Fractures in clavicle are ubiquitous orthopedic injuries which are a significant burden in clinical practice. Their prevalence is around 2.6 to 3.3% of all fractures and account for 44% of shoulder girdle injuries.1 These fractures typically arise from high impact events such as falls, direct trauma or automobile related accidents. A clavicle fracture is defined as a disruption of the bony continuity and these injuries are classified based on their location. The most common ones are Midshaft (Allman Group I) followed by lateral third (Group II) and medial third (Group III) fractures.2 Globally, the incidence of clavicle fractures for an year is estimated to be between 29 and 64 cases per 100,000 individuals.3 These fractures affect almost all demographics, but a higher incidence is noted in younger males between 15 to 30 years. This can be attributed due to their participation in sports and exposure to trauma or accidents. Conversely, low energy falls are the primary reason for clavicle fractures in older populations.4 Traditionally, the management of clavicle fractures has been done through conservative approaches which utilizes simple immobilization devices such as slings, figure of eight bandages etc. These approaches were followed due to clavicle’s inherent healing potential. However, these techniques have been increasingly scrutinised as long term studies have reported increased risk of complications such as malunion, prolonger pain and significant functional impairment due to clavicular shortening.5 Over the last two decades, a noticeable paradigm shift is observed in surgical management, specifically for displaced midshaft fractures. Historically, surgical fixation was implemented in 10% of the cases, however, recent data suggests that 40-50% of these fractures are now a days undergoing surgical fixation.6 This change can be rendered to the advancements in surgical techniques and a growing body of evidence indicating that internal fixation, especially with plating which offers superior functional outcomes. Current indications for surgical management are clear and include a displacement with shortening greater than 2 cm, severe comminution, open fractures, neurovascular compromise, or a high probability of nonunion or malunion. Recent studies involving randomised control trials have demonstrated the advantages of surgical plating. This approach not only reduces the risk of non union but also facilitates faster pain relief, superior shoulder function, and enhanced patient satisfaction as compared to non operative care. Locking compression plates (LCPs) have emerged as the go to implant as they are biomechanically stable and have less complications. The efficiency of any treatment is extensively studied using scales such as the Disabilities of the Arm, Shoulder, and Hand (DASH) Score.7 Despite the strong evidence which favours surgical intervention, a constant debate exists regarding its universal application also while considering a resource constrained settings where conservative treatment is preferred due to costs and risks. However, untreated or inappropriately managed fractures of clavicle can cause long term disability, which can severely impact quality of life and day to day activities of the patient. The present study aims to assess the functional outcomes of plating in displaced midshaft clavicle fractures. The study evaluated key recovery metrics, including pain relief, fracture healing time, restoration of motion and overall recovery and patient satisfaction. This will contribute in guiding clinical decision making regarding optimal treatment strategy for this common injury.

