Surgery for clavicular fractures provides better outcomes but more harms than conservative treatment

Reference

Guerra E, Previtali D, Tamborini S, Filardo G, Zaffagnini S, Candrian C. Midshaft clavicle fractures: surgery provides better results as compared with nonoperative treatment: A meta-analysis. Am J Sports Med 2019;47(14):3541-3551.

Synopsis

These authors, a number of whom reported potential conflicts of interest, searched several databases and registries to identify randomized trials published in English that compared the outcomes of patients with midshaft clavicular fractures who were treated surgically or conservatively. Conservative treatment included immobilization with a sling, arm pouch, or a figure-of-8 harness. Two authors independently evaluated the studies for inclusion and assessed each included study's risk of bias. They identified 14 unique studies with 1372 patients between the ages of 25 and 41 years; 82% were men. Most of the studies were of moderate to high risk of bias. Twelve of the studies included patients with a completely displaced fracture, one study included patients with comminuted fractures, and one study included patients with mildly to moderately displaced fractures. Ten of the 705 (1.4%) surgically treated patients had nonunion compared with 110 of the 667 conservatively treated patients (16.5%; number needed to treat = 7; 95% CI 6 - 9). However, the rate of subsequent surgery was 17% in the surgically treated patients and 13% in the conservatively treated patients (number needed to treat to harm = 26). Most often the subsequent surgery in the operatively treated patients was for removal of troublesome hardware or debridement of deep infections, while the conservatively treated patients were more likely to have surgery to correct fracture malunion. Three studies reported that the surgically treated patients had better function scores, but it is unclear if the improvements were clinically important. Three studies found no significant difference in speed of return to previous activities.