***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVES To evaluate the outcome and satisfaction of closed treatment versus open reduction and internal fixation in comminuted clavicular fractures . METHODS Sixty patients with displaced clavicular fractures were r and omized into operative ( 29 patients ) and nonoperative ( 31 patients ) groups . Three patients in the operative group did not accept the surgery , and seven patients in the nonoperative group did not complete the one-year follow-up . Outcomes were assessed using the Disability of the Arm , Shoulder and H and ( DASH ) score , Constant shoulder score , specific questions regarding patients ' final satisfaction , physical examination , measurement of the shortening of the clavicular length , and plain radiographs . RESULTS There was one nonunion in the operative group and one in the nonoperative group . The nonunion in operative group was the result of the only infection in this group . Four malunions were developed in the operative group and nineteen malunions in the nonoperative treatment , ( p<0.001 ) . Three patients in the operative group were completely dissatisfied with their treatment . Eighteen patients in the nonoperative group were partially satisfied . Pain was the main reason for dissatisfaction in this group . The mean shortening of the clavicle was 26.5 mm in the nonoperative group and 4.0 mm in the operative group . The mean DASH score for the operative and nonoperative groups were 8.6 and 21.3 , respectively ( p<0.001 ) ; and the Constant shoulder scores were 89.8 and 78.8 ( p<0.001 ) . CONCLUSION Open reduction and internal fixation of comminuted fractures of the clavicle using a reconstruction plate is an effective treatment modality . Despite the variety of complications , this method has a higher satisfaction rate than conservative treatment BACKGROUND Recent literature supports surgical intervention for shortened , displaced , mid-shaft clavicle fractures . We present the results of a r and omized clinical trial comparing locked intramedullary fixation and plate fixation for short , displaced , mid-shaft clavicle fractures . MATERIAL S AND METHODS Local ethical approval was obtained and power analysis and sample size calculations were performed prior to commencement . Patients r and omized to 2 groups to be treated with either locked intramedullary fixation or plating .  Patients regularly followed up to clinical and radiographic union . The primary outcome measure was the Constant score , secondary outcome measures included the Oxford shoulder score , union rate , and complication rates . RESULTS Seventeen patients were r and omized to locked intramedullary fixation and 15 r and omized to plating . Mean age was 29.3 years . Mean follow-up was 12.4 months . There was no significant difference in either Constant scores ( P = .365 ) or Oxford scores ( P = .773 ) . There was 100 % union in both groups . In the intramedullary group , 1 case of soft tissue irritation settled after the pin removal ; 1 pin backed out and was revised . Three superficial wound infections result ed in plate removal and 8 plates ( 53 % ) were removed . DISCUSSION Intramedullary fixation has the theoretical advantage of preserving the periosteal blood supply , but carries the morbidity of pin removal . Clavicle plates are not routinely removed but require greater exposure and may compromise periosteal blood supply . CONCLUSION Both locked intramedullary fixation and plating produce good functional results ; however , metalwork may need to be removed as a second procedure We developed a 12-item question naire for completion by patients having shoulder operations other than stabilisation . A prospect i ve study of 111 patients was undertaken before operation and at follow-up six months later . Each patient completed the new question naire and the SF36 form . Some filled in the Stanford Health Assessment Question naire ( HAQ ) . An orthopaedic surgeon assessed the Constant shoulder score . The single score derived from the question naire had a high internal consistency . Reproducibility , examined by test-retest reliability , was found to be satisfactory . The validity of the question naire was established by obtaining significant correlations in the expected direction with the Constant score and the relevant scales of the SF36 and the HAQ . Sensitivity to change was assessed by analysing the differences between the preoperative scores and those at follow-up . Changes in scores were compared with the patients ' responses to postoperative questions about their condition . The st and ardised effect size for the new question naire compared favourably with that for the SF36 and the HAQ . The new question naire was the most efficient in distinguishing patients who said that their shoulder was much better from all other patients . The shoulder question naire provides a measure of outcome for shoulder operations which is short , practical , reliable , valid and sensitive to clinical ly important changes Objectives : To compare results of primary internal fixation of acute displaced midshaft clavicle fractures with those managed nonoperatively in terms of fracture union and functional outcome . Design : Prospect i ve cohort study . Setting : Level II military trauma center . Patients / Participants : Seventy-three patients ( civilian and military ) between 20 and 50 years of age with displaced midshaft clavicle fractures were allocated either to the operative ( n = 45 ) or nonoperative ( n = 28 ) group . Intervention : Patients in the nonoperative group were managed by simple sling immobilization , whereas in the operative group , fractures were reduced and fixed with a contoured reconstruction plate . Main Outcome Measurements : The patients were actively followed up during an 18-month period . Primary outcome measures were the rates of nonunion and symptomatic malunion ; secondary outcomes included the assessment of the Constant score and the overall local complication rate . Results : The 18-month follow-up rate was 90 % . All fractures in the operative group united compared with eight nonunions ( 29 % ) in the nonoperative group ( P = 0.002 ) . Ten symptomatic malunions ( 36 % ) occurred in the nonoperative group , whereas only two ( 4 % ) were reported for the operative group ( P = 0.0008 ) . Constant shoulder scores were significantly better for the operative group at all follow-ups ( P < 0.0001 ) . All six operative complications were implant-related . Conclusions : In this prospect i ve cohort study , primary open reduction and internal plate fixation of acute displaced midshaft clavicular fractures result ed in improved outcomes and a decreased rate of nonunion and symptomatic malunion compared with nonoperative treatment Seventy-nine out- patients with midclavicular fractures were included in a prospect i ve , r and omized trial comparing treatment with a figure-of-eight b and age and a simple sling .  