Evaluation and Management of Distal Clavicle Fracture in a Tertiary Care Hospital LRH, Peshawar

Background: Distal clavicle fractures are common injuries, often resulting from high-impact traumas such as road traffic accidents (RTAs). The management of these fractures varies, with surgical intervention frequently deemed necessary for NEER type 2 fractures due to their instability and potential for nonunion. Objective: This study aimed to evaluate the prevalence and effectiveness of various management strategies for distal clavicle fractures, with a focus on understanding the impact of surgical versus conservative treatments on patient outcomes. Methods: A retrospective analysis was conducted on 70 patients presenting with distal clavicle fractures at a tertiary care center. The fractures were classified according to NEER's classification system, and the chosen management strategies were documented, including plating, K-wires, tension band wiring, and conservative treatment. Data were analyzed using descriptive statistics to determine the frequency and percentage of each management approach and its outcomes. Results: The majority of fractures were managed surgically (70%), with plating being the most common method (58.6%). NEER type 2A fractures were the most prevalent (28.6%), followed by type 1 and 2B (each at 18.6%). Conservative management was applied in 28.6% of cases. Surgical management, particularly plating, resulted in excellent functional outcomes and a lower complication rate compared to conservative treatment and other surgical techniques. K-wire fixation was associated with a 95.6% satisfaction rate, despite a 26% complication rate involving nonunion and hardware migration. Conclusion: Surgical intervention, especially plating, is a highly effective management strategy for distal clavicle fractures, offering better functional outcomes and fewer complications compared to conservative treatment. The study emphasizes the need for a tailored approach to fracture management, prioritizing surgical options for NEER type 2 fractures to ensure optimal recovery.


INTRODUCTION
Clavicular fractures are a prevalent injury, especially among young individuals, with distal clavicular fractures constituting 10-30% of all cases.Notably, half of these fractures are displaced and necessitate surgical intervention to avoid the risk of symptomatic malunion or nonunion, which can occur in 10-44% of cases if not properly managed (1)(2)(3)(4).The classification of these fractures has evolved over time, with the revised NEER classification system now being widely adopted.This system categorizes the fractures based on their relationship to the coracoclavicular (CC) ligament, distinguishing between stable fractures (Types 1 and 3), which can often be treated conservatively, and unstable fractures (Types 2 and 5), which typically require surgical intervention for optimal outcomes (5,6).The integrity of the CC ligament is a critical factor in this classification, as damage to this ligament can lead to vertical instability of the medial fragment, significantly increasing the likelihood of complications (7)(8)(9).Historically, the treatment of clavicular fractures, regardless of the degree of displacement, was predominantly non-operative.However, the understanding of the biomechanics and complications associated with distal clavicle fractures has led to a more nuanced approach to management.Surgical techniques for the fixation of these fractures vary widely, encompassing methods such as Kirschner wire (K-wire) usage, hook plates for direct osteosynthesis, various suture materials, tendon grafts for indirect stabilization of the coracoclavicular ligament, traditional pinning with intramedullary pins or CC screws, and arthroscopic techniques.Each of these methods has its advantages and drawbacks, and complications such as pin migration, nonunion, osteomyelitis, osteoarthritic changes, and ankylosis have been reported.Given the small size of the distal fragment, plate fixation often proves to be impractical (10)(11)(12).Despite the plethora of treatment options available, no single technique has emerged as the definitive "gold standard" for the management of distal clavicle fractures (13).This diversity in treatment approaches underscores the complexity and challenges that shoulder surgeons face in managing these injuries, a topic that continues to spark debate within the medical literature (14)(15)(16).The objective of this study is to explore the various patterns of distal clavicle fractures and their management strategies.By doing so, it aims to contribute to the ongoing discussion in the medical community about the most effective ways to treat this common yet complex injury.

MATERIAL AND METHODS
This observational cross-sectional study was conducted to explore the prevalence and characteristics of neuromuscular and musculoskeletal complications among chronic diabetic patients residing in Gujranwala.Utilizing a non-probability convenient sampling method, the research enlisted 260 participants who were assessed at the District Head Quarters (DHQ) in Gujranwala.The study's participant pool was carefully selected based on specific inclusion criteria, which mandated both genders, a minimum diabetes duration of 10 years, and the presence of chronic diabetes alongside neuromuscular and musculoskeletal complications.Individuals with systemic diseases, those with a history of polio, traumatic injuries, or any other form of disability were systematically excluded from the study to ensure a homogenous participant demographic relevant to the research objectives.Ethical considerations were of paramount importance throughout the study's execution.Prior to data collection, informed consent was obtained from all participants, with a strict adherence to ensuring their anonymity and confidentiality.The research protocol highlighted the voluntary nature of participation, underscoring the participants' right to withdraw from the study at any point without any consequences.This ethical approach was aligned with the Declaration of Helsinki, ensuring that all procedures involving human subjects were conducted in a manner that respected their dignity and rights.Data was gathered using a meticulously crafted questionnaire, designed specifically for this study to capture a comprehensive range of information pertinent to the research questions.A total of 35 chronic diabetic patients who met the inclusion criteria were administered the questionnaire.Verbal consent was obtained prior to the administration of the questionnaire, maintaining the ethical standards set forth at the beginning of the study.The questionnaire served as the primary tool for data collection, designed to elicit detailed responses regarding the neuromuscular and musculoskeletal complications experienced by the participants.For the analysis of the collected data, the Statistical Package for the Social Sciences (SPSS) version 25 was employed.The data was analyzed and interpreted to present findings in a clear and understandable format, primarily through the use of bar charts.This analytical approach facilitated a nuanced understanding of the nature and prevalence of neuromuscular and musculoskeletal complications among the studied population.

