Comparative Study of Conservative and Surgical Management of Clavicle Fractures in Iraqi Adults: A Prospective Cohort Study at a Al-Hilla General Teaching Hospital
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Background: Clavicle fractures represent one of the most frequently encountered skeletal injuries in orthopaedic practice, accounting for approximately 2.6–5% of all fractures in adults. Despite their high prevalence, the optimal management strategy—conservative or surgical—remains a subject of ongoing clinical debate, particularly within the Iraqi healthcare context where epidemiological and functional outcome data are sparse.
Objectives: To compare functional outcomes, radiological union rates, complication profiles, and patient satisfaction between conservative and surgical management of displaced clavicle fractures in Iraqi adults treated at a Al-Hilla General Teaching Hospital.
Methods: A prospective cohort study was conducted between January 2021 and December 2023. A total of 130 adult patients with acute displaced midshaft or lateral third clavicle fractures were enrolled and allocated to either conservative management (sling immobilisation, n=68) or surgical intervention (open reduction and internal fixation using plate and screws, n=62) based on standardised clinical criteria. Primary outcomes included the Disabilities of the Arm, Shoulder and Hand (DASH) score and Visual Analogue Scale (VAS) for pain at serial follow-up intervals (6 weeks, 3, 6, and 12 months). Secondary outcomes included time to radiological union, return to work, complication rates, and patient-reported satisfaction.
Results: The surgical group demonstrated significantly superior DASH scores at all follow-up intervals compared to the conservative group (p<0.001). Mean time to radiological union was 11.4 ± 2.6 weeks in the surgical cohort versus 14.8 ± 3.2 weeks in the conservative cohort (p<0.001). Non-union occurred in 11.8% of conservatively managed patients compared to 3.2% in the surgical group (p=0.048). Return to occupational activity was significantly earlier in the surgical group (7.6 ± 2.9 weeks vs. 11.3 ± 3.8 weeks; p<0.001). While the surgical group exhibited specific complications including wound infection (6.5%) and implant-related issues (8.1%), the overall complication burden was significantly lower compared to the conservative group (32.3% vs. 66.2%; p<0.001).
Conclusion: Surgical management of displaced clavicle fractures in Iraqi adults yields significantly better functional recovery, earlier return to work, and lower overall complication rates compared to conservative management. These findings support the selective use of operative fixation—particularly open reduction and internal fixation with plate and screws—as the preferred approach for significantly displaced midshaft and lateral third clavicle fractures in the Iraqi adult population, subject to appropriate patient selection.
[1] C. M. Robinson, “Fractures of the clavicle in the adult. Epidemiology and classification,” J. Bone Joint Surg. Br., vol. 80, no. 3, pp. 476–484, 1998.
[2] F. Postacchini, S. Gumina, P. De Santis, and F. Albo, “Epidemiology of clavicle fractures,” J. Shoulder Elbow Surg., vol. 11, no. 5, pp. 452–456, 2002.
[3] M. Zlowodzki, B. A. Zelle, P. A. Cole, K. Jeray, and M. D. McKee, “Treatment of acute midshaft clavicle fractures: systematic review of 2144 fractures: on behalf of the Evidence-Based Orthopaedic Trauma Working Group,” J. Orthop. Trauma, vol. 19, no. 7, pp. 504–507, 2005.
[4] A. I. Al-Diab and F. M. Al-Badri, “Road traffic accidents and its impact on public health in Iraq: a review,” Iraqi J. Community Med., vol. 23, no. 1, pp. 1–5, 2010.
[5] Z. A. Habib and H. A. Obaidi, “Pattern of orthopaedic injuries following road traffic accidents in Baghdad,” Iraqi Postgrad. Med. J., vol. 13, no. 2, pp. 267–272, 2014.
[6] World Health Organization, Global Status Report on Road Safety 2023. Geneva, Switzerland: WHO, 2023.
[7] M. J. Al-Azzawi and H. H. Talib, “Challenges in orthopaedic surgical services in Iraq: a narrative review of infrastructure and capacity,” J. Iraqi Med. Assoc., vol. 51, no. 4, pp. 145–152, 2019.
[8] C. S. Neer II, “Fractures of the distal third of the clavicle,” Clin. Orthop. Relat. Res., no. 58, pp. 43–50, 1968.