Study design: Prospective observational study. Study duration: 18 months Study Population: Patients presented with fracture of the clavicle to the casualty and inpatient department (IPD) of the Department of Orthopaedics at the study center. Inclusion Criteria • Adults aged 18 years and above of both sexes. • Patients diagnosed with fracture of the clavicle requiring surgical fixation. Exclusion Criteria • Patients with pathological fractures of the clavicle. Sample Size: 55 patients. Data Collection and Procedure • All patients underwent a detailed clinical evaluation, including history- taking and physical examination. • Radiographic investigations (X-rays of the clavicle, shoulder AP view) were performed for fracture classification and preoperative planning. • Patients underwent open reduction and internal fixation (ORIF) with plating, performed by orthopedic surgeons following standard surgical protocols. • Postoperative rehabilitation was initiated based on standardized physiotherapy protocols. • Functional outcomes were assessed using clinical examination, range of motion (ROM) assessment, and validated scoring systems such as the - Disabilities of the Arm, Shoulder, and Hand (DASH) Score at follow-up visits. Ethical Considerations - Ethical approval was obtained from the Institutional Ethics Committee

The study population majorly consisted of middle aged adults with a mean age of 38.5 years. The study group had a predominance of male patients accounting for nearly 75% of cases (Table 1). Right side had more fractures as compared to left side. The midshaft region was the most common site as per as the Allman classification (Table 2). Injuries were mainly caused due to road traffic accidents followed by falls and sports injuries and other associated injuries such as rib and scapula fractures were relatively uncommon (Table 3). For management, operative techniques such as locking compression plates, utilized in over 65% of cases (Table 4). The Disabilities of the Arm, Shoulder, and Hand (DASH) Scoring System is a widely used patient-reported outcome measure that evaluates the functional status symptoms, and disability of individuals with upper limb conditions, including clavicle fractures (Annexure 1). Functional evaluation with the DASH score demonstrated significant improvement from preoperative to 12 week follow up values (Table 5) with a high proportion of patients achieving excellent or good outcomes (Table 6). Radiological assessments exhibited a mean union time of approximately 9 weeks, with union rates exceeding 90% with low incidences of non union and malunion (Table 7). The patients experienced some complications such as implant related issues and infections, which negatively affected functional outcomes (Table 8). Functional outcomes were measured by using DASH score which were analysed against mode of injury, fracture location, fracture type, displacement, implant type and complications. It was observed that there was no significant association between the mode of injure and DASH scores. Similarly, the fracture side was also not significantly associated with DASH scores. Interestingly, fracture type based on Allman classification was significantly associated with Midshaft fractures (Type I), demonstrating a higher proportion of excellent and good outcomes compared to lateral and medial fractures (Table 9). Fracture displacement analysis revealed that non displaced fractures were associated with better functional outcomes, a greater proportion of patients in this group achieved excellent DASH scores and none of them had poor results. The outcomes were affected by implant choice also, with locking compression plates (LCP) yielding a better DASH score related to other implants. Poor functional results were strongly associated with complications (Table 10). These findings underscore the importance of fracture type, displacement status, implant selection, and complication prevention in optimizing functional recovery following clavicle fracture fixation. Table 1: Gender distribution in study participants Gender Percentage Male 72.7% Female 27.3% Table 2: Fracture side distribution and classification Parameter Classification Frequency Percentage Fracture Side Right 32 