|Year : 2019 | Volume
| Issue : 1 | Page : 15-23
Management of clavicle fractures and adjacent clavicular joint dislocations in a Tertiary Health Center, North West, Nigeria
Friday Samuel Ejagwulu, Yau Zakari Lawal, Inuwa Mohammed Maitama, Kenneth Ezenwa Amaefule, Siyaka Simpa Audu
Department of Trauma and Orthopaedic Surgery, Ahmadu Bello University, Zaria, Nigeria
|Date of Web Publication||5-Mar-2019|
Dr. Friday Samuel Ejagwulu
Department of Trauma and Orthopaedic Surgery, Ahmadu Bello University, Zaria
Source of Support: None, Conflict of Interest: None
Background: Fractures of the clavicle are known to be common and occur in all ages and genders. It is commoner in the young and elderly, especially postmenopausal women. The mechanism of injury is either direct resulting in transverse fracture or indirect resulting in oblique fracture. The results of treatment are more favorable in the younger age groups because of their inherent healing potentials compared with the elderly. Aims and Objectives: To assess the incidence of clavicle injuries, treatment modalities with their outcomes, and to evaluate the X-ray union of the pathology. Patients and Methods: The patients were recruited over a period of 4 years (2009–2012) with informed and duly signed consent obtained. Fractures or dislocations were confirmed clinically and radiologically. One group of the patients was managed conservatively and the other operatively with various surgical options. Results: A total of 49 patients comprising 34 males (69.4%) and 15 females (30.6%) were studied. The age range was 2 weeks (0.6 years) to 62 years (mean- 32.1 years). Middle third shaft fractures were the commonest (77.6%), while medial third shaft fractures and acromioclavicular joint dislocation were the least common (2.0% each). Thirty-three (67.3%) and 16 (32.7%) of the patients were managed conservatively and operatively, respectively. The average X-ray healing duration was 16.2 and 14.6 weeks for those managed conservatively and surgically, respectively. Conclusion: Middle third clavicle fractures constitute the commonest variety, and both conservative and operative treatment modalities are applicable.
Keywords: Ahmadu Bello University Teaching Hospital, clavicle fracture, conservative management, operative management, Zaria
|How to cite this article:|
Ejagwulu FS, Lawal YZ, Maitama IM, Amaefule KE, Audu SS. Management of clavicle fractures and adjacent clavicular joint dislocations in a Tertiary Health Center, North West, Nigeria. Niger J Basic Clin Sci 2019;16:15-23
|How to cite this URL:|
Ejagwulu FS, Lawal YZ, Maitama IM, Amaefule KE, Audu SS. Management of clavicle fractures and adjacent clavicular joint dislocations in a Tertiary Health Center, North West, Nigeria. Niger J Basic Clin Sci [serial online] 2019 [cited 2019 May 26];16:15-23. Available from: http://www.njbcs.net/text.asp?2019/16/1/15/253409
| Introduction|| |
Clavicle fractures are known to be common in children and adults. It accounts for about 2.6%–4.0% of adult fractures and 35% of injuries to shoulder girdle. In children, clavicle fractures account for about 10%–13% of childhood fractures. It has an incidence of 29–64/100,000 persons per annum, and most of the fractures occur in ages less than 30 years and the elderly over 70 years of age.,,, The majority of the fractures occur in the middle third segment, accounting for about 82% of all clavicle fractures. These diaphyseal fractures are more likely to be displaced compared with the medial and lateral third segment fractures., The lateral and medial third shaft fractures, on the other hand, are less common and less likely to be displaced as well.