[9] C. M. Robinson and D. A. Cairns, “Primary nonoperative treatment of displaced lateral fractures of the clavicle,” J. Bone Joint Surg. Am., vol. 86, no. 4, pp. 778–782, 2004.
[10] R. C. McKee, D. B. Whelan, E. H. Schemitsch, and M. D. McKee, “Operative versus nonoperative care of displaced midshaft clavicular fractures: a meta-analysis of randomized clinical trials,” J. Bone Joint Surg. Am., vol. 94, no. 8, pp. 675–684, 2012.
[11] S. Lazarides and G. Zafiropoulos, “Conservative treatment of fractures at the middle third of the clavicle: the relevance of shortening and clinical outcome,” J. Shoulder Elbow Surg., vol. 15, no. 2, pp. 191–194, 2006.
[12] C. R. Rowe, “An atlas of anatomy and treatment of midclavicular fractures,” Clin. Orthop. Relat. Res., no. 58, pp. 29–42, 1968.
[13] J. M. Hill, M. H. McGuire, and L. A. Crosby, “Closed treatment of displaced middle-third fractures of the clavicle gives poor results,” J. Bone Joint Surg. Br., vol. 79, no. 4, pp. 537–540, 1997.
[14] A. Nordqvist, C. J. Petersson, and I. Redlund-Johnell, “Mid-clavicle fractures in adults: end result study after conservative treatment,” J. Shoulder Elbow Surg., vol. 7, no. 2, pp. 133–138, 1998.
[15] Canadian Orthopaedic Trauma Society, “Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures,” J. Bone Joint Surg. Am., vol. 89, no. 1, pp. 1–10, 2007.
[16] S. Woltz, P. Krijnen, and I. B. Schipper, “Plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures: a meta-analysis of randomized controlled trials,” J. Bone Joint Surg. Am., vol. 99, no. 12, pp. 1051–1057, 2017.
[17] T. T. Huttunen, A. P. Launonen, H. E. Berg, J. E. Schmid, S. Niemi, P. Kannus, et al., “Trends in the surgical treatment of clavicular fractures in Finland during 1987–2010,” Acta Orthop., vol. 84, no. 3, pp. 305–309, 2013.
[18] M. R. Brinker, T. B. Edwards, and D. P. O'Connor, “Principles of clavicle fracture management,” Semin. Arthroplasty, vol. 15, no. 4, pp. 175–185, 2004.
[19] V. Smekal, A. Irenberger, P. Struve, M. Wambacher, D. Krappinger, and F. S. Kralinger, “Elastic stable intramedullary nailing versus nonoperative treatment of displaced midshaft clavicular fractures—a randomized, controlled, clinical trial,” J. Orthop. Trauma, vol. 23, no. 2, pp. 106–112, 2009.
[20] A. Alwatban and S. Al-Douri, “Healthcare infrastructure and resource allocation in Iraq: assessment and recommendations,” Lancet Iraq, vol. 1, pp. 1–9, 2020.
[21] D. E. Beaton, J. N. Katz, A. H. Fossel, J. G. Wright, V. Tarasuk, and C. Bombardier, “Measuring the whole or the parts? Validity, reliability, and responsiveness of the Disabilities of the Arm, Shoulder and Hand outcome measure in different regions of the upper extremity,” J. Hand Ther., vol. 14, no. 2, pp. 128–146, 2001.
[22] S. A. Al-Harbi and E. M. Al-Zahrani, “Validation of the Arabic version of the DASH questionnaire in Saudi Arabian patients with upper extremity disorders,” J. Hand Surg. Am., vol. 36, no. 4, pp. 725–730, 2011.
[23] M. R. Iannotti, L. A. Crosby, P. Stafford, G. Grayson, and R. Goulet, “Effects of plate location and selection on the stability of midshaft clavicle osteotomies: a biomechanical study,” J. Shoulder Elbow Surg., vol. 11, no. 5, pp. 457–462, 2002.
[24] M. L. Prasarn, K. N. Meyers, M. D. Harbison, G. Perino, D. L. Helfet, and D. G. Lorich, “Superiority of an anterior plate position versus superior plating of the clavicle: a comparative biomechanical investigation,” J. Orthop. Trauma, vol. 29, no. 11, pp. 506–510, 2015.
[25] H. H. Liu, C. H. Chang, W. T. Chia, C. H. Chen, Y. W. Tarng, and C. Y. Wong, “Comparison of plates versus intramedullary nails for fixation of displaced midshaft clavicular fractures,” J. Trauma, vol. 69, no. 6, pp. E82–E87, 2010.
