Avinash clavicle

Jebmh.com Original Research Article
J Evid Based Med Healthc, pISSN - 2349-2562, eISSN - 2349-2570 / Vol. 8 / Issue 30 / July 26, 2021 Page 2679
A Prospective Observational Study on Outcomes of
Displaced Mid-Shaft Clavicle Fractures Treated with Locking
Compression Plate at a Tertiary Center in Jaipur
Vishal Singh1
, Anil Kumar Marotia2
, Avinash Gundavarapu3
, Alokeshwar Sharma4
1, 2, 4
Department of Orthopaedics, Dhanwantri Hospital, Jaipur, Rajasthan, India.
3
Department of Orthopaedics, Yashoda Super-speciality Hospital, Hyderabad, Telangana, India.
ABSTRACT
BACKGROUND
Fracture of the clavicle shaft forms 70 % to 80 % of all clavicular fractures. More
recent data, suggests that the incidence of non-union in displaced comminuted
midshaft clavicular fractures after conservative treatment is higher than previously
presumed. The purpose of our study was to analyse the functional outcome of mid
third displaced clavicular fractures treated using locking compression plate.
METHODS
Our study is a prospective observational study conducted in Department of
Orthopaedics, Dhanwantri Hospital & Research Centre, Jaipur, Rajasthan, from
May 2016 to June 2017. Patients presented to emergency room with displaced
middle third clavicle fracture, treated with locking compression plate (LCP) were
the subjects in our study. 20 cases were evaluated in our study. The functional
outcome was assessed by constant and Murley score.
RESULTS
Mean age in our study of 20 cases was 34.85 year. Out of the them, 13 (65 %)
patients were males and 7 (35 %) patients were females. According to Robinson
classification, 13 cases (65 %) were type 2b1 and 7 cases (35 %) were type 2b2.
In majority of cases, (75 %) hospital stay was less than 4 days. Out of the 20
cases, 17 (85 %) patients returned to work within 14 weeks. Majority of cases, 90
% (18) patients in the present study fracture union occurred before 10 weeks.
Post-operative complications were seen in 5 cases (25 %). This study showed 85
% of patient (17) had excellent functional outcome and 15 % of patients (3) had
good results, the mean ± SD (min to maximum) constant score was 94.20 ± 3.48
(84 to 98).
CONCLUSIONS
Treatment of displaced midshaft clavicle fracture with locking compression plate
provides better biomechanical stability, good fracture union rates, high post-
operative constant score, early pain resolution, early return to activity, high patient
satisfaction rates and excellent functional outcome. These benefits of plating
overweigh complications when used in specific indications like displaced with or
without comminuted middle third clavicle fracture (Robinson Type 2B1, 2B2).
KEYWORDS
Midshaft Clavicle Fractures, Locking Compression Plate (LCP), Constant Murley
Score
Corresponding Author:
Dr. Avinash Gundavarapu,
Department of Orthopaedics,
Yashoda Super-speciality Hospital,
Hyderabad, Telangana, India.
E-mail: avinashrao.dr@gmail.com
DOI: 10.18410/jebmh/2021/493
How to Cite This Article:
Singh V, Marotia AK, Gundavarapu A, et
al. A prospective observational study on
outcomes of displaced mid-shaft clavicle
fractures treated with locking
compression plate, at a tertiary center in
Jaipur. J Evid Based Med Healthc
2021;8(30):2679-2684. DOI:
10.18410/jebmh/2021/493
Submission 09-04-2021,
Peer Review 17-04-2021,
Acceptance 11-06-2021,
Published 26-07-2021.
Copyright © 2021 Vishal Singh et al.
