***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 
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    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 We conducted a prospect i ve , r and omized study to determine if patients with midshaft clavicle fractures would benefit from immediate operative stabilization with a modified Hagie pin in comparison with a matched group treated with nonoperative therapy . At a level II trauma center , patients with closed midshaft clavicle fractures were prospect ively r and omized to receive either operative or nonoperative treatment . Fifty-seven ( 29 operative , 28 nonoperative ) patients were enrolled in the study . Operative patients underwent open reduction and internal fixation of the clavicle using a modified Hagie pin ; nonoperative patients were treated with a sling for comfort . All patients were followed at regular intervals for 1 year . They were evaluated for radiographic healing and complications and were scored with the Single Assessment Numeric Evaluation and L'Insalata instruments .  Injury severities  and radiographs were not statistically significantly different between the 2 groups . Functional scores in the operative group were slightly higher at 3 weeks , and the nonoperative group had slightly higher scores at 6 months and 1 year . The only statistically significant difference between the groups was at 3 weeks . Percentage follow-up at 1 year was 93 % for the operative group and 82 % for the nonoperative group . One patient in each group developed a nonunion , and 1 patient in each group had a refracture . Complications were higher in the operative group , and most were related to pin prominence at the posterior shoulder . Results of this study suggest that , though patients with midshaft clavicle fractures had higher functional scores at short-term follow-up after internal fixation , functional scores were similar at 6 months and 1 year . In addition , internal fixation with a modified Hagie pin was associated with a higher complication rate Objectives : To determine the cost-effectiveness of open reduction internal fixation ( ORIF ) of displaced , midshaft clavicle fractures in adults . Design : Formal cost-effectiveness analysis based on a prospect i ve , r and omized , controlled trial . Setting : Eight hospitals in Canada ( seven university-affiliated and one community hospital ) . Patients / Participants : One hundred thirty-two adults with acute , completely displaced , midshaft clavicle fractures . Intervention : Clavicle ORIF versus nonoperative treatment . Main Outcome Measurements : Utilities derived from SF-6D . Results : The base case cost per quality -adjusted life-year ( QALY ) gained for ORIF was $ 65,000 . Cost-effectiveness improved to $ 28,150/QALY gained when the functional benefit from ORIF was assumed to be permanent with cost per QALY gained falling below $ 50,000 when the functional advantage persisted for 9.3 years or more . In other sensitivity analyses , the cost per QALY gained for ORIF fell below $ 50,000 when ORIF cost less than $ 10,465 ( base case cost $ 13,668 ) or the long-term utility difference between nonoperative treatment and ORIF was greater than 0.034 ( base case difference 0.014 ) . Short-term disutility associated with fracture healing also affected cost-effectiveness with the cost per QALY gained for ORIF falling below $ 50,000 when the utility of a fracture treated nonoperatively before union was less than 0.617 ( base case utility 0.706 ) or when nonoperative treatment increased the time to union by 20 weeks ( base case difference 12 weeks ) . Conclusions : The cost-effectiveness of ORIF after acute clavicle fracture depended on the durability of functional advantage for ORIF compared with nonoperative treatment . When functional benefits persisted for more than 9 years , ORIF had a favorable value compared with many accepted health interventions Background The traditional view that the vast majority of midshaft clavicular fractures heal with good functional outcomes following non-operative treatment may be no longer valid for all midshaft clavicular fractures . Recent studies have presented a relatively high incidence of non-union and identified speciic limitations of the shoulder function in subgroups of patients with these injuries . Aim A prospect i ve , multicentre r and omised controlled trial ( RCT ) will be conducted in 21 hospitals in the Netherl and s , comparing fracture consolidation and shoulder function after either non-operative treatment with a sling or a plate fixation . Methods / design A total of 350 patients will be included , between 18 and 60 years of age , with a dislocated midshaft clavicular fracture . The primary outcome is the incidence of non-union , which will be determined with st and ardised X-rays ( Antero-Posterior and 30 degrees caudocephalad view ) . Secondary outcome will be the functional outcome , measured using the Constant Score . Strength of the shoulder muscles will be measured with a h and held dynamometer ( MicroFET2 ) . Furthermore , the health-related Quality of Life score ( ShortForm-36 ) and the Disabilities of Arm , Shoulder and H and ( DASH ) Outcome Measure will be monitored as subjective parameters . Data on complications , bone union , cosmetic aspects and use of