58.2% Left 23 41.8% Group Midshaft (Group I) 42 76.4% Lateral (Group II) 8 14.5% Medial (Group III) 4 9.1% Table 3: Mode of injury and associated injuries in the study population Frequency Percentage Mode of Injury Road Traffic Accident 30 54.5% Fall 15 27.3% Sports Injury 7 12.7% Direct Trauma 3 5.5% Associated injuries No injury 40 72.7% Rib fracture 6 10.9% Scapula fracture 3 5.5% Upper Limb Fracture 4 7.3% Head injury 2 3.6% Table 4: Type of implant used Implant Type Frequency Percentage Locking Compression Plate 36 65.5% Dynamic Compression Plate 12 21.8% Lateral Hook Plate 7 12.7% Table 5: Functional outcome based on Mean DASH score Follow-up Time Mean DASH Score ± SD Preoperative 85.4 ± 10.2 At 2 weeks 72.8 ± 8.5 At 6 weeks 52.3 ± 7.8 At 12 weeks 28.6 ± 5.4 Table 6: Functional Outcome Based on DASH Score in study participants DASH Score Category Score Range Frequency (n) Percentage (%) Excellent <40 22 40% Good 40–70 20 36.40% Fair 70–100 10 18.20% Poor >100 3 5.40% Total - 55 100% Table 7: Radiological and Healing Outcomes in study participants Parameter Value Mean time to radiological union 9.2 ± 1.8 weeks Union Rate 92.7% (51/55) Nonunion Rate 5.5% (3/55) Malunion Cases 1.82% (1/55) Table 8: Complications in study participants Complication Type Frequency (n) Percentage (%) Infection 4 7.30% Implant-related issues 5 9.10% Plate irritation 3 5.50% Implant failure 2 3.60% Re-fracture post-implant removal 2 3.60% Delayed union 1 1.80% Nonunion 1 1.80% Nerve injury 1 1.80% Soft tissue complications 1 1.80% Total Patients with Complications 18 32.70% Table 9: Association Between Functional Outcome (DASH Score) and Side of Fracture Excellent (n=22) Good (n=20) Fair (n=10) Poor (n=3) Total (n=55) p-value Mode of Injury RTA (n=30) 12 (40%) 10 (33.3%) 6 (20%) 2 (6.7%) 30 (54.5%) 0.41 (NS) Fall (n=15) 6 (40%) 6 (40%) 2 (13.3%) 1 (6.7%) 15 (27.3%) Sports Injury (n=7) 3 (42.9%) 3 (42.9%) 1 (14.2%) 0 (0%) 7 (12.7%) Direct Trauma (n=3) 1 (33.3%) 1 (33.3%) 1 (33.3%) 0 (0%) 3 (5.5%) Side of Fracture Right (n=32) 13 (40.6%) 10 (31.3%) 6 (18.8%) 3 (9.3%) 32 (58.2%) 0.78 (NS) Left (n=23) 9 (39.1%) 10 (43.5%) 4 (17.4%) 0 (0%) 23 (41.8%) Fracture Type (Allman Classification) Midshaft (Type I) (n=42) 18 (42.9%) 14 (33.3%) 8 (19%) 2 (4.8%) 42 (76.4%) 0.03* (Sig.) Lateral (Type II) (n=8) 3 (37.5%) 4 (50%) 1 (12.5%) 0 (0%) 8 (14.5%) Medial (Type III) (n=5) 1 (20%) 2 (40%) 1 (20%) 1 (20%) 5 (9.1%) Table 10: Association Between Functional Outcome (DASH Score) and Fracture Displacement Excellent (n=22) Good (n=20) Fair (n=10) Poor (n=3) Total (n=55) p- value Fracture Displacement Displaced (n=38) 14 (36.8%) 14 (36.8%) 7 (18.4%) 3 (7.9%) 38 (69.1%) 0.02* (Sig.) Non- Displaced (n=17) 8 (47.1%) 6 (35.3%) 3 (17.6%) 0 (0%) 17 (30.9%) Type of Implant LCP (n=36) 15 (41.7%) 12 (33.3%) 7 (19.4%) 2 (5.6%) 36 (65.5%) 0.04* (Sig.) DCP (n=12) 5 (41.7%) 5 (41.7%) 2 (16.7%) 0 (0%) 12 (21.8%) Lateral Hook Plate (n=7) 2 (28.6%) 3 (42.9%) 1 (14.3%) 1 (14.3%) 7 (12.7%) Complications No Complications 17 (77.3%) 13 (65%) 5 (50%) 2 (66.7%) 37 (67.3%) 0.006* (Significant) Complications (n=18) 5 (22.7%) 7 (35%) 5 (50%) 1 (33.3%) 18 (32.7%) Representative images (Case 1) – A 22 Year Female History of RTA Having Closed Fracture of Right Clavicle Fig. 2: (A) X-ray showing plate fixation and satisfactory alignment and healing of the clavicle. (B) Clinical photographs demonstrating healed surgical scar, full pain-free abduction and flexion of the shoulder, and return of functional shoulder range of motion at follow-up. Patient exhibits no complications and satisfactory cosmesis. Case – 2 : A 33 year Male Present with history of fall on outstretch hand on ground And Left Fracture Clavicle Fig. 2: (A) Preoperative X-rays showing displaced clavicle fracture and immediate postoperative X-rays with anatomical reduction and fixation using a locking plate. (B) Follow-up radiograph indicating maintained alignment and healing and clinical photographs at follow-up displaying full, pain-free shoulder movements in multiple planes, signifying excellent functional recovery and restoration of shoulder range of motion. Annexure 1: Scoring Methodology • The DASH questionnaire consists of 30 items, covering daily activities, symptoms, and social/psychological impact. • Each item is rated from 1 to 5, where: o 1 = No difficulty o 5 = Unable to do or extreme difficulty • The final DASH score is calculated by: DASH Score=[∑(responses - 1)/Total items answered]×25 o A higher score indicates greater disability. o A score cannot be calculated if more than 3 responses are missing. DASH Score Interpretation <40 Excellent 40-70 Good 70-100 Fair >100 Poor

