TRAUMA

Comparison of simple arm sling and figure of

eight clavicular bandage for midshaft
clavicular fractures
A RANDOMISED CONTROLLED STUDY
A. Ersen, Only a few randomised, controlled studies have compared different non-operative methods
A. C. Atalar, of treatment of mid-shaft fractures of the clavicle.
F. Birisik, In this prospective, randomised controlled study of 60 participants (mean age 31.6 years;
Y. Saglam, 15 to 75) we compared the broad arm sling with the figure of eight bandage for the
M. Demirhan treatment of mid-shaft clavicle fractures. Our outcome measures were pain, Constant and
American Shoulder and Elbow Surgeons scores and radiological union.
From Istanbul The mean visual analogue scale (VAS) pain score on the first day after treatment was
University Istanbul significantly higher (VAS 1 6.8; 4 to 9) in the figure of eight bandage group than the broad
Medical Faculty, arm sling group (VAS 1 5.6; 3 to 8, p = 0.034). A mean shortening of 9 mm (3 to 17) was
Istanbul, Turkey measured in the figure of eight bandage group, versus 7.5 mm (0 to 24) in the broad arm
sling group (p = 0.30).
The application of the figure of eight bandage is more difficult than of the broad arm
sling, and patients experience more pain during the first day when treated with this option.
We suggest the broad arm sling is preferable because of the reduction of early pain and ease
of application.
Cite this article: Bone Joint J 2015;97-B:15625.

A. Ersen, MD, Orthopaedic
Surgeon,
A. C. Atalar, MD, Orthopaedic
Surgeon, Associate Professor,
F. Birisik, MD, Orthopaedic
Surgeon,
Y. Saglam, MD, Orthopaedic
Surgeon,
Department of Orthopaedics
and Traumatology
Istanbul University Istanbul
Medical Faculty, Capa, Istanbul,
Turkey.
M. Demirhan, MD,
Orthopaedic Surgeon,
Professor, Department of
Orthopaedics and
Traumatology
KOC University School of
Medicine, Istanbul, Turkey.
Correspondence should be sent
to Dr A. C. Atalar; e-mail:
atalar.ac@gmail.com
2015 The British Editorial
Society of Bone & Joint
Surgery
doi:10.1302/0301-620X.97B11.
35588 $2.00
Bone Joint J
2015;97-B:15625.
Received 22 December 2014;
Accepted after revision 10 July
2015
Fractures of the clavicle are common, account-
ing for approximately 2.5% of all fractures
presenting to orthopaedic surgeons and occur-
ring most commonly in young males.1
Although the proportion managed operatively
has increased in recent years, the majority
(80%) occur at the mid-shaft and are treated
non-operatively.2 The rate of nonunion for
completely displaced mid-shaft fractures has
recently been reported to be 15.1% in a meta-
analysis of 2144 fractures treated non-opera-
tively.2 A number of studies have compared
operative and non-operative treatment for dis-
placed mid-shaft clavicle fractures, most
reporting better functional results with open
reduction and internal fixation with a plate
and screws.3-6 While this may become the ref-
erence standard for treatment for completely
displaced mid-shaft fractures, there remains a
role for non-operative treatment. Non-
operative methods ranging from a spica cast to
benign neglect.7 The figure of eight bandage
and the broad arm sling are most commonly
used and, despite their wide use, very few ran-
domised studies have compared the two.8,9
Our experience has been that patients appear
less comfortable when the figure of eight band-
age is used and so we set out to compare the
two methods in the first 14 days of treatment
with the primary outcome measures of pain
and radiological shortening and secondary
measures of radiological union and functional
status, with the hypothesis that the figure of
eight demonstrated inferiority.
Patients and Methods
Between August 2012 and September 2013, 60
eligible patients with a mean age of 31.6 years
(15 to 75) were randomised to conservative
treatment with either a broad arm sling or a
figure of eight bandage. Patient counselling
and informed consent was carried out by two
authors (AE, FB). We employed non-stratified
randomisation in blocks of two using the
sealed envelope method, so when one patient
had chosen an envelope, the next patient
would be allocated to a group according to the
remaining envelope of the pair. The protocol
was approved by our institutional review
board.
Patients meeting our inclusion criteria were
those over the age of 15 years who sustained
an isolated, mid-shaft clavicular fracture and
presented on the day of injury. Those under 15
years of age, with fractures of other parts of
the clavicle, open injuries or pathological frac-
tures, involvement in polytrauma or presenta-
tion delayed beyond 24 hours post-injury were

