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Evidence summaries

Surgical Versus Conservative Interventions for Treating Fractures of the Middle Third of the Clavicle

Surgical treatment may not have additional benefits in terms of function, pain and quality of life compared with conservative treatment, but may result in fewer treatment failures overall. Level of evidence: "C"

The level of evidence is downgraded because of several study limitations (lack of allocation concealment and blinding, incomplete outcome data, selective reporting).

Summary

A Cochrane review [Abstract] 1 included 14 studies with a total of 1469 subjects. All studies included adults, with the overall range from 17 to 70 years. Of the studies that reported gender, men were over-represented. Ten studies compared plate fixation with sling or figure-of-eight bandage, or both, and four studies compared intramedullary fixation with wearing either a sling or a figure-of-eight bandage.

Evidence from 10 studies (838 participants), showed that, compared with conservative treatment, surgical treatment of acute middle third clavicle fractures may not improve upper arm function at followup of one year or longer: SMD 0.33, 95% CI 0.02 to 0.67. This corresponds to a mean improvement of 2.3 points in favour of surgery (0.14 points worse to 4.69 points better), on the 100-point Constant score; this does not represent a clinically important difference. There may be no difference in pain measured using a visual analogue scale (0 to 100 mm; higher scores mean worse pain) between treatments (mean difference (MD) 0.60 mm, 95% CI 3.51 to 2.31; 277 participants, 3 studies). Surgery may reduce the risk of treatment failure, that is, number of participants who had non-routine secondary surgical intervention (excluding hardware removal), for symptomatic non-union, malunion or other complication RR 0.32, 95% CI 0.20 to 0.50; 1197 participants, 12 studies. The main source of treatment failure was mechanical failure (3.4%) in the surgery group and symptomatic non-union (11.6%) in the conservative-treatment group.

It is uncertain whether surgery results in fewer people having one or more cosmetic problems, such as deformities, which were more common after conservative treatment, or hardware prominence or scarring, which only occurred in the surgery group (RR 0.55, 95% CI 0.31 to 0.98; 1130 participants, 11 studies). It is uncertain whether there is any difference between surgery and conservative treatment in the risk of incurring an adverse outcome that includes local infection, dehiscence, symptomatic malunion, discomfort leading to implant removal, skin and nerve problems: RR 1.34, 95% CI 0.68 to 2.64; 1317 participants, 14 studies). Hardware removal for discomfort was a common adverse outcome in the surgery group (10.2%) while symptomatic malunion was more common in the conservative-treatment group (11.3% versus 1.2% in the surgery group). Infection occurred only in the surgery group (3.2%).

Note

    References

    • Lenza M, Buchbinder R, Johnston RV et al. Surgical versus conservative interventions for treating fractures of the middle third of the clavicle. Cochrane Database Syst Rev 2019;(1):CD009363. [PubMed]

Primary/Secondary Keywords