable distal clavicle fracture.

Evaluation of sternoclavicular joint

Ap view may fail to identify these fractures because of the overlap of ribs and shadows of mediastinum. A cephalic tilt (40°) view of both clavicle and a computed tomographic scan or bone scan may be helpful to diagnose this fracture.


  Classification Top


Allman [Figure 8]:
Figure 8: Allman and Neer Classification of Clavicular fractures

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  • Group I: Fractures of the middle third of clavicle
  • Group II: Fractures of the lateral third of clavicle
  • Group III: Fractures of the medial third of clavicle.


Robinson

  • Type 1: Medial [Figure 9]
  • Figure 9: Type 2 Robinson Classification of Clavicular fracture

    Click here to view


    • A Nondisplaced
    • A1 Extra-articular
    • A2 Intra-articular
    • B Displaced
    • B1 Extra-articular
    • B2 Intra-articular.


  • Type 2: Middle


    • A Cortical alignment
    • A1 Nondisplaced
    • A2 Angulated
    • B Displaced
    • B1 Simple or single butterfly fragment
    • B2 Comminuted or segmental.


  • Type 3: Distal


    • A Nondisplaced
    • A1 Extra-articular
    • A2 Intra-articular
    • B Displaced
    • B1 Extra-articular


  • B2 Intra-articular.


AO classification

  • Type A: Simple


    • A1 Spiral fracture
    • A2 Oblique fracture
    • A3 Transverse fracture.


  • Type B: Wedge


    • B1 Spiral wedge fracture
    • B2 Bending wedge fracture
    • B3 Fragmented wedge fracture.


  • Type C: Complex


    • C1 Complex spiral fractures
    • C2 Segmental fracture
    • C3 Irregular fracture.


Treatment modalities

The treatment of clavicular fractures is still a debatable issue. Most of the old teaching is in favor of nonoperative management of clavicular fractures. However, there are indications for primary fixation of clavicular fractures.

Fracture specific

  1. Displacement >2 cm
  2. Commination >3 fragments
  3. Segmental fractures
  4. Open fractures
  5. Impending compound fracture with soft tissue compromise.


Associated injuries

  1. Vascular injury
  2. Progressive neurological deficit
  3. Ipsilateral upper extremity injuries
  4. Floating shoulder
  5. Bilateral clavicular fractures.


Patient factors

  1. Polytrauma with requirement for early upper extremity weight-bearing
  2. Patient motivation for rapid return of function.


Treatment modalities of middle third clavicular fractures include as follows.

  1. Nonoperative


  2. Different types of immobilization include:

    1. Commercial figure-of-eight
    2. Parham support[23]
    3. Bohler brace
    4. Taylor support
    5. Velpeau wrap
    6. Modified Velpeau wrap
    7. Modified Sayre bandage
    8. Billington yoke (plaster figure-of-eight).


  3. Operative[23]


    1. Closed reduction and nailing
    2. Open reduction and plate osteosynthesis/nailing
    3. External fixation.


A. Conservative management (photographic illustrations)

Figure 19 a-h : Types of conservative Management
Figure 10: Instruments and plate used during surgery

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Figure 11: (a) Supine position with sand bag between scapulae, (b) Skin incision

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Figure 12: (a) Reduction, (b) fixation with anatomical plate

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Figure 13: (a and b) Applying locking screws

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Figure 14: Suturing

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Figure 15: (a) Preoperative, (b) immediate postoperative, (c) postoperative a b c

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Figure 16: (a.c) Functional outcome (at 24 weeks)

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Figure 17: (a) Preoperative, (b) immediate postoperative, (c) postoperative (24 weeks). Functional outcome (at 24 weeks

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Figure 18: (a) Preoperative, (b) immediate postoperative, (c) postoperative (24 weeks). Functional outcome (at 24 weeks)

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a. Commercial figure-of-eight





b. Parham support



c. Bohler brace



d. Taylor support



e. Velpeau wrap





f. Modified Velpeau wrap





g. Modified Sayre bandage



h. Billington yoke (plaster figure-of-eight)



B. Operative technique

  1. Intramedullary nailing


  2. It is almost similar to intramedullary fixation of long bone fractures. Its advantages are smaller, cosmetic skin incision, decreased hardware prominence, and lower incidence of fracture at the end of the implant. Its disadvantages are inability to lock the pin, pin migration,[22] failure to maintain axial length and rotation, especially if there is fracture communition.[24]

  3. Plate osteosynthesis


  4. Plate osteosynthesisis the current method of treatment for mid-third clavicle fractures. Reconstruction plate or LCP is commonly used to fix clavicle fractures.