1562 THE BONE & JOINT JOURNAL

 COMPARISON OF SIMPLE ARM SLING AND FIGURE OF EIGHT CLAVICULAR BANDAGE FOR MIDSHAFT CLAVICULAR FRACTURES 1563

Assessed for eligibility (n = 112

clavicle fractures)

Excluded (n = 52)
Not meeting inclusion criteria
(n = 39)
Refused to participate (n = 13)

Randomised (n = 60 clavicle
fractures)

Allocated to simple arm sling Allocated to figure of 8 bandage

(n = 30 received intervention (n = 30) (n = 30 received intervention (n = 30)

Lost to follow-up (n = 3 unable to

Lost to follow-up (n = 1,
come to the hospital)
unable to come to the
Discontinued intervention (n = 3
hospital)
declined to continue)
Discontinued intervention
Excluded from the study (n = 1,
(n = 1, declined to continue)
not followed the study protocol)

Analysed (n = 28) Analysed (n = 23)

Fig. 1

Flow diagram of recruitment to the study.

excluded. The only analgesia permitted was paracetamol
and those who could not comply and required further anal-
gesia were also excluded.
The upper limb was immobilised in internal rotation
with the relevant sling for three weeks. Patients and rela-
tives of those in the figure of eight bandage were educated
on how to tighten the bandage when it loosened. The
patients were free to use their arms with the figure of eight
bandage and those in a broad arm sling were advised to flex
and extend their elbows three times a day for ten minutes.
Patients re-attended to complete the outcome measures
the next day (day one), and on days three, seven, 14 and 21.
The pain was recorded on a visual analogue scale (VAS)
from 1 to 10 (best to worst). Ongoing consent to participa-
tion was ascertained at each visit.
Anteroposterior (AP) radiographs were obtained and
assessed by two authors (AE, FB) at weeks four, eight and
12 and the time to union (appearing of the bone bridging)
recorded. Mean follow-up was 8.2 months (6 to 12). At the
end of the treatment, the length of both clavicles (fractured
and uninjured contralateral) on AP radiographs was meas-
ured and the degree of shortening was calculated. Constant
and American Shoulder and Elbow Surgeons10,11 scores
were used for functional evaluation at the last follow-up.
Sample size calculation. After enrolment of five patients to
both groups, a sample size calculation was carried out using
the comparison of two means method. For the broad arm
sling and figure of eight bandage groups the mean VAS and
standard deviations (SD) on day one were 5.00 (SD 2.31) and
7.00 (SD 1.63), respectively. On day seven, the values were
2.50 (SD 1.12) and 2.33 (SD 2.05). This produced a sample size
of 44 to identify a significant difference.
Statistical analysis. The primary outcomes were VAS at days
one, three, seven and 14 and the confirmation of mean union
at the end of the treatment. Secondary outcomes were Con-
stant and ASES scores. All continuous data were compared
using two-sample paired Student's t-tests with significance set
at a p-value of < 0.05. For the comparison of categorical vari-
able (patient satisfaction) the chi-squared test was used. All
analyses were performed with the MedCalc B-8400 statistical
analysis software package (MedCalc, Ostend, Belgium).
Results
Of the 60 patients initially enrolled, we excluded four
patients who declined to continue participation, four who
were unable to come to the hospital for evaluation in the
first two weeks and one who took different painkillers
(Fig. 1). Of the remaining 51 patients, 28 were treated with
broad arm slings, and 23 with figure of eight bandages. The
two groups were similar in terms of age, gender distribu-
tion, and proportion with their dominant hand affected
(Table I).

