***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 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 INTRODUCTION Fractures of the clavicle are some of the most common fractures which are seen in the adult population . Mid-shaft fractures of the clavicle are considered the most common form of clavicle fractures and about half of them are displaced fractures . They have been managed non-operatively over the years . However , severe displacement and comminution of these fractures have warranted the requirement of operative intervention , due to increased incidence of mal-union , worsening of shoulder functions etc . , after conservative management . The introduction of locking compression plates , have increased the incidence of operative intervention in the management of these injuries . AIM To study and compare the functional outcome of the shoulder after open reduction and internal fixation versus non-operative management of mid-shaft clavicle fractures . MATERIAL S AND METHODS A prospect i ve study was conducted from June 2013-October 2015 in the Department of Orthopaedic Surgery , K.S. Hegde Medical Academy , Mangalore . A total of 30 skeletally mature patients between the age groups of 20 - 50 years with diagnosed fresh mid-shaft clavicle fractures , AO type A and B mild to moderate displacement , were enrolled into the study with . They were divided into two groups r and omly . Group 1 consisted 16 patients who underwent open reduction and locking compression plate fixation  and Group 2 consisted of 14 patients who were managed with application of a clavicle brace and arm pouch for three weeks . Review s were done at three , six and 24 weeks postoperatively . The patients were assessed clinical ly and radiographs were taken during all the review s. Scoring of shoulder function was done using the Disabilities of the Arm , Shoulder and H and ( DASH ) score during all the review s. The results were tabulated compared and analyzed statistically using the ' Independent t-test ' and Chi-square test . RESULTS The DASH scores at the end of 24 weeks were noted to be 8.57±6.073 points for the 14 patients in the conservative management group and 7.74±16.422 points for the 16 patients in the open reduction and internal fixation group . This indicated that there was no significant difference noted in terms of shoulder function between the two groups . Six of the 14 patients in the conservative management group were noted to have mal-union of the fracture . No non-unions were noted in the conservative or operative groups . No mal-union was noted in the open reduction and internal fixation group . CONCLUSION Though open reduction and internal fixation of mid-shaft clavicle fractures reduced the incidence of mal-union , no significant difference was noted in the functional outcome of shoulder function as compared to when the fracture was managed conservatively BACKGROUND Conservative management of middle third clavicle fracture has been recently reported with suboptimal outcomes . Despite higher nonunion rates in initial open reduction and internal fixation , underst and ing the problem better and taking in accounts of previous shortcomings , such fractures can be optimally treated by open reduction and internal fixation with reconstruction plate . OBJECTIVE To study the outcome of middle third clavicle fracture treated with superior reconstruction plating in terms of function using Constant shoulder score , union time and rate , complications and patient satisfaction . METHODS Twenty patients with displaced middle third clavicle fracture ( Edinburg type 2 ) treated with open reduction and internal fixation with reconstruction plate implanted in superior surface were prospect ively followed for at least one year after surgery . RESULTS There were 20 patients , 16 males and 4 females . The mean age of the patients was 31.5 years with SD 11.5 years ( range 15 - 60 years ) and 5 patients ( 25 % ) had associated injuries . All fractures united in 16 weeks or less in near anatomic position with complication in 2 ( 5 % ) patients , one deep infection and one frozen shoulder which on subsequent management recovered well . There was no nonunion or implant failure . The average Constant score was 97.45 in one year follow up and the patients were relatively satisfied with the treatment . The most common indication ( 25 % ) for hardware removal was young age of the patient , hardware prominence and occasional discomfort . CONCLUSION This small series shows that displaced midshaft clavicle fracture can be optimally treated with operative fixation implanting the reonstruction plate in superior surface with six cortical purchases on either side and supervised physiotherapy , although subsequent surgery for implant removal might be necessary BACKGROUND Surgical treatment with open reduction and internal fixation ( ORIF ) of displaced middle-third clavicular fractures result ed in shorter complete return to work periods with earlier consolidation documented on computed tomography ( CT ) scans in this prospect i ve , r and omized controlled trial . METHODS The study r and omized 76 consecutive patients with displaced fractures ( 2B1 - 2B2 according to Robinson ) to conservative ( C , n = 42 ) and surgical ( S , n = 34 ) treatment with plates and screws .  