Advantages

  1. For transverse fractures, compression across the fracture site is achieved
  2. For oblique fractures or butterfly fragments, lag screw fixation is possible with the plate functioning in a neutralization mode
  3. Rotational control of the fracture is achieved
  4. Rigid fixation allows the patient to early mobilization of the upper limb and early return to the activities of daily living.


Disadvantages

  1. It includes the necessity for increased exposure and soft tissue stripping
  2. The plate itself sits subcutaneous and can be the source of irritation
  3. For plate removal another procedure is required.


Despite these short comings, plate fixation utilizing careful surgical techniques is an excellent method of treatment for mid-clavicular fractures.

Reconstruction plate (precontoured locking clavicle plate)

The 3.5-mm reconstruction plate is used for surgery involving clavicle and scapula. These plates are used with 3.5 cortical screws. The reconstruction plates have lateral notches between the holes, which enables twisting and bending in two dimensions.[25] Special bending irons and players are available. Bending angles greater than 15° at any site should be avoided. Stiffness of the plate is further diminished by bending.

The oval hole permits some self-compression if the screw is inserted eccentrically. The screws also accept 4-mm cancellous screws. It is made up of stainless steel and available in a variety of precontoured shapes, including:

  1. Straight reconstruction plate
  2. Curved reconstruction plates
  3. J-shaped reconstruction plates
  4. Precontoured locking clavicle plate.


  5. C. External fixation

    Open fracture of clavicle is an indication for external fixation. It takes the advantages of intrinsic healing ability of the clavicle and allows restoration of length.

    Complications of clavicle fractures

    1. Malunion


    2. In adults, there is no remodeling potential for the bone. Hence, shortening or angulation occurs as a common complication of displaced clavicular fractures. In a study, it is found out that shortening of around 15 mm is associated with pain

    3. Delayed union[8]


    4. The delayed union in clavicle is defined as the union that occurs between 12th and 24th weeks

    5. Nonunion


    6. Nonunion is defined as when union not occurred within 24 weeks.

      The causes of nonunion of clavicular fractures are as follows:

      1. Inadequate immobilization
      2. Markedly displaced (>2cm) fractures
      3. Muscle forces displacing the fracture fragments.


    7. Neurovascular sequelae


    8. Neurovascular sequelae can occur in both united and ununited fractures. Abundant callus or the fracture deformity may narrow the costoclavicular space.[4] It can cause compression of neurovascular structures and produce symptoms.


    Complications of surgery and its treatment

    1. Hard ware problems


    2. As with fresh fracture fixation inadequate purchase or plate size, collapse of the intercalary graft are important predictors of failures such as plate loosening, plate angulation, and plate breakage which may be treated by replating.

    3. Infection

      Infection is a nightmare for orthopedic surgeons. Superficial infection can be treated with antibiotics. Deep infection needs wound debridement and higher antibiotics.

    4. Hypertrophic scar


    5. Another complication is hypertrophic scar. It can be treated by scar excision at the time of plate removal.

    6. Nonunion, delayed union, and malunion


    7. These complications are very rare after plate osteosynthesis. It can be treated by replating and bone grafting.



  Materials and Methods Top


Patients with displaced fractures of clavicle (midshaft) admitted to SRG Hospital, Jhalawar, Rajasthan, from August 2017 to August 2018 were taken up for the study after taking the required consent.

Sample size

Thirty-four patients of displaced fractures of clavicle, satisfying inclusion criteria, were admitted in study period and were taken up for study. The results were analyzed by appropriate statistical methods.

Inclusion criteria

  • Male and female adults more than 20 years
  • Displaced middle one-third clavicle fractures
  • Middle one-third clavicle with fracture ends overlapping
  • Closed and compound Gustilo–Anderson type I of above categories.


Exclusion criteria

  • Patients aged below 20 years
  • Undisplaced or incomplete fractures of clavicle
  • Fracture clavicle involving lateral one-third or medial one-third
  • Patient reporting after 2 weeks
  • Patient not willing for surgery
  • Patient having associated bony or neurovascular injury
  • Open or infected fractures of clavicle.


All the cases were subjected to detailed history and clinical examination with emphasis on age, sex, mode of injury, fracture pattern, medical comorbidities, other associated bony injuries, associated neurological loss, associated visceral injury, duration of reporting after injury, and time interval between injury and treatment.

A thorough clinical evaluation of affected region was carried out according to the following points: attitude, pain, edema, ecchymosis, and deformity. The Examination also includes general, systemic examination and for associated injuries such as head injuries, chest-visceral injuries, and other associated skeletal injuries.