This is an open access article
distributed under Creative Commons
Attribution License [Attribution 4.0
International (CC BY 4.0)]

Clavicle fractures account for approximately 2 % to 6 % of
all fractures and 45 - 60 % of shoulder injuries are
associated with clavicle fractures. Fracture of the shaft
account for 70 % to 80 % of all clavicular fractures; whereas
fractures of the lateral and medial third of the clavicle
account for 15 % and 5 %, respectively. Open clavicular
fracture is an absolute rarity, found in only 0.1 % to 1 % of
cases.1
Historically, clavicle fractures have been treated
mostly non-operatively, with expectation for return to
painless, reliable function and the incidence of non-union of
mid-clavicular fractures ranged from 0.1 to 0.8 % previously.
More recent data, based on detailed classification of
fractures, suggests that the incidence of non-union in
displaced comminuted midshaft clavicular fractures after
conservative treatment is higher than previously presumed
and is between 10 and 15 %.2
Non-operative treatment of these fractures with axial
shortening is associated with non-union, delayed union, and
malunion. Surgery is accepted more and more as primary
treatment for displaced mid-shaft clavicular fractures, mainly
because the results of non-operative treatment are
interpreted as inferior to operative treatment both clinically
and functionally.3
There are various methods of treating
clavicle mid-shaft fractures such as intramedullary K-wires
or Steinmann pins fixation and plate fixation. In particular,
locking compression plate fixation can help obtain firm
anatomical reduction in severe displaced or comminuted
fractures.4,5
There are various plates including Sherman
plates, dynamic compression plates and semi tubular plates.
Among them a reconstruction plate or a pre-contoured
locking compression plate are the most preferred.
Objectives
1. To assess the outcome of surgical treated displaced mid-
shaft fractures of clavicle treated with LCP using constant
and Murley score.6
2. To assess the complications associated with clavicle
fractures treated with locking compression plate.
METHODS
Our study is a prospective observational study conducted in
Department of Orthopaedics, Dhanwantri Hospital &
Research Centre, Jaipur, Rajasthan, from May 2016 to June
2017. The study was approved by institutional ethics
committee (IEC no - DHRC / 2016 – 17 / 162 - a) prior to its
commencement. Patients between age group of 18 - 60
years, fulfilling inclusion and exclusion criteria, presented to
emergency room with displaced middle third clavicle fracture
were selected as subjects for the study. The sample size of
our study was 20 patients with isolated displaced middle
third clavicle fractures. A written informed consent was
obtained at the time of admission. All the patients were
treated operatively with open reduction and internal fixation
using locking compression plate, and all the patients had
regular follow-up visits to our out-patient department (OPD)
for the entire duration of treatment. Results of our study
were assessed by constant and Murley score.6
Sample size
was 20 patients with mid 1 / 3rd
clavicle fracture fulfilling
inclusion and exclusion criteria.
Inclusion Criteria
1. Age > 18 years and < 60 years.
2. Isolated closed fractures of midshaft clavicle fractures
with displacement > 2 cm, shortening > 2 cm.
3. Robinson classification 2B1 and 2B2 (displaced
fractures).7
4. 2B1 - Simple or single butterfly fragment.
5. 2B2 - Comminuted or segmental.
Exclusion Criteria
1. Open fracture.
2. Fracture in proximal or distal third of clavicle.
3. Pathological fractures and other injuries around
shoulder girdle.
4. Associated Neuro-vascular injury.
5. Clavicle fractures treated with other fixation modalities.
Study Procedure
Detailed history recording and thorough general physical
examination, local examination, X-ray of chest with both
shoulders antero-posterior (AP) view, plain radiograph of
clavicle AP view, 300
cephalo-caudal views were performed,
and documentation of injuries were done in emergency
room. All the patients were given arm pouch in emergency
room (ER) for temporary fracture splinting. Surgical profile
and pre-anaesthetic evaluation were performed prior to
admission. All our patients received prophylactic antibiotic
(Inj. cefoperazone + sulbactum) ½ hour prior to surgery
and were operated under general anaesthesia. Patients were
operated in supine position with sandbag under the
scapulae. Keeping the sandbag allows the shoulder girdle to
fall backwards. It restores the length and increases the
exposure to clavicle. Incision was marked along the axis of
the clavicle, centring the fracture site. Subcutaneous tissue
along with platysma was incised together and mobilized.