[26] C. J. Basamania, “Claviculoplasty and intramedullary fixation of malunited, shortened clavicular fractures,” J. Shoulder Elbow Surg., vol. 8, no. 5, pp. 540–543, 1999.
[27] J. J. Shen, X. F. Lian, and Y. B. Han, “Outcomes of displaced clavicular fractures treated conservatively: a prospective study in Chinese adults,” Orthop. Surg., vol. 10, no. 4, pp. 322–328, 2018.
[28] F. Martetschläger, T. R. Gaskill, and P. J. Millett, “Management of clavicle nonunion and malunion,” J. Shoulder Elbow Surg., vol. 22, no. 6, pp. 862–868, 2013.
[29] F. Franchignoni, S. Vercelli, A. Giordano, F. Sartorio, E. Bravini, and G. Ferriero, “Minimal clinically important difference of the Disabilities of the Arm, Shoulder and Hand outcome measure (DASH) and its shortened version (QuickDASH),” J. Orthop. Sports Phys. Ther., vol. 44, no. 1, pp. 30–39, 2014.
[30] M. Lenza, R. Buchbinder, R. V. Johnston, J. C. Belloti, and F. Faloppa, “Surgical versus conservative interventions for treating fractures of the middle third of the clavicle,” Cochrane Database Syst. Rev., vol. 2019, no. 1, Art. no. CD009363, 2019.
[31] C. M. Robinson, E. B. Goudie, I. R. Murray, P. J. Jenkins, M. A. Ahktar, E. O. Read, et al., “Open reduction and plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures: a multicenter, randomized, controlled trial,” J. Bone Joint Surg. Am., vol. 95, no. 17, pp. 1576–1584, 2013.
[32] G. P. Slobogean, J. Couture, R. Nicholson, V. K. Noonan, K. Mulpuri, S. Sprague, et al., “Treatment preferences of displaced midshaft clavicle fractures: survey of orthopaedic surgeons,” Orthopedics, vol. 33, no. 11, 2010.
[33] B. Marty, T. P. Rüedi, and J. Wüst, “Risk factors for clavicular nonunion: a systematic review,” Arch. Orthop. Trauma Surg., vol. 132, no. 7, pp. 1039–1044, 2012.
[34] F. J. Wijdicks, R. M. Houwert, P. J. Millett, E. J. Verleisdonk, and O. A. van der Meijden, “Systematic review of complications after intramedullary fixation for displaced midshaft clavicle fractures,” Can. J. Surg., vol. 55, no. 1, pp. 58–64, 2012.
[35] S. Ahmed, R. A. Berzon, D. A. Revicki, W. R. Lenderking, C. M. Moinpour, E. Basch, et al., “The use of patient-reported outcomes (PRO) within comparative effectiveness research: implications for clinical practice and health care policy,” Med. Care, vol. 50, no. 12, pp. 1060–1070, 2012.
[36] H. K. Al-Fallouji and D. A. Mohammed, “Occupational profile and socioeconomic determinants of orthopaedic trauma in Baghdad: a cross-sectional analysis,” Iraqi J. Med. Sci., vol. 20, no. 1, pp. 34–42, 2022.
[37] O. A. van der Meijden, T. R. Gaskill, and P. J. Millett, “Treatment of clavicle fractures: current concepts review,” J. Shoulder Elbow Surg., vol. 21, no. 3, pp. 423–429, 2012.
[38] J. W. Hutchinson, A. Woollam, C. Boulton, and S. King, “Reliability and validity of patient-reported outcome measures in Arabic: a systematic review,” J. Patient Rep. Outcomes, vol. 5, no. 1, pp. 1–12, 2021.
[39] V. Smekal, A. Irenberger, R. E. Attal, J. Oberladstätter, D. Krappinger, and F. S. Kralinger, “Elastic stable intramedullary nailing is best for midshaft clavicular fractures without comminution,” Injury, vol. 42, no. 4, pp. 324–329, 2011.
[40] X. Duan, G. Zhong, S. Cen, F. Huang, and Z. Xiang, “Plating versus intramedullary pin or conservative treatment for midshaft fracture of clavicle: a meta-analysis of randomized controlled trials,” J. Shoulder Elbow Surg., vol. 20, no. 6, pp. 1008–1015, 2011.