The required information was recorded and proforma was prepared. Radiographs of chest with shoulder were taken in approximate views and diagnosis was established by clinical and radiological means. All fractures were classified on the basis of AO classification.

Then patients was put on preoperative figure-of-“eight” bandages or clavicle braces with pouch arm sling.

All patients were taken for elective surgery as soon as possible after necessary blood, urine, and radiographic preoperative work-up.

Preoperative intravenous cephalosporin antibiotic was given and continued at 12-hourly interval postoperatively for 5 days and then switched to oral form till suture removal.

Clinical outcome and functional results were evaluated by Constant and Murley scoring system.

Selection of implant

Implant – Anatomically precontoured locking clavicle plate

The plate and screws made from 316L stainless alloy with gun drilling technique.

The anatomically precontoured locking clavicle plate available from four holed to eight holed with 3.5-mm thickness plate for clavicle [Figure 10].

Locking screws in the plate for a secure support of the locking screw is threaded which gets locked to the plate as it is tightened.

LCP combi holes plates are the Intraoperative choice because it maintains angular stability and/or compression.

Standard screws used for interfragmentary or dynamic Axialcompression.

Locking screws are used for stable plate screw fixation without loss of reduction, regardless of plate modeling.

It has lateral superior placement which provides less need to detach muscle than with anterior placement and thus easier plate placement.

Furthermore it has medial anterior placement which reduces risk of damaging surrounding structures, less plate prominence, and easier drilling and screw insertion under the chin.

Tapered plate tip facilitates subcutaneous placement by preventing soft tissue irritation.

3.5-mm self-tapping locking screws with 2.5-mm and 2.7-mm drill bits, along with threaded drill sleeves are available.

Instruments and plate used during surgery

Operative anesthesia

The patients were taken up for surgery under general anesthesia/regional anesthesia.

Patient positioning [Figure 11]

The patient was positioned supine or beach chair position on the table with sandbag between the scapulae to increase clavicle prominence.

The affected side upper arm along the side of chest with elbow flexed 90° and forearm in midprone position supported by the abdomen.

The C-arm image intensifier was used for Ap and oblique view.

Exposure

Draping and painting was done adequately from neck up to forearm and chest.

Approaches

Superior approach.

Operative procedure

Place the patient in supine position with sand bag between the scapulae. Keeping the sand bag allows the shoulder girdle to fall backward. It restores the length and increases the exposure to clavicle. Make an incision along the axis of the clavicle, and centering the fracture site. Subcutaneous tissue along with platysma incised together and mobilized.

Myofascial layer is incised and elevated. Fracture site exposed. Periosteum elevated. Fracture ends freshened. Fracture reduced using bone clamps. If there is a comminuted wedge fragment, fix it with a lag screw. Precontoured anatomical clavicular plate is used. The plate is placed over the superior surface of the clavicle [Figure 12]. 2.7-mm drill bit is used. Screw size was measured with depth gauge. Tapping was done with 3.5-mm tap. 3.5-mm cortical screws are used for reconstruction and locking screws in locking plate [Figure 13]. Minimum of six cortical purchases was attained on either side of the fracture. Myofascial layer followed by skin and subcuticular tissue sutured [Figure 14]. Sterile dressing applied and immobilized in a shoulder immobilizer.

Postoperative protocol

Adequate analgesics and intravenous (IV) antibiotics were given up to 5th postoperative day [Figure 15],[Figure 16],[Figure 17],[Figure 18]. After IV antibiotics, oral antibiotics were administered till removal of sutures.

Postoperative check X-rays were obtained.

Sutures were removed on 12th–15th postoperative day.

Patient was made to sit up on bed with side supported in pouch arm sling on the 2nd postoperative day and partial shoulder movements started from 15th day and full movements permitted including sports activity at 3 months.

Patient were discharged whenever comfortable.

Rehabilitation

The objectives of rehabilitation are to improve and restore the function of the shoulder for activities of daily living and vocational and sports activities. Rehabilitation of the affected extremity was done according to the stage of fracture union and time duration from day of surgery.

Pendulum movements/Codman's exercises started from the 3rd postoperative day.

  • The sling discontinued and unrestricted range of motion exercise allowed at the end of 2 weeks
  • They followed every 2 weeks till 3 months, then by every 4 weeks till 6 months, and every 8 weeks till 1 year
  • Sports activities and heavy weighting are avoided till 12 weeks.


The functional outcome was assessed by Constant and Murley score.