Myofascial layer is incised and elevated. Fracture site was
exposed with minimal periosteum stripping. Fracture
hematoma was washed out. Soft tissue attachments to the
small fracture fragments were preserved. Fracture pattern
was assessed intraoperatively. We studied Robinson 2B1
(Butterfly fragment) and 2B2 (segmental/comminuted) type
of fractures which involve displaced midshaft clavicle
fractures. 2B1 with large butterfly fragments with fragment
size more than twice diameter of bone was reduced with
bone clamps and a lag screw were used to fix the fragment
to fractured bony ends. Compression was achieved with lag
screw. Then LCP was used as a neutralization plate to
maintain the reduction achieved. In case of a small butterfly
fragment, it was reduced with cerclage wire only and used
LCP as a neutralization plate. Segmental fractures of
midshaft clavicle (Robinson 2b2) were reduced using bone
clamps and locking compression plate is placed over the
BACKGROUND

superior surface of the clavicle, fixed initially with
eccentrically placed 3.5 mm cortical screw on either side of
fracture site, to achieve compression at fracture sites and
affix plate to bone, later 3.5 mm locking screws in remaining
plate holes to stabilize fracture. If there is comminution
(Robinson 2B2) all the small fragments were meticulously
handled to preserve soft tissue attachments to them and
fixed with LCP as a bridging plate and cerclage wire was
used to align the fragments at fracture site. A minimum of
six cortical purchases were attained on either side of the
fracture. Myofascial layer was sutured to cover plate and
skin closure is achieved with sub cuticular tissue sutures.
Sterile dressing was applied, and extremity was immobilized
in arm pouch. Antibiotics were continued for 3 days.
Analgesics and tranquilizers were given for 5 days. The
operated upper limb was immobilized in an arm pouch.
Check x-rays were taken to study the alignment of fracture
fragments. The wound was inspected at 2nd post-operative
day and discharged later with an arm pouch. Suture removal
was done on 14th post-operative day. Pendulum movements
/ Codman’s exercises were started from 3rd
post-operative
day. 2nd
week: The sling was discontinued, and unrestricted
range of motion exercise was allowed. They followed every
two weeks till 3 months followed by every 4 weeks till 6
months and every 8 weeks till one year. Sports activities and
heavy weighting are avoided till 12 weeks. The functional
outcome was assessed by constant and Murley score.6
Statistical Analysis
Descriptive and inferential statistical analysis was carried out
in the present study using computer software (SPSS Trial
version 23 and primer). The qualitative data was expressed
in proportion and percentages, and the quantitative data
was expressed as mean and standard deviations. The
difference in proportion was analysed by using chi square
test and the difference in means among the groups was
analysed using the student t test. Significance level for tests
were determined as 95 % (P < 0.05).
RESULTS
This study was conducted in 20 cases with displaced mid-
shaft clavicle fractures treated with locking compression
plate, at the Department of Orthopaedics, Dhanwantri
Hospital and Research Centre, Jaipur from May 2016 to June
2017. The data obtained was coded and entered into the
Microsoft Excel Spread Sheet. The data was analysed, and
results obtained were tabulated. Age of the patients vary
from 19 years to 60 years. Mean age was 34.85 years. In
our study, 70 % of the patients were young belong to 3rd
and 4th
decade. Out of the 20 cases, 13 (65 %) patients were
males and 7 (35 %) patients were females. Male to female
ratio was 1.85 : 1. Out of the 20 patients, 10 patients
sustained injury to the right side and remaining 10 patients
on left side. In majority of the cases, road traffic accidents
(RTA) (70 %) was the cause for injury followed by accidental
fall (30 %). In our study equal numbers of patients sustained
injury by direct impact on shoulder (50 %) & fall on
outstretched hand (50 %). According to Robinson
classification, 13 cases (65 %) were type 2B1 and 7 cases
(35 %) were type 2B2. Out of 13 cases in 2B1, 4 required
inter-fragmentary lag screw fixation and remaining 6 cases
required cerclage wiring and 3 required buttressing of small
fragment under LCP and compression achieved at fracture
site. Out of 7 patients in type 2B2, 5 required cerclage
wiring, 2 cases with segmental fracture required
compression plating using LCP. In majority of cases (75 %)
hospital stay was less than 4 days. Mean ± SD was 4 ± 0.858
days with 3 to 6 days.
