Open Reduction and Internal Fixation Versus Nonsurgical Treatment in Displaced Midshaft Clavicle Fractures: A Meta-Analysis

Objectives: To compare open reduction and internal fixation (ORIF) and nonsurgical treatment outcomes in displaced midshaft clavicle fractures. Data Sources: PubMed, MEDLINE, EMBASE, Web of Science, Cochrane Library, and ClinicalTrials.gov were searched in September 2017. Study Selection: Inclusion criteria were randomized controlled trials reporting nonunion, shoulder functional outcomes, and subsequent surgery rates or pain scores. We excluded studies with patients younger than 16 years, maximum follow-up less than 9 months, and inaccessible full text. Data Extraction: Extracted data included the first author, publication year, number of patients, number of nonunions, Constant scores, disabilities of the arm, shoulder, and hand (DASH) scores, number of subsequent surgeries, and pain measured using the visual analog scale. Data Synthesis: The risk ratio of nonunion was 0.15 [95% confidence interval (CI), 0.08-0.31] in ORIF compared with that of nonsurgical treatment. Constant and DASH scores were significantly better in ORIF up to 6 months. The mean difference (MD) in DASH scores at 12 months was statistically insignificant in both treatments (MD, 24.19; 95% CI, 29.34 to 0.96). Constant scores remained significant in ORIF (MD, 4.39; 95% CI, 1.03-7.75). Subsequent surgeries and pain scores were similar in both treatments. Conclusions: Significant reduction in nonunions and favorable early functional outcomes are associated with ORIF. Nevertheless, late functional outcomes, subsequent surgeries, and pain scores are similar to those of nonsurgical treatment. Although patients treated with ORIF mainly had subsequent elective plate removals, non-surgically treated patients had more surgical fixations for nonunions. As a result, there remains inconsistent evidence regarding the best treatment for displaced midshaft clavicle fractures.