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Clavicle Surgery Improves Outcome

December 22, 2016

Short Attention Span Summary

Clavicles need surgery?
I was always taught the adage that if the two fractured ends of the clavicle were in the same county it would heal regardless of how displaced.  This study, a meta-analysis of 8 RCTs and 12 observational studies, showed that the surgical treatment of midshaft clavicle fractures decreased non-unions, probably decreased malunions, and hastened return to work.

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Midshaft clavicle fractures were once treated non-operatively but are increasingly repaired surgically with improved outcomes over non-op treatment.  This is important because we need to refer these patients to orthopedics for prompt follow up after ED discharge.


Am J Sports Med. 2016 Nov 18. pii: 0363546516673615. [Epub ahead of print]

Surgical Versus Nonsurgical Treatment for Midshaft Clavicle Fractures in Patients Aged 16 Years and Older: A Systematic Review, Meta-analysis, and Comparison of Randomized Controlled Trials and Observational Studies.

Smeeing DP1,2, van der Ven DJ3, Hietbrink F2, Timmers TK3, van Heijl M2,4, Kruyt MC5, Groenwold RH6, van der Meijden OA7, Houwert RM8,9.

Author information:

1Utrecht Traumacenter, Utrecht, the Netherlands diederiksmeeing@hotmail.com.

2Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.

3Department of Surgery, Meander Medical Center, Amersfoort, the Netherlands.

4Department of Surgery, Diakonessenhuis, Utrecht, the Netherlands.

5Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.

6Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands.

7Department of Orthopedic Surgery, SpaarneGasthuis, Hoofddorp, the Netherlands.

8Utrecht Traumacenter, Utrecht, the Netherlands.

9Department of Surgery, St Antonius Hospital, Nieuwegein, the Netherlands.



There is no consensus on the choice of treatment of midshaft clavicle fractures (MCFs).


The aims of this systematic review and meta-analysis were (1) to compare fracture healing disorders and functional outcomes of surgical versus nonsurgical treatment of MCFs and (2) to compare effect estimates obtained from randomized controlled trials (RCTs) and observational studies.


Systematic review and meta-analysis.


The PubMed/MEDLINE, Embase, CENTRAL, and CINAHL databases were searched for both RCTs and observational studies. Using the MINORS instrument, all included studies were assessed on their methodological quality. The primary outcome was a nonunion. Effects of surgical versus nonsurgical treatment were estimated using random-effects meta-analysis models.


A total of 20 studies were included, of which 8 were RCTs and 12 were observational studies including 1760 patients. Results were similar across the different study designs. A meta-analysis of 19 studies revealed that nonunions were significantly less common after surgical treatment than after nonsurgical treatment (odds ratio [OR], 0.18 [95% CI, 0.10-0.33]). The risk of malunions did not differ between surgical and nonsurgical treatment (OR, 0.38 [95% CI, 0.12-1.19]). Both the long-term Disabilities of the Arm, Shoulder and Hand (DASH) and Constant-Murley scores favored surgical treatment (DASH: mean difference [MD], -2.04 [95% CI, -3.56 to -0.52]; Constant-Murley: MD, 3.23 [95% CI, 1.52 to 4.95]). No differences were observed regarding revision surgery (OR, 0.85 [95% CI, 0.42-1.73]). Including only high-quality studies, both the number of malunions and days to return to work show significant differences in favor of surgical treatment (malunions: OR, 0.26 [95% CI, 0.07 to 0.92]; return to work: MD, -8.64 [95% CI, -16.22 to -1.05]).


This meta-analysis of high-quality studies showed that surgical treatment of MCFs results in fewer nonunions, fewer malunions, and an accelerated return to work compared with nonsurgical treatment. A meta-analysis of surgical treatments need not be restricted to randomized trials, provided that the included observational studies are of high quality.

© 2016 The Author(s).

PMID: 27864184 [PubMed – as supplied by publisher]

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