VOL. 97-B, No. 11, NOVEMBER 2015

1564 A. ERSEN, A. C. ATALAR, F. BIRISIK, Y. SAGLAM, M. DEMIRHAN

Table I. Demographic details of the two treatment groups

Broad arm sling Figure of eight bandage

Patients 23 28
Mean age (yrs) (range) 28.7 (15 to 72) 33.5 (16 to 75)
Gender distribution (male/female) 19/4 22/6
Arm (dominant/non-dominant) 13/10 15/13
Fracture displacement
Displaced/not displaced 15/8 18/10

Table II. Visual analoge scale (VAS) for pain changes during the first three weeks of the treatment. Data are presented as
means with standard deviation (SD)

VAS for pain (0 to 10) Broad arm sling group (n = 23) Figure of eight bandage group (n = 28) p-value
Day 1 5.5 (SD 1.8) 6.8 (SD 1.7) 0.034
Day 3 5.6 (SD 1.85) 6.8 (SD 1.7) 0.06
Day 7 2.0 (SD 2.1) 1.9 (SD 1.5) 0.9
Day 14 0.9 (SD 0.8) 0.9 (SD 1.4) 0.8
Day 21 0.5 (SD 0.3) 0.6 (SD 0.7) 0.9

Fig. 2 Fig. 3

Radiograph of the measurement of the clavicular length for a fracture of Radiograph of the measurement of the clavicular length for a fracture
the left clavicle treated with a figure of eight bandage. of the right clavicle treated with a broad arm sling.

The mean VAS on the first day after treatment was sig-
nificantly lower (p = 0.034, 95% confidence interval (CI)
0.10 to 2.46) in the broad arm sling group at 5.5 (SD 1.8)
than in the figure of eight group at 6.8 (SD 1.7). The mean
VAS on days three, seven, 14 and 21 were statistically sim-
ilar (p = 0.06, 95% CI 0.05 to 2.34; p = 0.9, 95% CI -1.34
to 1.2; p = 0.8, 95% CI -0.63 to 0.52; p = 0.9, 95% CI -0.6
to 0.7, respectively). In both groups pain was almost
resolved on day 14, with a decrease in the mean VAS to 1 or
below (Table II).
Patient satisfaction. A total of five (18%) of the 28 patients
in the figure of eight group were dissatisfied with the treat-
ment method; two had swelling of the injured extremity on
day one, which resolved after loosening of the bandage.
Three (10%) further patients had some abrasion of axillary
skin by day seven because of the friction and compression
from the bandage.
In contrast, three (12%) of the 25 patients comprising
the broad arm sling group were dissatisfied because of
mobility and crepitation of the fracture site. The difference
in rate of expression of dissatisfaction was not different
between the two groups (p = 0.6, chi-squared test).
Healing time and return to work/school. In total 48 (95%)
fractures had united in eight weeks, and the remaining three
had united by 14 weeks post-injury. Patients in the broad
arm sling returned to work or school in a mean of 4.6
weeks (3 to 9), compared with those in the figure of eight
group who required 4.3 weeks (3 to 8) (p = 0.19).
Radiological shortening. The mean shortenings in the figure
of eight bandage and broad arm sling groups were 9 mm
(SD 3.8) and 7.7 mm (SD 3.0), respectively (p = 0.30; 95%
CI -2.2 to 5.3, Figs 2 and 3). The maximum shortening was
24 mm in a patient in the broad arm sling group.
Functional evaluation. After a mean follow-up of 8.3
months (6 to 12), patients in both treatment groups
achieved high Constant and ASES scores. The mean Con-
stant scores were 96 (80 to 100) in the figure of eight group
and 96.75 (75 to 100) in the broad arm sling groups
(p = 0.676) and mean ASES scores were 94.5 (82 to 100)
and 96.15 (73.3 to 100), respectively (p = 0.873).