Clavicle fractures have been in occurrence since the Hippocratic era. However, Hippocrates pointed out that these fractures were easier to treat if they occurred across (transverse) than when they were diagonal (oblique)., Literature review has shown that there is a controversy about the choice of treatment between conservative and operative modalities. Traditionally, clavicle fractures have been treated nonoperatively regardless of the fracture pattern and part of the bone that is fractured. There has not been a gold standard treatment for these fractures most of which occur in the mid shaft and are therefore prone to displacement with consequent malunion or nonunion which results in residual pain and shoulder dysfunction., Therefore, there is need for the surgeon to understand the pattern of clavicle fractures so as to appreciate their likely behavior and plan the most appropriate mode of definitive treatment. Several classification systems have been put forward with a view to understanding the fractures for the purpose of clinical and research activities. Allman (in 1967) classified clavicle fractures into types I–III based on the anatomic location of the fracture. Neer on his own part further classified the lateral third clavicle fractures into three types based on the recognition of the importance of coracoclavicular (CC) ligaments to the stability of the segment. Robinson proposed the Edinborough classification anatomically into medial (type I), middle (type II), and lateral (type III). This classification provides more reliable prognostic information in middle clavicle fractures. In the treatment of these fractures, understanding the concepts of the classifications is pertinent in making the choice of treatment.,, Generally, there are conservative and operative treatment modalities. Each of these methods has its peculiar advantages and complications. The nonoperative treatment is absolutely indicated in clavicle fractures in children and adolescents regardless of the site of the fracture. This is because of the good healing potentials in these age groups. It is also indicated in undisplaced or minimally displaced (≤20mm) fractures in adults. Either arm sling or figure-of-eight (rucksack) bandage is known to provide good support and outcome. However, figure-of-eight bandage is less tolerable generally due to the risk of skin irritation and sometimes excoriations from pressure effects, particularly in the axillae., With the discovery of emergent complications following nonoperative treatment such as nonunion, malunion with shortening, persistent pain, and non-attainment of the premorbid status in terms of functions, surgical option with the use of various devices gradually evolved, though these surgical procedures are not without their peculiar complications such as anesthetic risk of aspiration and possible cardiac arrest, periosteal stripping seen in plating, implant migration, and sometimes breakage which may occur following intramedullary k-wire fixation of clavicle fracture, wound infection, ugly scar, and so on.
Radiographic union is defined as complete cortical bridging between proximal and distal fragments with no pain or motion with manual stressing of the fracture.
| Patients and Methods|| |
This prospective study took place between 2009 and 2012 (4-year period). The patients were recruited through the Accident and Emergency Department of Ahmadu Bello University Teaching Hospital, Zaria, following ethical approval. Recruitment criteria include the following:
- Only patients with isolated clavicle fractures and adjacent clavicular (sternoclavicular and acromioclavicular) joint dislocation/disruption were included
- Informed consents for the patients who were below 18 years of age were signed by their relatives who were above 18 years
- GSM numbers of the prospective patients or their relatives were obtained to ensure communication and subsequent regular outpatient clinic follow-ups
- Those who declined or absconded during the course of treatment and follow-ups were excluded from final compilations
- All age groups and both genders were eligible for recruitment in the study
- The number of all trauma cases that came through the accident and emergency in the years 2009–2012 was obtained to enable us compute the incidence.
There were a total of 49 patients who were recruited into the study. All the patients were assessed clinically and had initial resuscitation to stabilize them following which they had plane radiography done to confirm their injuries. Those who were under 18 years of age as well as those with minimally displaced fractures were managed nonoperatively. There were 33 patients in this category. They were given collar-and-cuff or arm slings for a period of 4 weeks along with diclofenac sodium (a nonsteroidal anti-inflammatory drug) for control of pain and methocarbamol for control of muscle spasm for 10 days. These patients were managed on outpatient basis after initial resuscitation and stabilization at the accident and emergency ward. Active muscle exercises (static) were encouraged in the shoulder and arm after the first week of treatment so as to avoid the risk of muscle atrophy and shoulder joint stiffness. The collar-n-cuff device was discontinued after 4 weeks and graded low range movement of the shoulder and arm commenced. The patients responded well to this method of treatment.