Out of the 20 cases, 17 (85 %) patients returned to work
within 14 weeks with mean ± SD was 13.90 ± 2.713. Only
one patient could return to work after 24 weeks due to
complication. Majority of cases (90 %), in 18 patients of the
present study, fracture union occurred before 10 weeks.
Mean ± SD 9.95 ± 3.502. In our study, one case took 24
weeks to unite fracture because of complication.
Complication No. of Patients Percentage (%)
Absent 15 75
Present 5 25
Infection 2 6.67
Plate loosening 0 0.0
Plate breakage 1 3.33
Hardware irritation 3 10
Restriction shoulder motion 1 3.33
Delay union 1 3.33
Malunion 1 3.33
Table 1. Distribution of the Cases According the Complication
In our study, we did not have any significant
intraoperative problems. Complications were seen in 5 cases
(25 %). Hardware irritation in 2 cases, infection and
restriction of shoulder motion in 1 case, plate breakage with
malunion was present in one case and infection + hardware
irritation + delayed union was present in one case. Infection
was managed with debridement with intravenous antibiotics
in one case. Debridement and bone graft was done in one
case of infection, hardware irritation and delayed union.
Plate removal was done in 2 cases of plate irritation, and re-
plating & bone graft was done in plate breakage and
malunion. The mean ± SD (min to maximum) constant score
was 94.20 ± 3.48 (84 to 98). So functional outcome with
LCP is excellent. Table 3 depicts the association of outcome
with Robinson classification. No significant difference was
observed in hospital stay days, return to work weeks, time
of union weeks and constant score in 2B1 & 2B2 cases.
Constant Score Number No. of Patients Percentage (%)
84 1 5
88 1 5
90 1 5
92 1 5
94 6 30
96 7 35
98 3 15
Mean ± SD 94.20 ± 3.48
Table 2. Distribution of the Cases
According to the Constant Score
Robinson
Classification
2B1 2B2
Number Mean SD Number Mean SD
Hospital days stay 13 3.85 0.69 7 4.29 1.11
Return to work weeks 13 13.08 1.32 7 15.43 3.95
Time of union weeks 13 9.23 1.01 7 11.29 5.79
Constant score 13 94.77 2.09 7 93.14 5.27
Table 3. Mean Scores of Different Outcome Variables
Based on Robinson Classification

Case 1.
Complication –
Plate Breakage
Complications
2B1 (N = 13) 2B2 (N = 7)
Number (%) Number (%)
Infection 0 7.69 1 14.29
Plate loosening 0 0.00 0 0.00
Plate breaking 0 0.00 1 14.29
Hardware irritation 1 7.69 2 28.57
Delay union 0 0.00 1 14.29
Malunion 0 0.00 1 14.29
Restriction shoulder motion 1 7.69 0 0.00
Table 4. Frequency Distribution of Complications
with Robinson Classification
No significant association was observed in complications
with Robinson classification. Minimal complications were
present in both 2B2 & 2B1 type of fractures. In the present
study, 85 % of patients (17) had excellent functional
outcome and 15 % of patients (3) had good results, in which
1 case had delayed union with infection and another one
infected, and one plate breakage with malunion.
DISCUSSION
Traditionally displaced mid-shaft clavicular fractures have
been successfully treated nonoperatively and have a high
union rate with few complications. In a study conducted to
analyse the results of conservative treatment by Hill et al.4
in 1997, and Robinson et al.7
in 2004 found poor results
following conservative treatment of displaced middle third
clavicle fracture. So, there is specific indication like
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 post-operative 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 hardware breakdown and
migration.
