Cerdika: Jurnal Ilmiah Indonesia, Juni 2021, 1 (6), 755-760
p-ISSN: 2774-6291 e-ISSN: 2774-6534
Available online at http://cerdika.publikasiindonesia.id/index.php/cerdika/index
10.36418/cerdika.v1i6.107 755
ARM SLING VERSUS FIGURE OF EIGHT FOR TREATING MIDSHAFT
CLAVICLE FRACTURE IN ADULTS – A SYSTEMATIC REVIEW
Teddy Arga Saputro
Medical Doctor of Sultan Imanuddin Hospital, Pangkalan Bun Central Kalimantan,
Indonesia
teddy.99.td@gmail.com
Abstract
Received:
Revised :
Accepted:
05-05-2021
20-06-2021
26-06-2021
Introduction: The clavicle is a long, dual-curved bone that
forms the only direct link between the axial and
appendicular skeletons. Clavicle fracture is the most
frequent trauma of the scapular girdle, and involves the
midshaft. Although the proportion managed operatively has
increased in recent years, the majority (80%) occur at the
midshaft are treated non-operatively. Conservative
treatments (including figure of eight and arm sling) has a
high union rate and good clinical outcome in majority of
cases, but very few randomized studies have compared the
two. Therefore, a systematic review is needed to compare
between arm sling and figure of eight bandage for treat the
midshaft clavicle fracture in adults. The author hopes that
this systematic review can be the consideration for the better
treatment in closed clavicle fracture in adults. Method: The
following strategy was used terms on several journals of
comparison between arm sling with figure of eight bandage
for threatening midshaft clavicle fracture in adults.
Preferred Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) guidelines were used to perform the
comprehensive data collection. The authors used 5 years
publication date and English language to select an
appropriate journal. Result: The result is presented by
comparison between arm sling and figure of egiht for the
treatment outcomes. The author identified 11 relevant
articles about comparison between arm sling and figure of
eight to treat midshaft clavicle fracture in adults. The total
number of patients was 3064 samples. The articles compare
about the level of pain by VAS score, level of shortening and
mean time of union. Conclusion: The arm sling has better
advantages for non-operative treatment to midshaft clavicle
fracture in adults than figure of eight bandage. It shows
from the level of pain, level of shortening and mean time of
union. The arm sling treatment has less level of pain, less
level of shortening and less mean time of union than figure
of eight bandage.
Keywords: clavicle fracture; figure of eight; arm sling.
Teddy Arga Saputro/Cerdika: Jurnal Ilmiah Indonesia, 1(6), 755-760
Arm Sling Versus Figure Of Eight For Treating Midshaft Clavicle Fracture In Adults – A
Systematic Review 756
CC BY ND
INTRODUCTION
The clavicle is a long, dual-curved bone that forms the only direct link between
the axial and appendicular skeletons. Clavicle is the first bone in the body to be ossified
(begins at 5 to 6 weeks' gestation) and the last bone to complete ossification (Kadam et
al., 2018).
Clavicle fracture is the most frequent trauma of the scapular girdle, and involves
the midshaft in 4 out of 5 cases (Ropars et al., 2017). Although the proportion managed
operatively has increased in recent years, the majority (80%) occur at the midshaft are
treated non-operatively (Goh et al., 2020). Most adults treated non surgically for midshaft
clavicle fractures will heal completely. Unfortunately, based on recent studies have
shown that midshaft fractures that has malunion, pain and deformity rates may be larger
number compared to those reported with conventional method. Latest evidence
demonstrates that operative treatment of midshaft clavicle fractures can result in better
functional status and patient satisfaction than non surgical treatment in patients meeting
certain criteria (Goh et al., 2020).
The rate of nonunion for completely displaced mid-shaft fractures has recently
been reported to be 15.1% in a metaanalysis of 2144 fractures treated non-operatively
(Goh et al., 2020). Conservative treatments (including figure of eight and arm sling)
has a high union rate and good clinical outcome in majority of cases (Rasheed, 2018).The
figure of eight bandage and the broad arm sling are most commonly used and, despite
their wide use, very few randomized studies have compared the two (Ersen et al., 2015).
A search strategy, updated in January 2014, did not find any new comparative studies on
conservative interventions for treating clavicle fractures (Lenza et al., 2016). There are
numerous conservative treatment options available, the most common being the use of a
sling or ’figure of eight bandage (also known as figure-of-eight splint, or back-pack
bandage), or a combination of these two methods (Kadam et al., 2018). Therefore, a
systematic review is needed to compare between arm sling and figure of eight bandage
for treat the midshaft clavicle fracture in adults. The author hopes that this systematic
review can be the consideration for the better treatment in closed clavicle fracture
in adults.