The present study evaluated the functional outcomes of clavicle fractures, treated with open reduction and internal fixation also known as ORIF. The results were presented with the help of demographic trends, patterns of fractures, mechanism of injury, surgical intervention and post op recovery using DASH scores. The patient population was dominated by males with a mean age of 38.5 years, reflecting upon the tendency for clavicle fractures in men, who are more exposed to physical traumas such as road accidents. The study resonates which previous literature, where occupational and recreational activities significantly increase the risk of fractures in young males. Majority of the fractures occurred on the right side and were classified as midshaft injuries. This observation corroborated the recognized anatomical susceptibility of the clavicle’s central third and similar distribution found in different studies.8,9 Apart from road accidents, other major causes of fractures included falls and sports related injuries which was in agreement with the urban epidemiology. The most common fracture type was displaced fractures, emphasizing the importance of meticulous assessment for associated injuries. More than a quarter of patients experienced additional thoracic injuries, which can be caused due to high energy traumas. For fixation, locking compression plates were favoured due to their biomechanical advantages in providing stable constructs, specifically for comminuted or displaced fractures. The observed mean union time was approximately 9.2 weeks, with an impressive union rate higher than 92%, reflecting outcomes from other studies as well where plate fixation outperformed other techniques. DASH score was used to quantify functional recovery. Significant improvement was observed at 12 weeks, with majority of the patients with excellent or good results. These outcomes reflects the superiority of operative management which helps the patients in faster recovery specially for active individuals. Furthermore, it also reduces the non union rates compared to non operative methods. Studies such as Hamid et al., 202410 also reported high rate of bone union and improved DASH scores post-ORIF plating. Elsenosy et al., 202511 conducted a meta analysis which concluded that surgical fixation improves early union and DASH scores versus conservative treatment and also reduces risk of nonunion. Advantages of ORIF plating were also reported by Wani et al., 201912, as it resulted in uniform functional recovery and swift return to activities with high patient satisfaction. Complications mainly occurred due to infection or due to irritation in implants but the occurrence was very low (33%). Another important aspect of successful ORIF is low non union rates as seen in the present study, highlighting the advantages of precise surgical technique and careful implant selection. Significant correlations were observed between functional outcomes and fracture classification, implant type, displacement and complications. Fractures of midshaft which are fixed with plates result in better results, These outcomes confirm that optimum results depend on both the factors – appropriate surgicak strategy and vigilant postoperative care. Mannan et al., 202413 have also reported ORIF with plating leads to lower early pain, faster union, and better subjective shoulder scores in displaced midshaft clavicle fractures. Overall, this study affirms the clinical benefit of ORIF with plating for displaced clavical fractures, underscoring the role of locking plates in achieving superior outcomes. The results also advocate for surgical management in suitable candidates, specially in young and active patients. It also underscores the importance of individualized implant selection and avoidance of complications to maximize functional recovery.