Out of the 20 cases in our study, 70 % of the patients
were young belong to 3rd
& 4th
decade. In our study the
average age group (mean ± SD) was 34.85 ± 12.64 years
and it varies from 19 years to 60 years. It is comparable with
study by Elidrissi et al.8
and K.B Ravi9
(2017) where mean
age was 36 ± 6 years. Dhoju D (2011) studied on cases with
mean age of the patients was 31.5 years with SD 11.5 years
(range 15 - 60 years).
In our study, according to Robinson classification,3
13
cases (65 %) were of 2B1 and rest 7 cases (35 %) were
2B2. Out of them, KB Ravi9
observed that study according to
the Robinson classification, 2A2 category was seen in 3.3 %,
2B1 was seen in 80 %, 2B2 was seen in 16.7 % of the
subjects. Dr. Saidapur SK10
et al. observed Robinson type-2
B1 in 81.6 % and Robinson type 2 in 18.3 % patients.
Mulimani VM et al.11
(2016) observed that type 2B1
(occurred in 16 patients (80 %) and type 2B2 fracture
occurred in 4 patients (20 %).
In majority of cases (75 %), hospital stay was less than
4 days. Mean ± SD was 4 ± 0.858 days with 3 to 6 days. KB
Ravi9
observed that 63.3 % had a stay of 4 - 6 days, 20 %
stayed for 7 - 10 days, 6.7 % were admitted for 11 - 16 days
and 6.7 % were hospitalized for 17 or more days. Mean
hospital stay was of 7 ± 5 days.
In our study, the average time of union was 9.95 ± 3.502
weeks (min 8 to 24 weeks). Union in (90 %) 18 cases were
within 10 weeks. It is also comparable with other studies like
Elidrissi et al.8
Dhoju et al.12
Most of our patients return to
work at 2-and-a-half-month time. KB Ravi9
observed that
most of the patients i.e., 16 (53.3 %) of them achieved
radiological union in 12 weeks and 11 patients (36.7 %)
achieved union in 24 weeks. 3 patients (10 %) had non-
union. Dr. Saidapur SK et al. observed that 93.3 % of his
patients had fracture union at an average of 12.7 weeks.
Three patients had delayed union which were united by 16
- 18 weeks (5 %). There was implant failure in one case
which went on to develop painless non-union as patient did
not want to have reoperation (1.7 %). Mulimani VM et al.11
(2016) observed that among 20 patients with middle third
clavicle fracture treated with pre-contoured locking plate, 18
fractures united at an average of 9.3 weeks.
Yong-Geun Park13
et al. (2017) observed that all 80 cases
were confirmed to have achieved bone union through
radiographs with an average union period of 10.9 weeks
(range: 7 – 18 weeks). The complications were present in 5
cases (25 %). Hardware irritation in 3 cases, infection, and
restriction of shoulder motion in 1 case, plate breaking with
malunion was present in only one case (5 %), delay union

with infection in 1 (5 %) case. KB Ravi9
observed that 10
(33.33 %) patients had complications. Plate prominence and
restriction of shoulder movements were noted in 10 % of
the study subjects. 7 % of the patients had non-union. Plate
breakage and infection were noted in 3 % of the patients.
There were no wound healing problems, infection or
refracture. Two patients developed incisional numbness.
There were no peri-operative complications. There was 1
case with moderate pain around shoulder joint, decreased
strength and restricted range of motion (ROM) of shoulder.
Infection
Nathan et al.14 Superior plating Nil
Antero inferior plating 2.50 %
Elidrissi et al.8
Deep infection 3 %
Dhoju et al.12
Deep infection 5 %
Our study Superficial infection
2 / 20 (10
%)
Study Implant failure Malunion
Dhoju et al. (Reconstruction Plate)12
Nil Nil
Elidrissi et al. (Reconstruction Plate)8
Nil Nil
Olivier et al. (low contact dynamic
compression plate)15 Nil 5 %
Nathan et al. (superior reconstruction Plate)14
3 % 20 %
Our study (superior LCP) 5 % 5 %
Table 6. Comparison of Complications
with Other Similar Studies
In our study of 20 cases of displaced mid clavicular
fractures, complications were treated with plate removal in
2 cases due to hardware irritation, debridement in one case
of infection, debridement, and bone graft in one case of
infection with delayed union, and re-plating and bone graft
in one case of plate breakage & malunion (5 %).
