Surgical versus conservative interventions for treating fractures of the middle third of the clavicle

Conservative treatment might possibly be as effective as surgical treatment for acute middle third clavicle fractures.

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 included 8 studies with a total of 555 subjects. Four studies compared plate fixation with wearing a sling and four studies compared intramedullary fixation with wearing either a sling or a figure-of-eight bandage.

Low-quality evidence from seven trials (429 participants) showed that, compared with conservative treatment, surgical treatment of acute middle third clavicle fractures may not result in a significant improvement in upper arm function at one year of more follow-up: SMD 0.46, 95% CI -0.06 to 0.98. This corresponds to an absolute mean improvement of 3.2 points in favour of surgery (0.4 points worse to 7 points improvement) on the 100-point Constant score. Low-quality evidence from seven trials (437 participants) indicates a marginal difference in the incidence of treatment failure between surgery (9/232, 3.9%) and conservative treatment (24/205, 11.7%) (RR 0.38, 95% CI 0.15 to 0.99). However, this was dominated by the results of the largest trial, which had an unusually high number of symptomatic malunions in the conservative treatment group. One trial providing pain results at one-year follow-up found no difference between the two groups. No trials reported on quality of life. No significant difference between groups was noted in the pooled results for adverse events but separate analyses by type of adverse events showed that wound infection and/or dehiscence (data from three trials) and secondary surgery due to hardware complications (data from five trials) occurred only in the surgical group. Skin and nerve problems were also more common after surgical treatment, although the difference between the two groups was not statistically significant (data from four trials). Conversely, stiffness or restriction of shoulder movement was more common after conservative treatment (data from three trials).

Clinical comments

The degree of fracture dislocation is more important than the fracture´s anatomic location in determining the choice between operative and non-operative treatment

Date of latest search: 2013-03-10

Ədəbiyyat

1. 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 2013;6():CD009363.