THE BONE & JOINT JOURNAL

 COMPARISON OF SIMPLE ARM SLING AND FIGURE OF EIGHT CLAVICULAR BANDAGE FOR MIDSHAFT CLAVICULAR FRACTURES
Discussion
The aim of treatment of clavicular fractures is to restore
shoulder function by allowing the clavicle to heal without
deformity or significant shortening. With non-surgical
methods, lower than 1% nonunion rates are reported in the
literature.12,13 In our study, 51 patients completed the treat-
ment period, all fractures healed successfully and no cases
of nonunion were observed. One possible reason for this
result is the small number of patients included in the study,
albeit this sample size was informed by an interim power
calculation. A high rate of union could also be anticipated
in a sample comprising a high proportion (19/51, 40%) of
non-displaced and minimally displaced fractures. The even
distribution of these patients between the groups should
not have caused any skewing of results.
Studies by Andersen et al8 and Hoofwijk and van der
Werken9 were randomised controlled, single-centre studies
(61 and 152 patients, respectively) comparing the broad
arm sling and figure of eight bandage for the conservative
treatment of clavicular fractures. Hoofwijk and van der
Weaken9 reported a statistically significant difference in
favour of the broad arm sling in terms of pain after 15 days
(mean difference 0.80, 95% CI 0.34 to 1.26). Our early
findings echoed this but, by day three, the differences
became statistically insignificant.
Andersen et al8 found that patient satisfaction following
treatment with the figure of eight bandage was lower than
for patients treated with the broad arm sling (9/34 vs 2/27).
In our study, the rates of dissatisfaction were similar in both
groups but the reasons for dissatisfaction were different. To
avoid irritation of the skin in the axillary area associated
with the use of the figure of eight bandage, we advocate
some form of padding.
It has been reported that clavicular shortening > 15 mm
may lead to chronic shoulder pain and discomfort.14,15 Ras-
mussen et al16 retrospectively compared the figure of eight
bandage and broad arm sling in terms of shortening and
found no difference between the two but did note that
shortening > 20 mm was correlated with poorer outcomes.
In this study, the mean shortening was < 15 mm in both
treatment groups, at 9 mm (SD 3, p = 0.8; figure of eight)
and 7.7 mm (SD 3.0; broad arm sling). Six patients from the
broad arm sling group and five from the figure of eight
group had > 15 mm shortening but this was not associated
with lower functional results.
The randomisation method is another limitation of the
study. Complete, software randomisation would offer bet-
ter statistical validity but lacked practicality in terms of
ensuring equally sized groups in this study.
In addition we acknowledge that while it is possible to
measure the length of the clavicle with an AP radiograph, it
is not possible to detect deformities in the sagittal plane. CT
VOL. 97-B, No. 11, NOVEMBER 2015
1565
would offer both greater accuracy in assessment of shorten-
ing and an ability to evaluate sagittal plane deformities.
In conclusion, both methods provided satisfactory func-
tional and radiological results for the treatment of mid-
shaft clavicle fractures. Although no difference in discom-
fort was seen at the end of the treatment period, the broad
arm sling was significantly more comfortable in the first
three days and, while no longer significantly different,
lower mean pain scores persisted throughout the first two
weeks. We therefore suggest the broad arm sling offers sim-
ilar functional outcomes and rates of union while providing
greater pain relief and hence advocate its use in mid-shaft
fractures of the clavicle.
Author contributions:
A. E. Ersen: Study design, writing of paper, data collection.
A. C. A. Atalar: Study design, writing of paper.
F. B. Birisik: Data collection, data analysis.Y. S. Saglam: Data analysis.
M. D. Demirhan: Senior author, revision of paper.
No benefits in any form have been received or will be received from a commer-
cial party related directly or indirectly to the subject of this article.
This article was primary edited by P. Page and first proof edited by G. Scott.
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