title: Smoking status and the Disabilities of the Arm Shoulder and Hand score are early predictors of symptomatic nonunion of displaced midshaft fractures of the clavicle.
abstract: OBJECTIVE
  This study identifies early risk factors for symptomatic nonunion of displaced midshaft fractures of the clavicle that aid identification of an at risk group who may benefit from surgery.
  
  
  METHODS
  We performed a retrospective study of 88 patients aged between 16 and 60 years that were managed non-operatively.
  
  
  RESULTS
  The rate of symptomatic nonunion requiring surgery was 14% (n = 13). Smoking (odds ratio (OR) 40.76, 95% confidence intervals (CI) 1.38 to 120.30) and the six week Disabilities of the Arm Shoulder and Hand (DASH) score (OR 1.11, 95% CI 1.01 to 1.22, for each point increase) were independent predictors of nonunion. A six week DASH score of 35 or more was identified as a threshold value to predict nonunion using receiver operating characteristic curve analysis. Smoking and the threshold value in the DASH and were additive risk factors for nonunion, when neither were present the risk of nonunion was 2%, if one or the other were present the nonunion rate was between 17% to 20%, and if both were present the rate increased to 44%.
  
  
  CONCLUSIONS
  Patients with either of these risk factors, which include approximately half of all patients sustaining displaced midshaft fractures of the clavicle, are at an increased risk of developing a symptomatic non-union.
  
  
  CONCLUSIONS
  Smoking and failure of functional return at six weeks are significant predictors of nonunion of the midshaft of the clavicle. Such patients warrant further investigation as to whether they would benefit from early surgical fixation in order to avoid the morbidity of a nonunion.
authors.affiliation: Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh EH16 4SA, UK.
authors.forename: N D
authors.initials: ND
authors.lastname: Clement
authors.affiliation: Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh EH16 4SA, UK.
authors.forename: E B
authors.initials: EB
authors.lastname: Goudie
authors.affiliation: Glasgow Royal Infirmary, 84 Castle Street, Glasgow G4 0SF, UK.
authors.forename: A J
authors.initials: AJ
authors.lastname: Brooksbank
authors.affiliation: Southmead Hospital, Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB, UK.
authors.forename: T J S
authors.initials: TJ
authors.lastname: Chesser
authors.affiliation: Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh EH16 4SA, UK.
authors.forename: C M
authors.initials: CM
authors.lastname: Robinson
mesh_terms: D000293:Adolescent; D000328:Adult; D001132:Arm / Q000502:physiology; D001860:Bone Plates; D002968:Clavicle / Q000293:injuries*; D006233:Persons with Disabilities; D042241:Early Diagnosis; D004812:Epidemiologic Methods; D005260:Female; D005593:Fracture Fixation, Internal / Q000295:instrumentation*; D005599:Fractures, Ununited / Q000175:diagnosis* / Q000503:physiopathology / Q000601:surgery; D006225:Hand / Q000502:physiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D010149:Postoperative Pain / Q000209:etiology; D012782:Shoulder / Q000502:physiology; D012907:Smoking / Q000009:adverse effects*; D055815:Young Adult
keywords: Clavicle; displaced; fracture; midshaft; nonunion; predictors