Bone union was documented with CT scans at 6 and 12 weeks . RESULTS Risk factors known to increase the risk of nonunion were similar between groups . Time until discharge for complete return to work was 3.7 ± 1.1 months for C and 2.9 ± 0.8 months for S ( P = .003 ) . On the CT scan at 6 weeks , 24.1 % of the patients presented advanced bone union in S vs 5.3 % in C ( P = .05 ) . At 12 weeks , 81 % of the patients presented advanced bone union in S vs 16.7 % in C ( P = .005 ) . At final follow-up , 4 nonunions were present in the C group that required surgery ; in the S group , 4 patients underwent revision surgery for plate removal . At 6 and 12 months of follow-up , Constant scores were higher for the S group . CONCLUSIONS Surgical treatment with ORIF of displaced middle-third clavicular fractures achieved good and excellent functional results , shorter time to complete return to work , earlier bone union , and fewer cases of nonunions in a working population under injury compensation BACKGROUND There is a growing trend to treat displaced midshaft clavicular fractures with primary open reduction and plate fixation ; whether such treatment results in improved patient outcomes is debatable . The aim of this multicenter , single-blinded , r and omized controlled trial was to compare union rates , functional outcomes , and economic costs for displaced midshaft clavicular fractures that were treated with either primary open reduction and plate fixation or nonoperative treatment . METHODS In a prospect i ve , multicenter , stratified , r and omized controlled trial , 200 patients between sixteen and sixty years of age who had an acute displaced midshaft clavicular fracture were r and omized to receive either primary open reduction and plate fixation or nonoperative treatment .  Functional assessment was conducted at six weeks , three months , six months , and one year with use of the Disabilities of the Arm , Shoulder and H and ( DASH ) and Constant scores . Union was evaluated with use of three-dimensional computed tomography . Complications were recorded , and an economic evaluation was performed . RESULTS The rate of nonunion was significantly reduced after open reduction and plate fixation ( one nonunion ) as compared with nonoperative treatment ( sixteen nonunions ) ( relative risk = 0.07 ; p = 0.007 ) . Group allocation to nonoperative treatment was independently predictive of the development of nonunion ( p = 0.0001 ) . Overall , DASH and Constant scores were significantly better after open reduction and plate fixation than after nonoperative treatment at the time of the one-year follow-up ( DASH score , 3.4 versus 6.1 [ p = 0.04 ] ; Constant score , 92.0 versus 87.8 [ p = 0.01 ] ) . However , when patients with nonunion were excluded from analysis , there were no significant differences in the Constant scores or DASH scores at any time point . Patients were less dissatisfied with symptoms of shoulder droop , local bump at the fracture site , and shoulder asymmetry in the open reduction and plate fixation group ( p < 0.0001 ) . The cost of treatment was significantly greater after open reduction and plate fixation ( p < 0.0001 ) . CONCLUSIONS Open reduction and plate fixation reduces the rate of nonunion after acute displaced midshaft clavicular fracture compared with nonoperative treatment and is associated with better functional outcomes . However , the improved outcomes appear to result from the prevention of nonunion by open reduction and plate fixation . Open reduction and plate fixation is more expensive and is associated with implant-related complications that are not seen in association with nonoperative treatment . The results of the present study do not support routine primary open reduction and plate fixation for the treatment of displaced midshaft clavicular fractures Background : The treatment of displaced midshaft clavicle fractures remains controversial . Methods : We undertook a multicenter r and omized controlled trial to compare effectiveness and safety between nonoperative management and ORIF ( open reduction and internal fixation ) for displaced midshaft clavicle fractures in adults . Three hundred and one eligible adult patients were r and omized to 1 of the 2 treatment groups and followed at 6 weeks , 3 months , and 9 months after recruitment . The primary outcome was the rate of radiographically evident nonunion at 3 months following treatment . Secondary outcomes were the rate of radiographically evident nonunion at 9 months , limb function measured using the Constant-Murley Score and DASH ( Disabilities of the Arm , Shoulder and H and ) score , and patient satisfaction . Results : There was no difference in the proportion of patients with radiographic evidence of nonunion at 3 months between the operative ( 28 % ) and nonoperative ( 27 % ) groups , whereas at 9 months the proportion with nonunion was significantly lower ( p < 0.001 ) in the operative group ( 0.8 % ) than in the nonoperative group ( 11 % ) . The DASH and Constant-Murley scores and patient satisfaction were all significantly better in the operative group than in the nonoperative group at 6 weeks and 3 months . Conclusions : Although at 3 months there was no evidence that surgery had reduced the rate of nonunion of displaced midshaft clavicle fractures , at 9 months nonoperative treatment had led to a significantly higher nonunion rate ( 11 % compared with < 1 % ) . The rate of secondary surgical intervention during the trial period was 12 ( 11 % ) of 
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Discussion This review shows that patient selection for surgery may influence functional outcome after midshaft clavicle fracture .
Our results also confirm that plate fixation provides better functional outcome and lower non-union rate