Study Constant Score
Eldrissi et al.8
95.33
Oliver et al.15
88
Dhoju et al.12
97.45
C.M Robinson et al7.
92
Yong-Geun Park et al.13
92.5 (range: 65-100)
Our study 94.20
Table 7. Comparison of Constant Score
with Other Similar Studies
This table depicts that the mean ± SD (min to maximum)
constant score was 94.20 ± 3.48 (84 to 98). It is also
comparable with other studies by Eldrissi et al.8
and Oliver
et al.15
and Yong – Geun Park et al.13
Study shows excellent
outcome with LCP clavicle plating. No significant difference
was observed in hospital stay days, return to work weeks,
time of union weeks and constant score in 2B1 & 2B2 cases.
No significant association was observed in complications
with Robinson classification. Minimal complications were
present in both 2B1 & 2B2 type fractures. We assessed the
functional outcome using constant score. According to the
outcome, out of 20 cases, 17 (85 %) were observed in
excellent category. 3 (15 %) cases were observed in good
category. Mulimani VM et al.11
(2016) observed that the
functional outcome according to constant and Murley score6
after fracture union were excellent in 16 patients, good in 3
patients and fair in 1 patient. KB Ravi9
observed that as per
the constant scoring system, in 23 patients (77 %) the
functional outcome was excellent, 4 patients (13 %) fell
under good category, 2 patients (7 %) had fair functional
outcome while 1 patient (3 %) had poor outcome. Dr.
Saidapur SK et al.10
observed that as per constant-Murley
scores, there were 55 patients (92 %) with excellent to
good, 3 patients (5 %) with fair and 2 patients (3 %) with
poor results. We assessed the functional outcome of
displaced mid shaft clavicle fractures treated with locking
compression plate using constant score. Patient treated with
locking compression plate showed an early return to day to
day activities and work. The score was significantly more in
excellent outcome as compared to good. (P < 0.001S).
Locking compression plate provides better biomechanical
stability.
CONCLUSIONS
Open reduction and internal fixation of displaced midshaft
clavicle fracture with locking compression plate provides
better biomechanical stability, good fracture union rates,
high post-operative constant score, early pain resolution
early return to activity and high patient satisfaction rating
and excellent functional outcome. The functional outcome
assessment was done using constant and Murley score, it
showed excellent to good results and scores were
significantly more in patients with excellent outcome.
Although complications like hardware irritation, incisional
numbness, infection, delayed union, and restriction of
shoulder motion associated with plating are seen, the
advantages of locking plate to maintain the length of clavicle
in comminuted fractures, little chance of hardware
breakdown and migration overweigh the surgical
complications which are encountered less frequently. When
used for specific indication like placement, with or without
comminuted middle third clavicle fracture (Robinson Type
2B1, 2B2), locking compression plating of clavicle provides
excellent to good functional scores. Complications like
infection can be managed effectively with debridement and
intravenous antibiotics. Hardware irritation can be addressed
by implant removal after satisfactory bony union. Incisional
numbness can be prevented by meticulous dissection of
supra clavicular nerve branches and avoiding injury to them.
Delayed union can be prevented to some extent by avoiding
excessive periosteal stripping and achieve compression at
fracture site, established cases can be treated by bone
grafting at fracture site.
Data sharing statement provided by the authors is available with the
full text of this article at jebmh.com.
Financial or other competing interests: None.
Disclosure forms provided by the authors are available with the full
text of this article at jebmh.com.
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[3] Stegeman SA, de Jong M, Sier CFM, et al. Displaced
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