The patients who were over 18 years and had markedly displaced fractures (from plane radiographs) were counseled to have operative treatment. Signed consent was obtained for this after due explanations. Sixteen patients fell into this category. They had their procedures carried out under general anethesia with endotracheal intubation and continuous monitoring throughout the period of the procedure. The patients had intraoperative antibiotics given at induction. Nine patients (eight with middle third shaft and one with lateral third shaft fractures) were treated with precontoured plates and screws. Two patients with lateral third shaft fractures were treated with intramedullary Kirschner wire fixation. One patient with lateral third shaft fracture was treated with intramedullary Knowles pin. Circlage wire was used in one sternoclavicular joint dislocation, one acromioclavicular joint disruption, and one lateral third shaft fracture, respectively, and a strong Nylon suture (Nylon 2) was used to reconstruct one case of sternoclavicular joint dislocation. All the operated patients had postoperative antibiotics (cefuroxime) and analgesics (diclofenac sodium) intravenously for the first 48 h and thereafter they were converted to oral. They all had collar-n-cuff support for the shoulder and arm on the side of operation. Postoperative check plane radiographs were done on all of them. Their sutures were removed on day 10 postoperatively. They had their postoperative antibiotics for a total of 7 days. Following the removal of sutures, the patients were discharged to the outpatient clinic for subsequent follow-ups. The follow-ups were conducted for both those that were managed nonoperatively and those that were managed surgically initially on 4 weekly basis for two visits and thereafter, 6 weekly. They had their repeat plane radiographs done on 6 weekly basis to assess the radiographic stage of fracture union, putting into cognizance the method of treatment used and the age factor. Gentle active movements of the shoulder and the arm/hand were introduced at the earliest possible time to minimize the risk of joint stiffness and disuse muscle atrophy especially the deltoid muscle.
Data analysis was done using Statistical Package for Social Sciences (SPSS IBM company, New York City, USA) version 21.
The total number of trauma cases that came through the accident and emergency center were obtained from the records of 2009–2012 to enable us compute the incidence which came out to be 34 per 1000 cases annually.
| Results|| |
The results of the study carried out have been represented in the form of tables, charts and radiographs.
Forty-nine patients were definitively included in the study going by the recruitment criteria set out. The group comprised 34 males and 15 females accounting for 69.4% and 30.6%, respectively [Table 1]. Thirty-three of the 49 patients were managed nonoperatively, while the remaining 16 had operative management of their clavicle injuries making up 67.3% and 32.5%, respectively. Of the 33 patients who were managed nonoperatively, 23 (69.7%) were males while 10 (30.3%) were females [Table 2]. [Table 3] shows the distribution of the 16 patients who had operative treatment with 11 (68.8%) males and 5 (31.2%) females. The age distributions and modalities of treatment are shown in [Table 2] and [Table 3], respectively. Of those managed nonoperatively, the majority fall between the age brackets of 15–49 years [Table 2], while the majority of those managed operatively fall within the age bracket of 20–44 years [Table 3]. It therefore goes to say that most of the patients in the study series are within the active and work-force group of the society. Eight of those who had surgical treatment presented with middle one-third shaft clavicle fractures and had plating done with pre-contoured plate and screws accounting for 50% of the operative treatment done. There were 5 (31.3%) cases of lateral one-third shaft fractures and were treated with one pre-contoured plate and screws, two Kirshner wires, one Knowles pin, and one circlage wire, respectively. Two (12.5%) patients presented as fresh cases of sternoclavicular joint dislocation with posterior displacement. One of them was treated with circlage wire, while the other one was treated using strong Nylon suture. One (6.3%) patient presented late after 6 weeks following a fall on his left shoulder and sustained acromioclavicular joint disruption with elevation of the lateral end of the clavicle which was of cosmetic concern. This was reconstructed using circlage wire by drilling through the adjacent parts of the acromion and the clavicle to apply double figure-of-eight after bringing down the elevated lateral end of the clavicle to re-establish the joint. The patient did very well postoperatively and the shoulder contour was restored [Table 4]. [Figure 1] shows the pie chart representation of fracture distribution among the patients who were treated by surgery with middle one-third shaft fracture accounting for 50% and acromioclavicular joint disruption being the least (6.3%). [Figure 2] gives the bar chart representation of the number of operated cases versus the types of implants that were used for operations. Pre-contoured plate and screws were the most commonly used, while Knowles pin and strong Nylon suture were the least used in this study series.
|Figure 1: Pie chart representation of fractured parts that were operated|
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The healing rate in the nonoperative versus the operative groups was generally found to be varied to some extent depending on the part of the bone that was fractured with particular reference to the degree of fracture displacement. Those that were fractured in the lateral one-third and were not significantly displaced and therefore managed nonoperatively got healed in 12–22 weeks [Figure 3]. The fractures that occurred in the middle one-third shaft with significant displacement (>2 cm) and were managed nonoperatively (by patient's choice) had delayed union (28–30 weeks) [Figure 4]. One patient had nonunion even after 30 weeks and was treated by plating with pre-contoured plate and screws [Figure 5] and [Figure 6]. Eight patients with displaced middle one-third shaft fractures and who consented for surgery were treated primarily with pre-contoured plate. They had complete cortical bridging between 12 and 16 weeks. In addition, the patient who had Kirshner wire fixation had the fracture healed within the same period [Figure 7] and [Figure 8].