Open reduction and internal fixation (ORIF) along with plating results in excellent functional and radiological outcomes for displaced clavicle fractures, specifically in midshaft injuries. Majority of patients were able to achieve early union, high rates of satisfactory shoulder function and quick return to day-to-day activities. Enhanced stability is associated with locking compression plates and provides superior outcomes as compared to other implants. Complications are rare and less but can significantly impair functional recovery. Careful implant selection and vigilant postoperative monitoring are crucial to minimize complications. These findings reinforce the preference for surgical management in suitable patients, supporting ORIF plating as a reliable method for optimizing recovery in active adults with displaced clavicle fractures. AUTHORS CONTRIBUTIONS: M.D: Contributed to conceptualization, literature synthesis, and initial drafting. P.N.B: Performed formal analysis and data collection, preparation of draft. A.P.: Assisted in resource curation, data validation and reviewed the draft manuscript. D.K.M. (Corresponding author): Supervised the research design and finalized the manuscript. CONFLICT OF INTEREST: The authors declare no conflict of interest, financial or otherwise ACKNOWLEDGMENTS: Declared none.

1. Amer KM, Congiusta D V., Suri P, Choudhry A, Otero K, Adams M. Clavicle fractures: Associated trauma and morbidity. J Clin Orthop Trauma. 2021 Feb;13:53–6. 2. Robinson CM. Fractures of the clavicle in the adult: Epidemiology and Classification. J Bone Joint Surg. 1998 May 1;80(3):476–84. 3. Sharma S, Kumar V, Sharma R, Aggarwal S. Burden of isolated clavicle fractures at tertiary care healthcare centre: a look into registry. Int J Res Orthop. 2020 Apr 22;6(3):542. 4. Postacchini F, Gumina S, De Santis P, Albo F. Epidemiology of clavicle fractures. J Shoulder Elbow Surg. 2002 Sep;11(5):452–6. 5. Smekal V, Irenberger A, Struve P, Wambacher M, Krappinger D, Kralinger FS. Elastic Stable Intramedullary Nailing Versus Nonoperative Treatment of Displaced Midshaft Clavicular Fractures-A Randomized, Controlled, Clinical Trial. J Orthop Trauma. 2009 Feb;23(2):106–12. 6. Verborgt O, Pittoors K, Van Glabbeek F, Declercq G, Nuyts R, Somville J. Plate fixation of middle-third fractures of the clavicle in the semi-professional athlete. Acta Orthop Belg. 2005 Feb;71(1):17–21. 7. Gummesson C, Ward MM, Atroshi I. The shortened disabilities of the arm, shoulder and hand questionnaire (Quick DASH): validity and reliability based on responses within the full-length DASH. BMC Musculoskelet Disord. 2006 Dec 18;7(1):44. 8. Jones SD, Bravman JT. Midshaft clavicle fractures—when to operate. Ann Jt. 2021 Apr;6:21–21. 9. Al-Moaish AA, Algabarty JA, Mughallas A, Alhamzi AM, Soliaman M, Hutaif M, et al. Functional Outcomes of Displaced Midshaft Clavicular Fractures Treated with Precontoured Locked Plates: A Prospective Study. F1000Res. 2025 Aug 28;14:374. 10. Hamid MA, Younis Z, Mannan M, Shrivastava N, Prabhu RM. Functional Outcomes and Complications After Open Reduction and Internal Fixation of Mid-shaft Clavicle Fractures: A Retrospective Study. Cureus. 2024 Nov 23; 11. Elsenosy AM, Hassan E, Al-Alawi M, Yousef AS, Elbagory W, Muthian S. Surgical Versus Non-Surgical Management of Displaced Midshaft Clavicle Fractures: A Systematic Review and Meta-Analysis. Cureus. 2025 Oct 5; 12. Wani MA, Ganaie MA, Ul islam N, Rasool A, Dar NA. Functional results of clavicle fractures in adults treated by open reduction and internal fixation using superior precontoured plate. International Surgery Journal. 2019 Jun 29;6(7):2484. 13. Mannan M, Hafeez U, Hassan A, Tahir R, Ajnin S. Functional Outcomes of Clavicle Open Reduction and Internal Fixation (ORIF). Cureus. 2024 Oct;16(10):e72048.