Constant and Murley scoring

The patients are graded as follows:

Total points = 100

1. Subjective = 35 points

2. Objective = 65 points

A. Subjective: Total points 35 (15 + 20)

1. Pain = total points 15

  • No pain – 15
  • Bearable pain – 10
  • Disabling pain – 5


2. Activities of daily living = total points 20

  1. Ability to perform full work – 4


    • No limitation – 4
    • Moderate limitation – 2
    • Severe limitation – 0


  2. Ability to perform leisure activities/sports – 4


    • No limitation – 4
    • Moderate limitation – 2
    • Severe limitation – 0


  3. Unaffected sleep – 2


    • Unaffected – 2
    • Sometimes disturbed – 1
    • Always disturbed – 0–2


  4. Level at which work can be done – 10


    • Up to waist – 2
    • Up to xyphoid – 4
    • Up to neck – 6
    • Up to head – 8
    • Above head – 10.


B. Objective: Total points 65 (40 + 25)

1. Range of movement of shoulder: total points 40 (10 + 10 + 10 + 10)

  1. Active (forward) flexion without pain: 10 points


    • 0°–30°: 0
    • 31°–60°: 2
    • 61°–90°: 4
    • 91°–120°: 6
    • 121°–150°: 8
    • 151°: 10


  2. Functional external rotation: 10 points


    • Hand behind head with elbow forward – 2
    • Hand behind head with elbow backward – 4
    • Hand above head with elbow forward – 6
    • Hand above head with elbow backward – 8
    • Full elevation from on top of head – 10
    • Active abduction without pain: 10 points


  3. With dorsum of hand on back, head of third metacarpal reaches


    • 0°–30°: 00
    • 31°–60°: 2
    • 61°–90°: 4
    • 91°–120°: 6
    • 121°–150°: 8
    • 151°: 10


  4. Functional internal rotation: 10 points


    • Ipsilateral buttock: 2
    • S1 spinous process: 4
    • L3 spinous process: 6
    • T12 spinous process: 8
    • T7 spinous process: 10


2. Strength of abduction total points 25 (1 point to be awarded if able to lift 1 pound after 90° of abduction with hand facing downward).


  Results Top


In our study, 34 cases of displaced middle third clavicular fractures were treated with plate osteosynthesis using anatomically precountered clavicle plate.

Of the 34 cases, 29 patients are male and five patients are female [Table 1] and [Graph 1]. Age of the patients varies from 20 to 50 years. Duration of the study was from August 2017 to August 2018 with a mean follow-up period for 1 year.
Table 1: Sex distribution

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Of the 34 patients, 20 patients sustained injury to the right side and remaining 14 patients on the left side [Table 2] and [Graph 2].
Table 2: Side Involed

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Of the 34 cases, 13 patients were between 20 and 25 years of age and 10 patients between 26 and 30 years of age [Table 3] and [Graph 3].
Table 3: Age Distribution

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In majority of the cases, road traffic accident (RTA, 25) was the cause for injury followed by fall [Table 4] and [Graph 4], [Graph 5].
Table 4: Mode of Injury

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Type of fracture (Based on radiological and intraoperative findings)

In all cases of the 34 patients, 8 were Type2B1 and 26 were Type2B2 [Table 5] of RTA, there was communition at the fracture site.
Table 5: Type of fracture based on radiological assessment

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Of 34 cases, 16 cases united in 8 weeks, while at the end of 12 weeks, all cases united except one [Table 6] and [Graph 6],[Graph 7].
Table 6: Time of Union

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Functional outcome

Of the 34 patients, 24 patients returned day-to-day activities after 2–3 weeks [Table 7].
Table 7: Day to day Activities

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Of the 34 cases, 30 patients returned to work within 3 months [Table 8] and [Graph 8].
Table 8: Return to work

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Constant score

Of 34 cases, 33 had excellent score and 1 had fair score [Table 9] and [Graph 9].
Table 9: Results

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Complications

Of 34 cases, 7 developed postoperative complications [Table 10] and [Graph 10].
Table 10: Post Operative Complications

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Case illustration

Case: 1

Name: xxxxx s/o yyyyy

Age/Sex: Male/20

Mode of injury: RTA

Diagnosis: Left midshaft clavicular fracture

Associated injury: nil

Follow-up:

Time of union: 10 weeks

Complications: Nil

Constant score: 95.

Case: 2

Name: x2x2x2 s/0 y2y2y2

Age/Sex: Male/21 years

Mode of injury: Accidental fall

Diagnosis: Left midshaft clavicular fracture

Associated injury: Nil

Follow-up:

Time of union: 11 weeks

Complications: Nil

Constant score: 95.