|Figure 3: Nonoperatively managed fracture lateral right clavicular fracture|
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|Figure 4: Fracture right clavicle with overlapping displacement, initially managed conservatively|
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|Figure 6: Fracture fixation left clavicle with inferior placement of implants|
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|Figure 8: Intramedullary K-wire fixation of lateral fracture right clavicle|
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The complications that occurred following the treatment are represented in [Figure 9]. Most of the complications that were observed mainly occurred following the nonoperative treatment; namely, delayed union 33.3% (120°), exuberant callus tissue 26.7% (96°), shoulder stiffness 20% (72°), and nonunion 6.7% (24°). The only complications encountered following the operation were K-wire migration which was 6.7% (24°) and wound infection 6.7% (24°).
|Figure 9: Pie chart representation of the complications from the two modalities of treatment|
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| Discussion|| |
Clavicle fractures have been recognized since the Hippocratic era and Hippocrates himself pointed out that transverse fractures of the clavicle are much easier to treat than oblique fractures., The classifications put forward by Allman, Neer, and Robinson variously have given an insight to the understanding of the peculiarities of the fractures in various parts of the clavicle.,, In our series, 38 patients sustained middle third clavicular shaft fractures accounting for 77.6%. Reports from several series also confirmed that the mid-shaft clavicle fractures are the most common and are more likely to be displaced as well.,,, The lateral and medial shaft clavicle fractures were found to be less and least common in our series, making up 14.3% and 4.1%, respectively. They have been reported to be less common and unlikely to be displaced.,,,
All the 33 patients who were managed nonoperatively in this study series were given simple arm or collar-n-cuff sling for a period of 4 weeks along with diclofenac sodium (a nonsteroidal anti-inflammatory agent) for control of pain and methocarbamol for control of muscle spasm. Active muscle exercises (static) were encouraged in the shoulder and arm after the first week of treatment. The collar-n-cuff was discontinued after 4 weeks and graded low range of movements commenced. This method produced excellent result in some of the patients [Figure 3]. Reports from some series revealed good outcomes using this conservative approach., Figure-of-eight or rucksack bandage applied across the shoulders and the axillae for immobilization is an alternative to collar-n-cuff method of treatment particularly for midshaft clavicle fractures. However, this was not used in any of the patients in our series because of the well-known problem of intolerance by patients generally, and the attendant complications of axillary pressure and sometimes skin excoriation.,,, Cochrane et al. (in 2009) recommended that further researches needed to be carried out concerning the use of figure-of-eight bandage in the treatment of clavicle fractures, going by the problems associated with its use.,,, In our series, a number of complications were observed following nonoperative treatment. These included shoulder stiffness in three patients accounting for 20% which was easily resolved with active exercise of the shoulder and analgesia; exuberant callus tissue formation was noted in four patients who had presented with midshaft clavicle fracture with displacement of greater than 20 mm and were offered the option of surgery but declined (26.7%). They presented with swellings which were painless and stony hard on palpation over the fracture site and were a cause of worry to the patients cosmetically. They were reassured and in the course of follow-ups, the swellings gradually regressed by the process of remodeling. Five patients had delayed union (33.3%) and presented with pain which was persistent for some weeks. The pain was managed with nonsteroidal anti-inflammatory agents and extended collar-n-cuff immobilization, and subsequently the fractures healed. One patient had nonunion of midshaft clavicle fracture (6.7%) and was subsequently operated on with pre-contoured plate fixation with screws. Reports of nonunion, malunion with shortening, late pain, stiffness, muscular tension, weakness, and chronic pain have been given in several series.,,,
Surgical treatment was carried out in 16 of the patients in our study series [Table 4]. Nine of them (56.3%) had fixation with pre-contoured plate and screws, comprising the most frequently used material in the operated patients in the series [Figure 6] and [Figure 7]. This is explained by the fact that the majority of the fractures were suitable for plate and screw fixation, added to the fact that these devices are readily available and suitable for use. The fixation is usually stable with excellent outcome, as the fractures are in the mid shaft of the clavicle. Eight of the patients had their plates placed superiorly with the attendant hardware prominence and pressure effect on the overlying skin with irritation in some cases.
