A Cochrane review on different surgical methods for acute fracture or non-union of the middle third of the clavicle included 7 studies with a total of 398 subjects. Intramedullary fixation did not result in a clinically important improvement in upper arm function (despite a statistically significant difference in its favour: standardised mean difference 0.45, 95% CI 0.08 to 0.81; 3 trials, n=120) at long term follow-up of 6 months or more. Low quality evidence indicated little difference between intramedullary fixation and plate fixation in pain (one trial). Low-contact dynamic compression plates appeared to be associated with significantly better upper-limb function throughout the year following surgery, earlier fracture union and return to work, and a reduced incidence of implant-associated symptoms when compared with a standard dynamic compression plate in the treatment of symptomatic non-union (n=36). Knowles pins appeared to be associated with lower pain levels and use of post-operative analgesics, reduced incidence of implant-associated symptoms, and shorter operation time and hospital stay when compared with a plate (n=69). One study (n=133) found that a three-dimensional technique for fixation with a reconstruction plate was associated with a significantly lower incidence of symptomatic delayed union than a standard superior position surgical approach.
Comment: The quality of evidence is downgraded by limitations in study quality (inadequate or unclear allocation concealment, inadequate intention-to-treat adherence), by inconsistency (heterogeneity in interventions and outcomes) and by imprecise results (limited study size for each comparison).