• Hendrik F S Fuglesang, Gunnar B Flugsrud, Per-Henrik Randsborg, Knut Stavem, and Stein E Utvåg.
• Orthopaedic Department, Akershus University Hospital, Lørenskog, Norway. drhendrik@me.com.
• Arch Orthop Trauma Surg. 2016 Jan 1; 136 (1): 17-25.

ObjectivesIt is unclear whether all completely displaced midshaft clavicle fractures require primary surgical intervention. The aim of this study was to elucidate the radiological and clinical outcomes after conservative treatment, and to identify subgroups at risk of an inferior outcome.DesignRetrospective case series.SettingLevel II trauma center.PatientsBetween 2005 and 2008, 122 patients were conservatively treated for a completely displaced midshaft clavicle fracture of whom 92 were eligible for inclusion in this study. Of these, 59 completed the study after a median of 2.7 years after the fracture (min-max, 1.1-4.9).InterventionThe patients received the standard treatment administered at our institution at the time: nonsurgically with a sling without physiotherapy. Patients with painful nonunions were subsequently offered surgery.Main Outcome MeasurementsAt follow-up, the patients' Disabilities of Arm, Shoulder, and Hand (DASH) and the Constant scores were evaluated. Radiographs were taken at follow-up and compared to those taken acutely.ResultsNonunion was found in 9 of the 59 (15.3%) patients. Twenty-four (24%) patients reported a fair-to-poor DASH score (i.e. >20). Patients with fractures that were vertically displaced by more than 100% (one bone width) were significantly less satisfied than those with fractures vertically displaced at 100% (p = 0.04). Initial shortening of more than 15 mm was not associated with a worse outcome or nonunion. The odds ratio of developing a nonunion increased with age (p = 0.04).ConclusionsBy treating completely displaced midshaft clavicle fractures conservatively with a sling and offering plate fixation for eventual painful nonunions, we found a 24% risk of a fair or poor clinical result with a DASH score over 20. A vertical displacement of more than 100 % between the main fragments on the initial radiograph was associated with an inferior clinical outcome in this study.Level Of EvidenceIV.

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