One patient had the plate placed anteroinferiorly and this gave a better postoperative result with no subcutaneous hardware prominence and less risk of damage to the subclavian structures. The clavicle is virtually a subcutaneous bone throughout its entire length. Because of this natural arrangement, whenever plating is done with the plates placed either anterosuperiorly or superiorly, the heads of the screws are felt under the skin and this gives the patient some degree of discomfort from subcutaneous pressure effect on the skin overlying the hard wares. These effects are much worse in very asthenic individuals because the plate will also be felt subcutaneously. These problems were noted in some of our patients who had the plate placed anterosuperiorly or superiorly. But in the case of the patient who had the anteroinferior plating in our series, the experience was not like that because the plate and the screws were placed deep on the inferior aspect of the clavicle with the subclavian structures well separated from the clavicle, though not without difficulties with accessibility. The fracture healed and the patient returned to his normal work. Neither the screw heads nor the plates were symptomatic. The tips of the screws did not create irritation to the subcutaneous tissue as experienced with the superiorly placed hard wares [Figure 6]. Gilde et al. did a 10-year study of 156 cases of mid-shaft clavicle fractures with anteroinferior plate fixation and reported a good clinical outcome with high fracture healing rate and lower fixation removal. Other series gave similar reports of good outcome following anterior–inferior placement of plate with resultant greater distance between the plate and skin with less risk of damage to subclavian neurovascular structures, and early return to function., Comparative studies between conservative and operative treatment of mid-shaft clavicle fractures were done by some study groups and it was reported that operative treatment with plate and screws gave accurate reduction and better stability with good outcome.,,
Kirschner wire was used as an intramedullay device for fixation in two of the patients who presented with fracture of the lateral third of the clavicle in our series [Figure 8]. One of them developed a complication of wire migration without evidence of callus formation and had to be converted to plate fixation [Figure 10]. Knowles pin was used as an externointramedullary device in another patient with lateral third fracture. However, the patient developed a superficial wound infection at the entry point on the skin which was adequately taken care of by wound dressing. The fixation was stable and the device was removed after 6 weeks following establishment of callus tissue at the fracture site. Both Kirschner wire and Knowles pin fixation procedures are known to be minimally invasive which is an advantage compared to fixation with plate and screws, the dissection of which is more elaborate and associated with periosteal stripping.,,
Kirschner wire, when used as an intramedullary device, is usually associated with problems of rotational instability and tendency to migration (which we encountered in one of our patients), since it is not a locking device. Knowles pin, on the other hand, is associated with the problem of localized entry point infection and sometimes skin necrosis at the entry point since it is an externointernal device with a knotting component at the skin level to prevent inward migration of the pin. A number of series have reported complications emanating from the use of intramedullary devices and these include migration, breakage of hardware such as Kirschner wire, rotational instability at the fracture site, risk of damage to neurovascular structures, damage to brachial plexus, pin exposure, loss of reduction, nonunion, malunion and re-fracture following removal of the hardware, local sepsis at the entry point, and sometimes skin necrosis (as may occur with Knowles pin device).,,, Other devices that can be used for the fixation of lateral end clavicle fractures include hook-plate, CC screws, and suture and sling techniques using polydioxane suture.,,,,, Each of the devices has its peculiar advantages and complications. Their general advantage is the fact that the procedures are minimally invasive and they also give stable fixation, better pain relief, and facilitate early mobilization of the shoulder postoperatively. Locking devices such as locking compression plate can be used as external fixators in cases of open clavicle fractures which may be contaminated or infected (though very rare).,
Two of the patients in our series sustained sternoclavicular joint dislocation with posterior displacement. One of them was treated with circlage wire fixation and the other one with strong non-absorbable suture (Nylon 2) fixation. These patients presented as fresh cases, and therefore it was much easier to reduce during surgery since there was no fibrosis. Both of them were given collar-n-cuff support for 6 weeks postoperatively. They did respond to treatment without complications. Sternoclavicular joint dislocation is generally rare, and when it occurs, it presents with either anterior or posterior displacement. The anterior displacement does not present with life-threatening consequences except for pain of trauma and cosmetic concerns as it manifests clinically as a swelling anteriorly over the joint area in question and as such does not require any surgical intervention. Treatment involves the use of collar-n-cuff sling and adequate analgesia to control the pain. Posterior displacement, on the other hand, poses some potential danger to the patient as the posteriorly displaced medial end of the clavicle can cause compression of the subclavian neurovascular structures.,,