painkillers will be collected with follow-up question naires . The follow-up time will be two years . All patients will be monitored at regular intervals over the subsequent twelve months ( two and six weeks , three months and one year ) . After two years an interview by telephone and a written survey will be performed to evaluate the two-year functional and mechanical outcomes . All data will be analysed on an intention-to-treat basis , using univariate and multivariate analyses . Discussion This trial will provide level-1 evidence for the comparison of consolidation and functional outcome between two st and ardised treatment options for dislocated midshaft clavicular fractures . The gathered data may support the development of a clinical guideline for treatment of clavicular fractures . Trial registration Netherl and s National Trial Register INTRODUCTION Elastic stable intramedullary nailing ( ESIN ) of displaced mid-shaft clavicular fractures is a minimally invasive technique which was reported to be an easy procedure with low complication rates , good cosmetic and functional results , restoration of clavicular length and fast return to daily activities . Recent studies , however , also report on higher complication rates and specific problems with the use of this technique . This prospect i ve study compares ESIN with non-operative treatment of displaced mid-shaft clavicular fractures . METHODS Between December 2003 and August 2007 , 120 patients volunteered to participate . Of these , 112 patients completed the study ( 60 in the operative and 52 in the non-operative group ) . Patients in the non-operative group were treated with a simple shoulder sling . In the operative group , intramedullary stabilisation was performed within 3 days of the trauma . Clavicular shortening was determined after trauma and after osseous consolidation on thorax posteroanterior radiographs as the proportional length difference between the left and right side with the uninjured side serving as a control for clavicular length ( 100 % ) . Radiographic union was assessed every 4 weeks on 20 degrees cephalad anteroposterior and posteroanterior radiographs of the clavicle . Constant shoulder scores and DASH scores ( DASH , disabilities of the arm , shoulder and h and ) were assessed at final follow-up after 2 years . RESULTS ESIN led to faster osseous healing and better restoration of clavicular length in simple fractures . We were not able to restore clavicular length in comminuted fractures using ESIN .  Functional outcome at a mean follow-up of 24 months ( range : 22 - 27 months ) was better in the operative group . Delayed union and non-union accounted for the majority of complications in the non-operative group . In the operative group , telescoping was the main complication , which occurred in complex fractures with severe post-traumatic shortening only . CONCLUSION We recommend ESIN for all simple displaced mid-shaft clavicular fractures in order to minimise the rate of delayed union , non-union and symptomatic mal-union . We also recommend ESIN in comminuted fractures with moderate ( < or = 7 % ) post-traumatic shortening , as they will heal with moderate shortening . In comminuted fractures with severe shortening , however , we recommend plate osteo synthesis in order to provide for stability , clavicular length and endosteal blood supply BACKGROUND Clavicle fractures are common and usually heal without complications . In this study , we evaluated the outcomes of non-operative versus operative management of displaced fractures . METHODS In a prospect i ve clinical trial study , sixty-five patients with displaced clavicle mid-shaft fractures were non-r and omly divided in two treatment groups . The first group underwent non-operative treatment with figure of 8 b and age ( 30 patients ) , and the other underwent operative treatment with plate fixation ( 35 patients ) . Figure of 8 b and age and 3.5 millimeter DCP plate with at least six cortical screws were used in non-operative and operative groups respectively . We followed up all patients at weeks 2 , 6 and 12 , and at month sixth . In addition to clinical examination and x-ray evaluation , we assessed satisfaction , DASH and Constant Shoulder Score for each individual . RESULTS The average duration s of union were 19.3 and 24.4 weeks in operative and non-operative groups respectively ( P=0.006 ) . Satisfaction with operative treatment was 74.3 % and with non-operative treatment was 66.7 % , showing no significant difference ( P=0.500 ) . The non-union rate was 5.7 % in the operative group and 13.3 % in the non-operative group ( P=0.518 ) . A significant difference between the two groups in terms of DASH and Constant Shoulder Scores after the six-month follow-up was not found ( P=0.352 ) . CONCLUSIONS According to our results , we recommend operative treatment in mid-shaft clavicle fractures only when there is a definitive indication 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 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 ( 2 
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Conclusion : This meta- analysis of high- quality studies showed that surgical treatment of MCFs results in fewer nonunions , fewer malunions , and an accelerated return to work compared with nonsurgical treatment .