Sixty-one patients completed the study and were reevaluated clinical ly and radiographically after 3 months . We found that treatment with a simple sling caused less discomfort and perhaps fewer complications than with the figure-of-eight b and age . The functional and cosmetic results of the two methods of treatment were identical and alignment of the healed fractures was unchanged from the initial displacement Objective : To compare elastic stable intramedullary nailing ( ESIN ) with nonoperative treatment of fully displaced midshaft clavicular fractures in adults . Design : The study was a r and omized , controlled , clinical trial . Setting : Level 1 trauma center . Patients and Methods : Sixty patients between 18 and 65 years of age participated and completed the study . They were r and omized to either operative or nonoperative treatment with a 2-year follow-up . Intervention : Thirty patients were treated with a simple shoulder sling and 30 patients with ESIN within 3 days after trauma . Main Outcome Measurement : Complications after operative and nonoperative treatments , Disabilities of the Arm , Shoulder and H and ( DASH ) score and Constant Shoulder Score for outcome measurement , and clavicular shortening . Results : Fracture union was achieved in all patients in the operative group , whereas nonunion was observed in 3 of 30 patients of the nonoperative group . Two symptomatic malunions required corrective osteotomy in the nonoperative group . Medial nail protrusion occurred in 7 cases in the operative group . Implant failure with revision surgery was necessary in 2 patients after an additional adequate trauma . DASH scores were lower in the operative group throughout the first 6 months and 2 years after trauma , with a significant difference during the first 18 weeks . Constant scores were significantly higher after 6 months and 2 years after intramedullary stabilization . Patients in the operative group showed a significant improvement of posttraumatic clavicular shortening ; they were also more satisfied with cosmetic appearance and overall outcome . Conclusions : ESIN of displaced midshaft clavicular fractures result ed in a lower rate of nonunion and delayed union , a faster return to daily activities , and a better functional outcome . Clavicular shortening was significantly lower , and overall satisfaction was higher in the operative group Operative treatment of midclavicular fractures in patients older than 60 years poses an increased risk of fixation failure . Although plating of midclavicular fractures in the elderly is still a popular fixation method , osteopenic bone may result in plate loosening and fixation failure . The purpose of this study is to prospect ively evaluate and compare the clinical outcomes of midclavicular fractures in patients older than 60 years who are treated with either a locking compression plate or nonlocking plate .  Sixty-four elderly patients with midclavicular fractures were surgically treated with either a locking compression plate or nonlocking plate , which included dynamic compression plates and reconstruction plates . The  locking compression plate group included 29 patients with an average age of 69.1 years . The  nonlocking plate group included 35 patients with an average age of 66.3 years . Both groups were similar for age , gender , injury mechanism , fracture patterns , and confounding medical condition ( P>.5 ) . However , the locking compression plate group had lower complication rates compared to the nonlocking plate group ( P=.087 ) . In addition , the locking compression plate group had higher rates of return to work and exercise ( P=.02 , P=.016 , respectively ) . If surgery of elderly patients with midclavicular fractures is indicated , internal fixation with a locking compression plate is preferable to a nonlocking plate In a prospect i ve study , the age- and gender-specific incidence and features of  clavicular fractures  were studied during 1989 and 1990 . The population at risk consisted of about 200,000 individuals aged 15 or above in the county of Uppsala , Sweden . There were 187 clavicular fractures in 185 patients corresponding to an annual incidence of 50/100,000 ( males 71/100,000 , women 30/100,000 ) . Males were significantly younger and sustained comminuted fractures more often than women . The fracture incidence decreased with age in both genders , although the reduction was significant only in men . Bicycle accidents most frequently caused clavicular fractures in both genders , whereas sports activities were significantly more common in men . Right and left clavicles were almost as frequently fractured , and a direct fall on the shoulder was the most frequent mechanism of injury for both genders . There was no difference between genders in the anatomical location with about three of four fractures occurring through the middle part and one of four through the acromial part of the clavicle . Ninety-five percent healed uneventfully , while non-union developed in 5 % - evenly distributed between the middle part of the clavicle and the acromial part 
    Output:
    
Overall , the functional outcome ( measured with the Constant score ) was better in the surgically treated groups than in the conservatively treated groups .
Surgical treatment of acute , displaced midshaft clavicle fractures with a plate yields a better functional outcome and lower mal- and nonunion rates than conservative treatment .
However , the clinical relevance of the observed functional benefits are question able as is the use of the shoulder outcome scores frequently employed to assess the functional outcome of clavicle fracture treatment .
When operative treatment is preferred , the number needed to treat to avoid a nonunion is high