METHODS
The following strategy was used terms on several journals of comparison
between arm sling with figure of eight bandage for threatening midshaft clavicle fracture
in adults. Preferred Reporting Items for Systematic Reviews and Meta-Analyses
(PRISMA) guidelines were used to perform the comprehensive data collection. A
bibliometric evaluation was done on all the search results. After searching with those
keywords, the authors used 5 years publication date and English language to select the
appropriate journal. Journals were reviewed from title and abstract and followed inclusion
and exclusion criteria. The inclusion criteria were an original article, a full-text paper,
retrospective design and compare of arm sling and figure of eight for threatening midshaft
clavicle fracture in adults. The exclusion criteria were a case reports, review articles,, and
no data analysis. Journal search strategy showed in figure 1.
Teddy Arga Saputro/Cerdika: Jurnal Ilmiah Indonesia, 1(6), 755-760
Arm Sling Versus Figure Of Eight For Treating Midshaft Clavicle Fracture In Adults – A
Systematic Review 757
Figure 1. Flow diagram of search strategy
RESULT AND DISCUSSION
A. RESULT
The initial journals of 45 titles that assessed according to the inclusion and
exclusion criteria, There were 11 final total number of articles which were analyzed.
Table 1. Studies included to analysis
Author
Design
Case Result
Ropars et al, 2017
retrospective
Sling less painfull in first 3
days
Kadam et al, 2018
retrospective
1.0 to 1.8 cm shortening is
seen in males treated with
“arm sling” as compared to
1.7-2.10 cm shortening is
Records identification
through database searching
(n=45)
Records after
duplicate removed
(n=40)
Records screened
(n=33)
Fulltext article
assessed
(n=23)
Studies included to
analysis
(n=11)
Article excluded
(n=12)
- Non retrospective (n=2)
- Review article (n=3)
-
Research with no data anaysis
(n=1)
- Research didn’t focus to
compare arm sling vs figure
of eight (n=6)
Records excluded
(n=10)
- >5 year publication date
(n=10)
Teddy Arga Saputro/Cerdika: Jurnal Ilmiah Indonesia, 1(6), 755-760
Arm Sling Versus Figure Of Eight For Treating Midshaft Clavicle Fracture In Adults – A
Systematic Review 758
seen in males treated with
“figure of eight bandage”
An average shortening of
1.0 to 1.7 cm shortening is
seen in females treated with
“arm sling” as compared to
shortening of 1.5-2.0 cm in
females treated with “figure
of eight bandage
Ersen et al, 2016
retrospective
VAS less in arm sling than
figure of eight bandage, but
after 3 days the VAS were
almost similar
Radiological shortening:
The mean shortenings in
the figure of eight bandage
and broad arm sling groups
were 9 mm and 7.7 mm
Nusrat Rasheed,
Jagdesh Kumar,
2018
retrospective
VAS score in day 1, 7, 14
and 21 was less in sling
than figure of eight
Mario Lenza et al,
2016
retrospective
The broad arm sling was
significantly more
comfortable in the first 3
days of treatment
Gyanendra et al,
2018
retrospective
The mean time of union
was almost similar
Tagliapietra et al,
2020
retrospective
Fracture comminution and
clavicular shortening did
not influence bone healing
of figure of eight bandage
Waldmann et al,
2017
retrospective
Both had excellent
functional outcome and
very low non-union rate of
0.13%
Goh T C et al, 2016
retrospective
Figure of eight bandage had
a higher rate of non union
than arm sling
Arm sling have a higher
rate of union than figure of
eight
Figure of eight had a higher
score of pain than arm sling
Teddy Arga Saputro/Cerdika: Jurnal Ilmiah Indonesia, 1(6), 755-760
Arm Sling Versus Figure Of Eight For Treating Midshaft Clavicle Fracture In Adults – A
Systematic Review 759
Culver et al, 2021
retrospective
No diferences of shoulder
function at 6-12 months
No differences of pain in
first week
No differences of in the
mean percentage of clavicle
shortening
Tamaoki et al, 2017
retrospective
No differences of VAS
score and union of both
Based on table 1, All studies used the retrospective cohort method. The total
number of patients was 3064 samples with the largest number of samples in a study by
(Waldmann et al., 2018) which had a total of 2000 patients of midshaft clavicle fracture.
B. DISCUSSION
This systemic review shows us the differences output of the non-operative
treatment of midshaft clavicle fracture in adults. It shows us of some differences like pain
by VAS score, shortening, and mean time of union.