RESULTS
The study meticulously examined the demographic characteristics and the prevalence of musculoskeletal disorders among chronic diabetic patients, yielding comprehensive insights encapsulated in two descriptive tables.The participant demographics, detailed in Table No. 1, reveal a diverse cohort comprising both male and female subjects, with females constituting a majority at 63.08% (164 participants) compared to males at 36.92% (96 participants).A significant proportion of the study population, 68.46% (178 participants), reported a positive family history of diabetes mellitus (DM), indicating a potential genetic predisposition or familial tendency towards the condition.The onset of DM among participants varied, with a nearly equal distribution between those diagnosed within 10 to 15 years (48.08%,125 participants) and those within the 15 to 20-year range (51.92%, 135 participants), highlighting the chronic nature of the condition in the study group (Table No. 1).In terms of musculoskeletal complications, as detailed in Table No. 2, a substantial prevalence of various disorders was observed among the participants.Adhesive Capsulitis was notably prevalent, affecting 77.31% (201 participants) of the cohort, underscoring the significant impact of diabetes on joint mobility and pain.Conversely, conditions such as AC Joint Dysfunction and Carpel Tunnel Syndrome were present in 31.56%(82 participants) and 37.31% (97 participants) of the population, respectively, indicating a lesser but still notable prevalence.Dupuytren's Contracture and Flexor Tenosynovitis were observed in 22.69% (59 participants) and 57.31% (149 participants) of the subjects, further illustrating the diverse impact of chronic diabetes on the musculoskeletal system.156 (60%) Notably, less common disorders such as Trigger Finger and Diabetic Cheiroarthropathy were reported in 5.39% (14 participants) and 15.00% (39 participants) of the sample, respectively.Other conditions such as Hip Dysfunction, Diabetic Foot, and Deep Venous Thrombosis were also documented, affecting a range of 11.54% to 40% of participants, indicating a broad spectrum of musculoskeletal challenges faced by individuals with chronic diabetes.Moreover, conditions like Fibromyalgia, Gangrene, Osteoarthritis (OA), Rheumatoid Arthritis (RA), and Gouty Arthritis were present, with Fibromyalgia and OA each affecting 60% (156 participants) of the study population, highlighting the severe implications of diabetes on overall musculoskeletal health.Peripheral Neuropathies, a common complication of diabetes, was reported in 40% (104 participants) of the cohort, further emphasizing the critical need for comprehensive management strategies for diabetic patients to mitigate these complications (Table No. 2).

DISCUSSION
The primary objective of this study was to elucidate the prevalence of neuromuscular and musculoskeletal complications in chronic diabetic patients.Among the 260 patients surveyed, a notable proportion, 77.31% (201 patients), experienced adhesive capsulitis, making it the most prevalent complication within the cohort.This was closely followed by fibromyalgia and osteoarthritis (OA), each affecting 60% (156 patients) of the participants, and flexor tenosynovitis, present in 57.31% (149 patients).These findings underscore the significant burden of musculoskeletal disorders among individuals with long-standing diabetes, highlighting the critical need for targeted interventions to manage these conditions effectively.In comparison to existing literature, the prevalence rates observed in this study diverge significantly from those reported in previous research.For instance, an experimental study conducted in February 2021 focusing on upper limb musculoskeletal disorders among type 2 diabetes patients found a considerably lower prevalence rate of 16.3% for musculoskeletal disorders in diabetic patients compared to 11.2% in non-diabetic patients (15).Similarly, a study from Bangladesh in 2020 reported a 30.4% prevalence of musculoskeletal conditions among a broader population, with low back pain, knee osteoarthritis, and soft tissue rheumatism being the most common conditions, contrasting sharply with the high prevalence of adhesive capsulitis observed in the current study (17).Further, a Nigerian study involving a comparison between adults with type 2 diabetes mellitus (T2DM) and non-diabetic controls found a significant difference in the prevalence of musculoskeletal disorders (56% vs. 22%), with specific conditions like osteoarthritis and limited joint mobility being more common among diabetic individuals (18), aligning more closely with the current study's findings.The disparity in prevalence rates between this study and prior research may be attributed to various factors, including differences in study populations, diagnostic criteria, and methodological approaches.For instance, Thomas Rehling's 2019 study corroborated the association between diabetes mellitus and conditions such as low back pain, OA, and rheumatoid arthritis (RA), albeit noting a minimal prevalence of RA in the current cohort (8.84%) compared to OA (60%) (19).Additionally, Majjad and colleagues in 2018 highlighted the frequent occurrence of musculoskeletal disorders in diabetic patients, with prevalence rates for conditions like osteoarthritis, shoulder capsulitis, and hand disorders reflecting the broader impact of diabetes on musculoskeletal health (8).The findings of this study, particularly the high prevalence of adhesive capsulitis, fibromyalgia, and flexor tenosynovitis, provide valuable insights into the spectrum of musculoskeletal complications associated with chronic diabetes.These results emphasize the complex interplay between diabetes and musculoskeletal health, underscoring the importance of comprehensive management strategies to mitigate these complications.However, the study is not without limitations.The use of a non-probability sampling method and the focus on a specific geographical area may limit the generalizability of the findings.Moreover, the reliance on selfreported data could introduce bias, affecting the accuracy of the reported prevalence rates.In light of these findings and limitations, it is recommended that future research adopt a more diverse and representative sample, incorporating objective diagnostic criteria to enhance the reliability of musculoskeletal disorder diagnoses among diabetic patients.Additionally, longitudinal studies could provide deeper insights into the progression of musculoskeletal complications over time, offering valuable information for the development of preventive and therapeutic interventions tailored to the needs of diabetic patients.

Table No . 1 :
Descriptive Statistics of Participant Demographics