I. General data The 32 patients with fractures of the middle 1/3 segment of the clavicle in this group were all unilateral closed fractures with poor manual repositioning, conforming to the indications for incisional repositioning, and no contraindications to surgery. Among them, 21 were male and 11 were female; age ranged from 14 to 52 years. The average age was 35.5 years; 19 cases were left-sided and 13 cases were right-sided; causes of injury: 17 cases of car accident, 4 cases of fall from height, 9 cases of fall, 2 cases of heavy object; fracture types: 18 cases of comminuted fracture, 9 cases of oblique fracture, 5 cases of transverse fracture; 2 cases of combined scapula fracture, 7 cases of rib fracture, 2 cases of hemopneumothorax, 3 cases of upper limb bone fracture, and 1 case of incomplete injury of brachial plexus nerve. The operation time after injury was 3-10 days, with an average of 3.4 days. After satisfactory brachial plexus anesthesia, the patient was placed in a supine position with appropriate padding at the thoracodorsal spine, so that both shoulders were in a posterior extension position. With the fracture end (slightly lateral) as the center, an 8-10 cm long incision was made along the long axis of the clavicle to reveal the fracture end layer by layer, and the periosteum was peeled off at the upper edge of the clavicle where the plate was placed, paying attention to the protection of the surrounding soft tissue blood flow, and the periphery of the fracture end was peeled off appropriately to show the bony markings to achieve direct visual repositioning. After the fracture is repositioned and temporarily fixed, the fracture is sampled with a shaped mold, and depending on the type of fracture, a 7-9 hole reconstructed plate is shaped and pre-curved, with the fracture end as the center, and the nail holes are eccentrically attached to the upper edge of the clavicle in the ratio of 3:4-6 (i.e., the proximal end of the fracture is placed in 3 holes, and the distal end of the fracture is placed in 4-6 holes), and compression fixation is performed along the longitudinal axis of the clavicle, with 3 screws used to fix the proximal end, and the distal end is placed forward The screws are screwed in multiple angles and directions, such as forward, backward, inward or outward. If there is a large comminuted bone mass between the fractures, the soft tissues on the bone mass are not peeled off too much and fixed with tension screw technique after repositioning (including large oblique fractures). If the fracture is severe and there is a bone defect at the severed end, autologous cancellous bone graft is used. The injured shoulder was suspended by a triangular scarf for 4 weeks after the operation, and then the injured shoulder was gradually put into functional activities and participated in light work after 8 weeks. Efficacy assessment criteria According to the floating shoulder function score standard [4] (Herscovici standard), the function was graded from subjective examination, lifestyle, and objective examination, and 13-16 was considered excellent; 9-12 was considered good; 5-8 was acceptable; and Q4 was poor. Results Of the 32 cases in this group, excellent: 22 cases (68.75%); good: 7 cases (21.88%); acceptable: 3 cases (9.37%); poor: 0 cases (0%). All cases in this group were followed up for a mean of 11 months (6-24 months). All the cases in this group had bony healing after surgery, and there were no cases of distal fracture detachment, plate upturning, plate bending, fracture and fracture re-displacement (3 cases had a functional grade of “OK”, 1 case had a combined scaphoid fracture and failed to follow the medical advice for timely exercise after surgery, so the shoulder joint function recovery was poor; 2 cases had a combined hemopneumothorax with serious injury and fracture In two cases, the hemopneumothorax was combined with serious injury, fracture treatment was delayed, postoperative fracture healing time was prolonged, and functional exercise was not performed in a timely manner). The overall excellent rate was 90.63%. Discussion Reconstructive plate internal fixation, one of the methods for treating clavicle fractures, is gradually becoming standardized, especially for comminuted fractures of the middle part of the clavicle. Between December 2006 and January 2008, 188 cases of clavicle fractures were treated surgically in our hospital, of which 108 cases (57.4%) were treated with internal fixation of reconstructive plates for middle clavicle fractures (comminuted, oblique, transverse), and 3 cases had surgical failure (plate fracture, distal fracture debridement), and the failure rate of internal fixation of reconstructive plates was 2.8%. Although the percentage of failed cases in the overall surgery is small, the resulting medical disputes and mental and economic losses to patients are great. For this reason, after analyzing and summarizing the causes of failure, we concluded that the conventional placement of internal fixation plates, which are equally distributed at both ends of the fracture, is not suitable for the use of middle clavicle fractures (especially comminuted fractures). Although the failure of internal fixation with reconstructed plates is the result of many factors, the neglect of the local anatomical characteristics of the clavicle and the dull routine operation can be summarized as one of the many failure factors. Reasons: ① The clavicle is an “S”-shaped long bone, and its shape, thickness and cortical thickness vary from one part to another, with the outer 1/3 of its cross-section being flat and the inner 1/3 being trigonous, and the bone is relatively dense. The reconstruction plate is evenly distributed between the two ends of the fracture with unequal morphology and texture, and the holding force of the screws at the two ends is not equal, and the anatomical characteristics determine that the holding force of the screws at the distal end of the fracture must be smaller than that at the proximal end. After fracture, this dynamic balance is disrupted and the medial fracture end is displaced posteriorly and superiorly by the traction of the sternocleidomastoid muscle over the pectoralis major muscle, while the lateral fracture end is displaced anteriorly and inferiorly by the contracted muscles and the gravity of the upper limb [6], thus showing the typical displacement of the middle clavicle after fracture form [1] (Figure 1). Even after the reconstruction of the clavicle, the proximal end of the fracture is still subject to the “crane” type of lifting force by the sternocleidomastoid muscle. The clavicle is rotated about 50° around its longitudinal axis during upper arm elevation and posterior extension activities. If the upper limb does not move properly after surgery (including involuntary activities during sleep), the stress of axial rotation of the clavicle will be concentrated in the distal end of the fracture, which will cause the distal screw, which is already not firmly held, to cut the bone channel, resulting in enlargement of the nail hole and loosening of the screw, and the gravity of the upper limb and the pulling of the sternocleidomastoid muscle will make surgical failure inevitable. Based on the above analysis, we improved the plate placement in the reconstruction plate internal fixation surgery. For different types of middle clavicle fractures, we chose the length of the plate between 7-9 holes (not less than 7 holes), on the premise of ensuring that 3 screws can be driven into the proximal end, the rest of the nail holes are allocated to the distal end of the fracture as much as possible, and the screws are screwed in multiple angles and directions to avoid parallelism with the gravitational force line of the upper limb, so as to enhance the holding force of the screws (in order to enhance the gravitational force of the upper limb). to enhance the holding force of the screws (Figure 2), maximize the fixation strength of the weak site (distal end of the fracture), and resist the stresses present in anatomical factors, thus improving the success rate of the operation. In summary, the failure of internal fixation of the reconstruction plate is the result of multiple factors, and the local anatomical characteristics are only one of them, and the eccentric placement of the reconstruction plate is only one of the countermeasures to solve one of the problems. We emphasize the strong fixation of the distal end of the fracture, the correct treatment of the fracture end (especially the comminuted fracture), the standard specification of the surgical operation, the attachment and shaping of the reconstruction plate, the postoperative suspension of the injured limb The correct treatment of the fracture end (especially comminuted fractures), the standardization of the surgical operation, the shaping of the reconstructive plate, the postoperative suspension of the injured limb, and the correct guidance of future functional exercises are still equally important!