The study from (Ropars et al., 2017) showed that the sling treatment was less
painful than the treatment with figure of eight bandage. The study of (Ersen et al., 2015)
was also show us that the pain level by VAS score of figure of eight was more painful
than arm sling. It was showed in first 3 days, but after that the level of pain almost
similar. The study of (Rasheed, 2018) showd that the arm sling was less painful than
figure of eight in day 1, 7, 14 and 21. In other hand, the study of (Tamaoki et al., 2017),
117 patients had a similar of pain level in both arm sling and figure of eight.
The shortening level was also different in arm sling streatment than figure of
eight. The study of (Kadam et al., 2018) showed that 1.0 to 1.8 cm shortening was seen in
males treated with “arm sling” as compared to 1.7-2.10 cm shortening is seen in males
treated with “figure of eight bandage”. An average shortening of 1.0 to 1.7 cm shortening
was seen in females treated with “arm sling” as compared to shortening of 1.5-2.0 cm in
females treated with “figure of eight bandage. It was aslo similar with the study of (Ersen
et al., 2015) about the Radiological shortening. The mean shortenings in the figure of
eight bandage and broad arm sling groups were 9 mm and 7.7 mm.
About the union time, The mean time of union was almost similar based of the
study of (Jha et al., 2018) and (Tamaoki et al., 2017). Unlike with the study of (Goh et al.,
2020) that showed of 60 patients that arm sling have a higher rate of union than figure of
eight.
This study does have a number of limitations. First, all of this research uses 5
years of publication thus allowing previous research cannot be analyzed. Secondly, some
of the studies presented didn’t show the the patient conditions everyday, so it could be the
bias. For these reasons, it still difficult to definitely compare between arm sling with the
figure of eight bandage.
Teddy Arga Saputro/Cerdika: Jurnal Ilmiah Indonesia, 1(6), 755-760
Arm Sling Versus Figure Of Eight For Treating Midshaft Clavicle Fracture In Adults – A
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CONCLUSION
The arm sling has better advantages for non-operative treatment to midshaft
clavicle fracture in adults than figure of eight bandage. It shows from the level of pain,
level of shortening and mean time of union. The arm sling treatment has less level of
pain, less level of shortening and less mean time of union than figure of eight bandage.
REFERENCE
Ersen, A., Atalar, A. C., Birisik, F., Saglam, Y., & Demirhan, M. (2015). Comparison of
simple arm sling and figure of eight clavicular bandage for midshaft clavicular
fractures: a randomised controlled study. The Bone & Joint Journal, 97(11), 1562–
1565.
Goh, T. C., Bajuri, M. Y., Nadarajah, S. C., Rashid, A. H. A., Baharuddin, S., & Zamri,
K. S. (2020). Clinical and bacteriological profile of diabetic foot infections in a
tertiary care. Journal of Foot and Ankle Research, 13(1), 1–8.
Jha, G. K., Timsina, P., Yadav, D., Lamichhane, S., & Jha, S. (2018). Conservative Vs
Operative Management of Displaced Midshaft Clavicle Fracture-A Comparative
Study. Biomedical Journal of Scientific & Technical Research, 11(1), 8293–8303.
Kadam, R., Ghodke, A., Gupta, A., Chhallani, A., Agrawal, A., & Sawant, R. (2018).
Evaluation of Clavicle Shortening in Clavicle Fractures Treated with “ARM Sling”
Or “figure of Eight Bandage.” Journal of Trauma, 13(1), 27–30.
Lenza, M., Taniguchi, L. F. P., & Ferretti, M. (2016). Figure-of-eight bandage versus arm
sling for treating middle-third clavicle fractures in adults: study protocol for a
randomised controlled trial. Trials, 17(1), 1–8.
Rasheed. (2018). Midshaft Clavicle Fracture; Comparison Of Poly Arm Sling And Figure
Of Eight Bandage. Professional Medical Journal, 25(1).
Ropars, M., Thomazeau, H., & Huten, D. (2017). Clavicle fractures. Orthopaedics &
Traumatology: Surgery & Research, 103(1), S53–S59.
Tamaoki, M. J. S., Matsunaga, F. T., da Costa, A. R. F., Netto, N. A., Matsumoto, M. H.,
& Belloti, J. C. (2017). Treatment of displaced midshaft clavicle fractures: figure-
of-eight harness versus anterior plate osteosynthesis: a randomized controlled trial.
JBJS, 99(14), 1159–1165.
Waldmann, S., Benninger, E., & Meier, C. (2018). Nonoperative treatment of midshaft
clavicle fractures in adults. The Open Orthopaedics Journal, 12, 1.
© 2021 by the authors. Submitted for possible open access publication under the
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license (https://creativecommons.org/licenses/by/3.0/).