A patient in the series sustained disruption of the acromioclavicular joint ligaments and presented late with elevation of the lateral end of the clavicle with associated cosmetic concern as a result of disfigurement due to pulling effects of sternocleidomastoid and descending fibers of trapezius muscles. Open reduction/approximation was done using circlage wire by drilling holes through the clavicle(1 cm from the tip) and the underlying acromion and passing the wire through the holes in the form of figure-of-eight. With this, the shape and contour of the shoulder were restored. Postoperatively, a body bandage was applied with the upper limb of the operated side placed across the chest for 2 weeks with intermittent loosening to avoid the risk of developing sores. After 2 weeks, the patient was continued with a forearm sling (following removal of sutures) for a further period of 6 weeks. Thereafter, gentle active physiotherapy was introduced and the patient responded positively. The use of CC screws in the treatment of acromioclavicular joint disruption was first described by Bosworth (in 1941). A number of series have reported its use with some records of success in the treatment of this pathology., Hook-plate is another device that is particularly useful in the surgical treatment of acromioclavicular joint disruption and fracture of the lateral end of the clavicle. It was first introduced for distal clavicle fracture fixation in 1997 in Europe by AO/ASIF. It was designed and meant to overcome the problems of other available implants used in the treatment of distal clavicle fracture. The normal linear plate will not be suitable for fixation of the short distal fragment of the clavicle because there will be no good purchase of the distal fragment. The Kirschner wire and Knowles pin may also not be very suitable because of the risk of rotational instability, migration, infection, and sometimes localized cutaneous necrosis at the entry point. Also CC screw, which can be an alternative, will restrict the range of motion till union is achieved and implant is removed and as such delays the process of rehabilitation. If the initial precaution of limited range of movement is not adhered to, it can risk screw breakage. When hook-plate is used, it levers under the acromion with its hook which is small, and with that it will not be very necessary to disturb the distal fragment. The principle of hook-plate is such that it does not cause any rotational stiffness; rather it allows normal rotation at the acromioclavicular joint thereby enhancing fracture healing. However, abduction of the arm beyond 90° is not allowed as this could lead to subacromial structural damages on getting in contact with the hardware. This implant, however, has a number of complications arising from its use such as acromion fractures, rotator cuff ruptures, subacromial impingement, acromial osteolysis and pain from the enlargement of hook hole.
The average time to radiographic union was 16.2 weeks in those who were treated nonoperatively and 14.6 weeks in those treated operatively. The values ranged from 5 weeks in the youngest to 28 weeks in the oldest patients, respectively. The healing of the fractures in our series was affected by the location of the fracture with respect to the expected degree of displacement (middle one-third fractures are more likely to be displaced than lateral one-third fractures). Displaced fractures take longer time to heal with nonoperative treatment. Major invasive procedures with periosteal stripping, as seen in clavicle platting, take longer time to heal. The age of the patient also plays a role. The younger a patient, the shorter time it takes for the fracture to heal. The average weeks in the nonoperative and operative groups were fewer than those reported in the series in Canadian Orthopeadic Trauma Society.
| Conclusion|| |
Midshaft clavicle fractures constitute the commonest types of clavicle fractures. Non-operative and operative treatment modalities are still practicable as none of the modalities is exclusively free of complications. Simple collar-n-cuff sling should be used in nonoperative treatment of fractures that are either minimally displaced or not displaced at all. It is suggested that those fractures of the midshaft that present with gross displacement (≥2 cm) should be offered primary plate fixation so as to avert the risk malunion with shortening and nonunion. There is need for public awareness campaign to the populace as well as financial assistance toward research projects on the part of the government.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
[Table 1], [Table 2], [Table 3], [Table 4]