Case: 3

Name: aaaaaa w/o bbbbbb

Age/Sex: Female/32 years

Mode of injury: Accidental fall

Diagnosis: Left midshaft clavicular fracture

Associated injury: Nil

Follow-up:

Time of union: 9 weeks

Complications: Nil

Constant score: 95.


  Discussion Top


Clavicle fractures are usually treated conservatively. In a study conducted to analyze the results of conservative treatment by Hill et al. in 1998, Nordqvist et al. in 1994 and Robinson et al. in 2004 found poor results following conservative treatment of displaced middle third clavicle fracture. Hence, there is specific indication for surgery such as displacement, with or without comminuted middle third clavicle fracture (Robinson Type – 2B1, 2B2).

The patients treated with early, rigid fixation of their clavicle fractures shared a high postoperative constant score, early pain resolution early return to activity, and high patient satisfaction rating. Plating has the advantages of maintaining the length, especially in comminuted fractures. There is little chance for hard ware breakdown and migration.

Clavicle nailing is an option for midthird clavicle fractures. Intramedullary nailing is difficult in clavicle because of the anatomical shape. Nailing has the advantages of less soft tissue dissection and periosteal disruption. The disadvantages are the following.

  1. No static locking is available
  2. Hard ware canbreak
  3. Hard waremigration
  4. Breakdown of skin
  5. In comminuted fracture, shortening occurs overtime.[20]


In our study, the clavicle fracture is more common in male than females. There were 29 male and five female patients. This is comparable with other studies by Mohammed et al. where of 34 patients, 32 were male and two were females.[21] In a study by Dhoju et al., out of 20 patients, 16 were males and four were females. From this, we can conclude that it is more common in active individuals.[8],[26]

In our study, right-sided clavicle is commonly involved than left side. This is also comparable with the study by Mohammed et al. where of 34 cases, 28 were on the right side and 6 were the left side. From this, we can come to conclusion that dominant hand involves usually.[25]

In our study, the average age group was 27.5 years. It is also comparable with study by Mohammed et al.[21] This again indicates that clavicle fracture is more common in active, working age group.[8]

In our study, RTA was the most common cause for clavicle fractures. Fall on out stretched hand was the most common mechanism of injury. We studied the fracture pattern (intraoperative finding) based on mode of injury and mechanism of injury. From this, Robinson type 2B2 (comminuted midshaft fracture) is associated with high-velocity injury and direct impact on the shoulder.

In our study, the average time taken for surgery was less than 1 h. Average blood loss was less than 100 ml.

The average time of union was 9.5 weeks. It is also comparable with other studies such as Mohammed et al. and Dhoju et al. Most of our patients returned to work at 2½ months' time.

We assessed the functional outcome using constant score. We got excellent result in all patients except one. The patient came after 6 months for evaluation of pain, fracture found to be malunited after implant breakage. The patient was not willing for implant removal. He treated with analgesics. The mean constant score in our study is 94.75. It is also comparable with other studies by Mohammed et al. and Oliver et al.

In our study, there are four patients complained of hard ware irritation. In these patients, functional outcome was good. We removed implant in two patients.

One case had superficial infection. This was managed with IV antibiotics. Superior plating has the advantage of plating over the tension surface. Superior plating is the preferred technique when there is inferior cortical communition. We considered stability more than cosmesis, so our choice was superior plating than anteroinferior plating which has less hard ware irritation.[13]

According to literature, superior plating is associated with neurovascular complications. To avoid neurovascular injury, we measured the clavicle size pre operatively and we adjusted the drill bit length.


  Conclusion Top


In our study, open reduction and rigid internal fixation of displaced midshaft clavicular fracture has resulted in good fracture union rate and excellent functional outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Iannotti MR, Crosby LA, Stafford P, Grayson G, Goulet R. Effects of plate location and selection on the stability of midshaft clavicle osteotomies: a biomechanical study. J Shoulder Elbow Surg 2002;11:457-62.  Back to cited text no. 13
    
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Huang JI, Toogood P, Chen MR, Wilber JH, Cooperman DR. Clavicular anatomy and the applicability of precontoured plates. J Bone Joint Surg Am 2007;89:2260-5.  Back to cited text no. 14
    
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Patra SK, Patro BP, Sahu MC, Samal S. A comparative study of functional outcome following internal fixation and conservative management; in non union clavicle. Int Surg J 2016;3:291-5.  Back to cited text no. 19
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]



 

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