Operative Versus Nonoperative Outcomes of Middle-Third Clavicle Fractures: A Systematic Review and Meta-Analysis

Objectives:Middle third clavicle fractures have long been managed conservatively with immobilization. Some patients, especially those with completely displaced or shortened clavicle fractures are now thought to have increased risk of nonunion or symptomatic malunion. The authors performed a meta-analysis to study the incidence of nonunion and symptomatic malunion and test the hypothesis that surgical fixation of these fractures significantly lowers the risk of these complications.Methods:A search was performed in the PubMed, Embase, and Cochrane Library databases for randomized clinical trials and quasi-experimental trials that compare outcomes of operative and nonoperative management for clavicle fractures that are fully (100%) displaced or have greater than 2 cm of shortening. Pooled patient data were used to construct forest plots for the meta-analysis.Results:Eleven studies including 497 patients who were treated and 457 patients treated conservatively were analyzed. Patients managed operatively had significantly lower relative risk of developing nonunion [0.17 (95% confidence interval 0.08-0.33)] and symptomatic malunion [0.13 (95% confidence interval 0.05-0.37)]. Plate fixation significantly reduced the risk of nonunion, but intramedullary nail fixation did not. There was no difference in Constant-Murley or DASH scores between the 2 treatment groups or in the rate of secondary operative procedures.Conclusions:Patients who undergo operative fixation of displaced middle-third clavicle fractures have a lower incidence of nonunion and symptomatic malunion. The clinical significance of this effect is uncertain, as functional scores were similar in both groups. Further research into the risk factors for nonunion and symptomatic malunion will be necessary to determine which patients benefit from operative fixation.Level of Evidence:Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.